psychodynamic psychiatry
How are we to bring together medical and psychoanalytical
perspectives on schizophrenic psychosis?
Treatises on psychosis tend to be either of a decidedly non-psychoanalytic, or occasionally of a decidedly psychoanalytic, sort. My own - which is admittedly rather niche in that it concerns itself only with distinctly philosophical issues in the theory of psychosis - is of neither sort. In it - in my book On Madness, that is - I hope to show, in a way which won't simply alienate those of more Kraepelinian persuasions, that matters motivational (drive, avoidance, defence, resistance, symbol formation, etc) are indeed often fundamental to mental illness. The fundamental feelings, anxieties, and defensive motivations which generate and maintain psychotic processes are not, I want to suggest, some psychological overlay sitting on top of a more purely biological processes. Rather, they themselves are disturbances in the deeply psychobiological drive structure of the human organism.
Treatises on psychosis tend to be either of a decidedly non-psychoanalytic, or occasionally of a decidedly psychoanalytic, sort. My own - which is admittedly rather niche in that it concerns itself only with distinctly philosophical issues in the theory of psychosis - is of neither sort. In it - in my book On Madness, that is - I hope to show, in a way which won't simply alienate those of more Kraepelinian persuasions, that matters motivational (drive, avoidance, defence, resistance, symbol formation, etc) are indeed often fundamental to mental illness. The fundamental feelings, anxieties, and defensive motivations which generate and maintain psychotic processes are not, I want to suggest, some psychological overlay sitting on top of a more purely biological processes. Rather, they themselves are disturbances in the deeply psychobiological drive structure of the human organism.
Psychodynamic concerns present themselves at three main
junctures of the book. First, in its understanding of mental illness as often
essentially involving an unconsciously motivated avoidance of suffering (ch. 1).
Second, in its explication of the psychoanalytic concept of symbolisation to
make sense of hallucination, thought disorder, and in particular, delusional
content (chs. 2, 7, and especially 9). Third, in its explication of the
motivational dynamics underlying what Bleuler - before the term was coopted by
Kanner et al to describe a developmental disturbance of childhood - termed
schizophrenic autism: a particular kind of 'living in your own world' (ch.
4). At other points in the work I clarify and retheorise certain concepts -
especially 'reality testing' (ch. 4) and 'ego boundary disturbance' (ch. 6) -
which stem mainly from psychoanalytically-minded theorists but which don't make
essential reference to psychodynamics. In what follows I present extracts from
the book to exemplify how, in my view, psychoanalytic concerns belong properly
to psychiatric investigation.
In the first extract (from ch. 1 of On Madness) I elucidate how I see reference to matters motivational as belonging not simply to an empirical psychoanalytic theory of what happens to make for mental illness, but instead as central to our very understanding of the ill mind.
Another schizophrenic subject talked of how he ‘suppressed feeling as I suppressed all reality. I dug a moat around me.’ The philosopher Arthur Schopenhauer also put it well:
In such ways the ‘mental illness’ concept provides us with a reminder to maintain contact with the mentally ill patient’s latent suffering. Ilse’s psychosis developed when she was utterly overwhelmed by her first sexual encounters and her school examinations. Whether her delusions were a mere breakdown product of a mind overwhelmed by such suffering as ‘exceeds its strength’, or whether instead she ‘seized upon madness’ by way of motivated retreat from an anguish that was ‘positively unbearable’ to her, isn’t something we can decide on from the information in the case report. But we anyway aren’t forced to choose between these: the family resemblance concept of ‘mental illness’ includes both possibilities within it.
In the second extract (from ch. 4 of On Madness) I take issue with Eugene
Minkowski's scepticism about the significance of psychodynamics in
schizophrenia. Minkowski, recall, was the Jewish/Polish/French psychiatrist
who wrote the classic La Schizophrénie, the first edition of which appeared
in 1927. (Here, by the way, is my very rough and ready translation of
ch. 3
of the second edition.) His work is rightly called the best treatise on
schizophrenia yet written. But his reformulation of schizophrenic autism -
from motivated withdrawal to a cut-off inner domain to a non-motivated loss
of grounding vital contact with reality - seems to me to be based on a
misreading of motivation. On a reading of the psychobiological dynamism of
motivation as the reflective choosing we find in intention. Put this right
and we can once again help ourselves to an understanding of the
psychodynamics of psychosis in which the biological and the psychological
are of a piece rather than in competition.
