Cognitive behavioral therapy is now a worthy replacement for psychoanalysis. It didn’t come into use until long after I received my medical training. But lately, I have gained some insig ht into how it works—and realized that in my sixty years of general medical practice, I had been applying the technique without knowing it!
By way of illustration, consider a patient encounter that occurred some forty years ago—one that would turn on a bizarre psychiatric consequence of mammalian anatomy and physiology. I had been taught in medical school that patients may take a new physician’s measure over the course of a visit or two before divulging their chief complaint. In this case, I needed a similar measure of my patient before I could give him the simple reassurance that his “problem” called for. What follows is the account of such a mutual measure-taking with a man who would become my long-term patient. My recollection begins with the visit during which he “dropped the bomb.”
“Doc,” he began, “I think I am a pervert.” He went on to describe how he enjoyed having his nipples manipulated but he considered this a serious perversion. Apparently I did not seem immediately convinced of its scandalous character, so he repeated his concerns more emphatically.
My response was, “Let us talk this over to see if we can figure out how your problem came to be.” I began with an explanation of “witch’s milk,” a serous (clear amber) discharge from the nipples of newborn infants of either sex. This occasional phenomenon results from the infants’ recent exposure to the hormones in the mother’s body that prepare the mother for lactation. Mothers have the same discharge at roughly the same time; indeed the phenomenon is more common in new moms than in their infants.
The technical name for this initial milk is “colostrum.” The reason that male babies sometimes produce colostrum is that the original equipment in the chest wall is identical in infants of both sexes. An inevitable consequence is that the nerves to the nipples are also identical. A rather obvious reason for these nerves is that the association of pleasant sensations with breast-feeding for infant and mother alike is obviously beneficial for humans as it has been throughout the mammalian lineage. So my patient and I agreed that male mammals possess these nerve endings in their nipples throughout their lives through no fault of their own. It is scarcely fair to fault nature for taking the easy way out in making the chest walls of mammals of both sexes initially similar.
It is obvious why my patient needed time to get acquainted with me (and my possible biases). In retrospect, I recognize that I also needed to take my measure of him, especially his intellectual ability and possible religious biases, before I could have led our discussion so promptly to a positive conclusion. Because he was prepared to understand and accept my argument from evolution, he instantly became a normal human being in his own eyes, and I became his trusted physician. If he had been what we today would call a “creationist,” my lifelong fascination with evolutionary biology might not have been so useful in “curing” his “problem.”
Soon after I first drafted this account, I read an article about the history of cognitive behavioral therapy (David B. Smith, “The Doctor Is In,” The American Scholar, Autumn 2009). On its last page, the article very strongly implied—though it stopped short of explicitly stating—that cognitive behavioral therapy resembles modern psychotherapy as Socrates might practice it. I was gratified to learn that I had achieved something similar by questioning patients in such a way that they learned to deal with their problems through their own insight rather than from external authority. That is, incidentally, the essence of the Socratic method.