Of the various characteristics of mental illness discussed in chapter one - irrationality, suffering, a self-maintaining character, motivated avoidance of anguish - the last characteristic, motivation, was offered as essential but non-necessary. We can acknowledge cases of mental illness wherein madness is properly ascribed on the basis only of sheer overwhelm and self-maintaining rational breakdown. ‘Mental illness’, however, is a family resemblance concept, so we shouldn’t take the mere possibility of non-motivated delusionality to mean that, when a mind becomes mad to avoid anguish, it isn’t thereby manifesting an essential aspect of mental illness. In such cases talk of ‘mental illness’ signals not only suffering and disorganization in the face of overwhelm, but also the supervening of an alternative organization wherein the mind sacrifices its primary tasks of maintaining intelligibility-finding (and hence intelligible) world-involvement and of sublating inner conflict (through emotional work and personal growth) to the end of self-preservation. Whilst the self-preservation met with in ordinary illness is properly described in functional terms (‘killer-T lymphocytes function to destroy virally infected cells’), the self-preservation met with in mental illness is, as befits the psychological context, often properly described in motivational terms (‘the mind … seeks refuge in madness from the mental suffering that exceeds its strength’ (Schopenhauer).) This mind isn’t merely compromised; it’s also compromising as it beats its retreat from unbearable overwhelm to a world of its own in which reality and fantasy have collapsed together.
On this conception, then, it’s prima facie reasonable to think of someone’s schizophrenic autism as at least sometimes a function of his psychodynamics - i.e. as a result of his motivatedly, if unconsciously, distorting his mind’s own defining, reality-facing, form in order to manage his emotional equilibrium. Yet a somewhat different conception is offered us by Eugène Minkowski, the most profound of our post-Bleulerian schizophrenia interpreters, and nearly all of today’s biological psychiatry follows in his lead. For Minkowski provides an extended discussion of the personally meaningful ‘content of psychosis’ only to proceed to deprecate the significance of painful predicament and its motivated avoidance in an understanding of the essential nature of the illness.
Contending with predicament is of course often important, he opines, and naturally we owe a great debt to Jung’s depth psychological investigations of psychosis, investigations which help us grasp the obscure meanings of various individuals’ psychotic experiences in relation to their pre-psychotic predicaments. Yet the essential autistic core of schizophrenia is, he suggests, far more clearly appreciated in terms of mere deficit or defect rather than in terms of psychodynamic processes. We all, schizophrenics and non-schizophrenics alike, have our existential predicaments, and it’s therefore only to be expected that these show up in the delusional life of the schizophrenic as also in the inner life of the non-psychotic subject. But understanding what makes definitively for a schizophrenic inner life, rather than just grasping what contingently is that life’s psychology, is, he suggests, better pursued merely by reference to what now is damaged or deficient. Such damage or deficiency, he reasons, is after all what makes for illness.
From the perspective of the present work, it’s surprising to see Minkowski in effect reduce schizophrenia from a prototypical (suffering- and motivation-involving) illness to a mere disorder or disability. For sure, in doing so he follows a venerable psychiatric tradition associated especially with Emil Kraepelin. And there is of course nothing to stop anyone reserving the terms ‘schizophrenia’ and its cardinal trait of ‘autism’ for whatever disturbances of association, boundaries, and reality contact are intelligible only in non-motivational terms. What would be of concern, however, is if that decision led to core aspects of the psychotic experience being overlooked. When Barbara tells us that by ‘Riding off in the bus, I left safely behind me a mess of reality with which I was totally incapable of coping’ - or when she hallucinates the frightening Operators whose threats, unlike her real-world predicaments, at least have a thinkable and hence more manageable form - does this really just accidentally diminish her angst, or is it rather motivated by an urgent need for the angst’s abating? And when we turn to some of Minkowski’s own examples of lost reality contact, what we find is that rather than suggesting the irrelevance, they rather seem to suggest the significance, of motivation in our understanding of the loss of reality testing.
Consider first the man who, when out walking, ‘was sometimes struck with the appearance of a woman. He would then return to his house, sit down on a chair, cross his arms and take up a position as symmetrical as possible to reflect on the event. He would try to solve the problem of why a woman’s body made a particular impression on a man.’ What’s striking is that, in his treatment of the case, Minkowski gives no thought at all to the natural understanding that here we find the intolerable emotional experience of frustrated sexual desire, and the practical problem of how to achieve sexual intimacy with women, being delusionally sublimated into the bizarre intellectual problem of why heterosexual men are attracted to sexually attractive women.
Or consider the case of Paul, a socially withdrawn 17 year old schoolboy,
whose morbid rationality and diminished vital contact with reality
Minkowski again describes beautifully. Just before his autism set in, Paul
‘seems to have been preoccupied with questions of a sexual nature; he
would question his father and ask him for explanations, revealing a
complete ignorance of the subject.’ At bedtime Paul would take over an
hour ensuring the linen was perfectly symmetrical on the bed. He also
spent hours in the bathroom, explaining this in terms of his preoccupation
with: the size of a feather duster in there, the exact time he entered,
and the size of the crack at the door’s base and whether he may be seen
through it - which latter thought, Paul alleges, troubles him not at all.
Again, it’s hardly a great leap to detect here a defensive
intellectualising retreat from various psychosexual troubles. Yet
Minkowski opines that the ‘sexual curiosity that appears at the outset of
the illness, which could be considered for that reason a point of
departure, can only be a precursory sign of the interrogative attitude
that takes a firm hold afterwards. In any case, it is this attitude that
must be rectified before attending to anything else.’ Yet why might it not
instead be that the deployment of this intellectualising, interrogative
attitude is a defensive reaction to a normal, but for this teenager
utterly unmanageable, preoccupation with matters bodily and sexual?
Consider, next, Minokwski’s case of the schizophrenic woman who ‘in an advanced stage of her illness, passed the time making hats for herself. She had made 16 of them. One day, she lost two of them. As a form of retaliation against this she decided to break two of her mother’s 16 cups.’ Once again we’re hardly going out on a limb if we here risk a hypothesis about the symbolic resonance of the hats, cups and breakages – for example that the patient made hats to provide herself with her own version of that which she enviously felt her mother to both cherish and unfairly withhold, so that, following her loss, she was driven to even the score by breaking two of mother’s cups. Of course, we don’t know the details, so must indeed here be content with mere hypothesis. But what’s evident, and what’s already registered in Minkowski’s mention of retaliation, is that matters motivational are not incidental to the case.
Throughout his text Minkowski keeps a careful eye on the distinction between delusion’s motivated, symbolic, content and delusional form so as to not lose sight of the latter. Yet whilst the distinction between content and form is important, what gets lost is the above-articulated Sartrean notion that it’s in fact not just the content, but the form, of the delusional world that is sought by she who finds the discord between the real and the desired world too painful to handle. To live in one’s own world becomes for Minkowski merely a matter of being detached from reality, and psychological functions such as wish or imagination, shame and guilt, repose and confidence become mere content-providers for a mind the alternative form of which is to be understood otherwise. Yet from the alternative perspective offered here, matters biographical and formal do not keep to their own enclaves any more for psychotic delusion than for everyday mood. To insist that they do is, far from exercising a clear-sighted restraint, to risk colluding with the delusional subject’s efforts to dismantle his reality contact in the domain of his disquiet. For, as we already know, we often become moody when we fail to tolerate, process, understand, or get to grips with our specific emotional predicaments. Our worlds are now encountered under a formally altered aspect, an aspect that resolves when (amongst other possible resolutions) we find a way to own, acknowledge or fathom the specific significance of our situated encounters. When mood resolves, and we find a way to once again meaningfully suffer what we experience, predicament once more becomes thinkable in its particularity. Delusion can here be understood as a further step on from unbearable mood, the mood’s form resolving not into thinkable content but into the merely ersatz thoughts of a quasi-dreaming mind. Something like, but by definition not, thinkability in its specificity is now restored, albeit at the cost of reality contact.
Perhaps the principal reason Minkowski struggles to find a place for motivation in his understanding of autism is his tendency, widespread also in today’s biological psychiatry, to judge the attribution of motivation to the schizophrenic autist to be too much of a stretch only because of a prior conflation of motivation with intention. He’s surely right to think it wrong-headed to suppose that the overwhelmed subject typically intends to enter a delusional world. Even taken to it’s extreme, the ‘policy of the ostrich’ - i. e. putting one’s head in the sand - is not, as Minkowski notes, a good model for entering a delusional world. But unconscious motivation is properly ascribed to subjects on the basis of the shape of their behaviour, thought and feeling over time - rather than on the self-ascriptions they’re disposed to make at the time. And the avoidance of anguish by flight to a delusional world is best understood as having a reflex character, and as motivated in a similar way to much animal behaviour. Retrospectively, however, the patient may be able to own the motivated character of their flight from reality; thus Minkowski himself cites a patient who reports of himself that ‘I suppressed feeling as I suppressed all reality. I dug a moat around myself.’
Notwithstanding, it’s plausible to suggest that the schizophrenic person’s motivated autistic retreat exploits his schizotaxic disposition – i.e. his non-motivationally-intelligible weakened reality contact, loose cognitive associations, and unstable ego boundaries. So too the bipolar patient’s psychosis may exploit the abnormal ease with which his self-conception separates from his emotional life. And this in turn may explain why many can suffer hideous tormenting conflicts without yet going psychotic: their (non-schizotaxic) constitution ruling it out as a live option for them. Yet whilst such dispositions may be necessary for schizophrenic illness, they’re insufficient (for we at least need suffering before we shall talk properly of mental illness), and they obtain also in those who haven’t become ill. Furthermore we have the observation (of Bleuler and Jung amongst others) that, when we’re considering mental illness, autism and accessory symptoms such as delusion prevail in the ambit of emotionally charged complexes. In short Minkowski does not provide good reason to doubt that the patient is not only thrown, but also take flight, into his own world. And especially when we consider the retrospective testimony of the patient, and take note of his psychodynamics and the relief that delusionality affords his complex-ridden person, we can surely find a place for the motivational element within our understanding of his autism.
Against the above it might be suggested that to read motivational dynamics into the very core of our understanding of schizophrenic illness gives the psychological discipline of psychoanalysis an ontological promotion it hasn’t earned; and that the autistic core of schizophrenia is in any case better explicated in ‘basic’ neurobiological terms rather than in terms of ‘higher level’ motivational factors. Let’s consider these in turn.
As for the first suggestion, we may counter that the concept of motivational dynamics belongs not first and foremost to the science of psychoanalysis, but rather to both our pre-psychoanalytic articulation of the more difficult moments of our daily lives and our psychopathological system quite generally. If psychoanalysis here builds on our insight into what we already latently grasp then all well and good. But when it comes to our understanding of mental illness it takes a curiously blunted psychopathological sensibility to read the psychodynamics out of our intuitive grasp of what we encounter, and not any particular schooling in psychoanalysis to read them there where they’re to be found.
As against the second consideration – that the fundamental nature of schizophrenic autism is such as to invite neurobiological rather than psychodynamic explanation – we may ask why these accounts should be thought to compete. After all, it’s part of the design of such motivational concepts as the drive or the need state that they sit rather closer to matters physiological than do other psychological concepts. (They are, we may say, ‘psychobiological’ in character.) And the basic conflicts which psychoanalytic investigation tracks – to do with sexual desire, social affiliation, competition, aggression, attachment, etc. – and the basic affects here in play – of interest, lust, love, rage, fear, anxiety, terror, etc. – do not float free of the brain but are all – as affective neuroscience well describes – directly anchored in distinct neural circuitry. Without taking a stand on matters empirical, it’s surely at least imaginable that unless there is, say, sufficiently complex cortical activity to allow competing drive activations to be negotiated, then the clashing of such activations may constitute an overwhelming degree of that inner push-pull tension we call ‘anxiety’. And if someone is sufficiently schizotaxic to not be inexorably tethered to the world, it’s conceivable that such anxiety will propel him into orbiting a different, this time psychotic, sun. In short, shouldn’t we need positive reason to suppose that matters neurological and affective are here not of a piece, rather than have that assumption of brain/affect dualism be our starting point and then have to justify a psychodynamic understanding of schizophrenic autism?
In the final extract (from On Madness ch. 9) I offer a retheorisation of the psychoanalytic concept of symbolisation:
The psychology of psychological symbolization
The above examples give us a sense of how symbolization dares venture in terrains where mentalization fears to tread. A patient recounting his dreams, a child in her play, and a Sunday painter in the field give symbolic articulation to feelings which they may as yet be unable to mentalize. The examples also make clear how far the notion of psychological symbolization is from the traditional notion of symbolic production: the ordinary symbol stands for or represents that which it symbolizes, whereas a subject’s symbolization of his experience involves his use of a medium wherein his experience may itself begin to take determinate shape.
It’s easy enough to see why someone looking at the above examples may be drawn to say that the child, artist, dreamer, or woman in labour is using symbols to represent experience that already enjoys determinate form. If, that is, we take the notion of a symbol in its ordinary sense - namely ‘something that stands for, represents, or denotes something else’ - and if we take as our paradigm of emotional experience those mature feelings which are already clearly structured and apt for avowal, then the relation of a moment of child’s play or of a painted figure’s facial expression to particular emotions will naturally appear as one of representation. Yet this appears a clear instance of a pre/trans fallacy: a state which is prior to mentalization is here conflated with one which presupposes it to have already obtained.
We may even here hazard an error theory as to why Freudian psychoanalysis has typically considered psychological symbolization in terms of substitution. On that conception the mind in conflict represses out of awareness emotions or urges which nevertheless lie determinately within it, and in a moment of bad faith offers up for itself substitutes which provide at least some of the gratification which the repressed emotions or urges would, in happier circumstances, themselves have provided. This conception, if it’s not to straightway fall foul of the contradictions inherent in the very idea of a mind which must somehow know what it yet disavows, must also make use: of an inner ‘censor’, of inner mental ‘partitions’ to keep the repressed feeling apart from the self-knowing subject, and of some kind of ‘introspective’ faculty for enabling access to the symbolic substitute – all of which quickly leads us into a complexified, reified and alienated characterization of mental life. If, however, we consider unconscious emotion not as extant yet hidden, but instead as an inchoate dispositional force which has not yet taken shape (either partly in symbolization or fully in mentalization) – then we may avoid a conception of the symbol as a substitute for that which is ‘known yet repressed’. Any notion of substitution, or of a determinate unconscious content for which the symbol is substituted, may now be seen to pertain not to the symbolising subject but instead merely to the form of our representation of her predicament. An ‘unconscious’ feeling now becomes that which, along with a high load of anxiety, would unfold in a determinate manner were certain defensive strategies not deployed – rather than something extant but somehow squirreled away within the recesses of a self-concealing mind. And a symbol now becomes not a stand-in for an emotional thought extant yet gone into hiding, but instead a somewhat inarticulate expression of unconscious feeling. Affect is now mobilized, even though its expression doesn’t take a mentalising shape and so doesn’t voice that thought which a subject better able to metabolize her predicament would voice (‘I’m frightened of father’), but instead voices something analogous (‘This toy monster terrorizes this doll’).
Consider too the different senses of ‘articulate’. One sense considers articulation to be the voicing of that which is already structured. Another considers it to be the development of such discrete structuration. A third considers it in terms of such jointedness as now permits movement. It’s these second and third senses which are relevant when we’re considering what’s meant by psychological symbolization. A subject too sunk into her predicament to be able to give it voice, too identified with it to be able to develop feelings about it, develops instead some feelings in relation to what we naturally consider its analogue. Through imaginative involvement in play, through ritual, dreaming, or artistic production, she imaginatively bodies forth feelings in articulate form and becomes more given to flexible response in the face of her predicament. Now the ghost will be killed with a knife, the denizens of Muu’s abode will be defeated, the cypress will be cleared from the roof of the house, and angry attacking impulses will be allowed their breathing space alongside loving and tender feelings. As a consequence, agitation decreases, labour or mourning proceed, artistic vision is rendered incarnate – and life once again unfolds without inhibition.
Psychotic symbolization
Having elucidated the collapse of the literal and the metaphoric in
psychotic thought, and outlined the nature of psychological symbolization,
we’re now in a position to bring these together in a fresh understanding
of psychotic symbolization. This understanding, if it’s to be of value,
should allow us to make reflective sense of what’s readily intuitively
grasped in the following:
Here Bleuler’s patient engages in an act which, superficially at least, resembles a rite. Yet by contrast with our appreciation of religious acts, we readily recognize it as psychotic. Regularly encountered explanations for this difference include: i) religious acts are in fact themselves essentially psychotic, but because we’re attached or habituated to them we give them a special pleading they’ve not earned; ii) religious acts are necessarily participated in by many people, and are not just individual inventions, and it’s this which makes it incorrect to consider them psychotic; iii) what in a religious rite is treated metaphorically is here treated literally, and this is what makes it right to designate it psychotic. Yet if the understanding of psychosis and of psychological symbolism advanced in this chapter is right, we can begin to see our way to an alternative understanding of such acts.
To make clear the character of this understanding, let’s invent a plausible empirical setting for the Quittenbaum delusion. Thus let’s imagine that here we meet with an unhappily married woman who has become erotically attached to her caring pastor. She now finds herself in intolerable conflict - both because her desire is unrequited and because her conscience can’t condone it. Rather than being able to develop this predicament in clear thought, allowing both for a lucid articulation of the desire and for the acknowledgement of the impossibility of its fulfilment, Bleuler’s patient is instead overwhelmed and becomes psychotic. That’s to say, her thought is no longer rooted in and calibrated by reality, so she enters a ‘waking dream’ in which her thoughts no more belong properly either to imagination or to judgement but instead manifest a collapse of the two into each other. Her concrete equation of the quince branches and her sins is not a matter of her treating literally what a non-psychotic rite participant would treat as metaphor. What has instead happened is that she has psychologically symbolized her predicament, i.e. given it a non-mentalistic verbal elaboration, whilst in a psychotic state. Her acts cannot be seen by her as play, art or ritual, nor can either she or we clearly approach her thought and experience using the categories of the literal or the metaphorical, for her state of mind is such as to make such distinctions void.
Or consider this:
Let’s again invent a backstory to psychologically fill out this brief clinical report. Imagine then that, when young, the patient’s mother suffered an insufficient degree of reliable nurture and emotional containment. She’s unable to mentalize this deprivation, but finds refuge in collecting symbolic substitutes for (what psychoanalysis calls) the ‘absent breast’. With these cups she can feed herself; they enable her to become self-satisfying; unlike the absent breast, they’re reassuringly within her control, hanging as they do on the dresser hooks. Nevertheless, her impoverishing early experience, and her self-involvement, in turn impair her capacity to provide adequate emotional containment to her daughter. To tolerate her own exclusion from the domain of care symbolized by the mother’s relationship with her precious cups, the daughter in turn creates her own substitute ‘breast’ – i.e. she knits herself a hat for each of her mother’s 16 cups. With these hats for comfort, she can avoid becoming angry at her mother’s emotional neglect. Losing two of them, however, threatens the fragile emotional balance they provide. She can mentalize none of the emotional meaning, but her painful loss is nevertheless mitigated by breaking two of her mother’s cups: this breakage perfectly demonstrates what we might call the ‘logic’ of delusional symbolization.
There’s no such thing as our developing here a rational (or what Jaspers called ‘empathic’) understanding of the patient’s breaking of her mother’s cups, since this poor patient is not engaged in a rational act. She might say ‘I broke them because I lost two of my hats’ - yet this, qua reason, makes no sense. Minkowski - the author of this report - articulates her vandalism as something done ‘in retaliation for’ the loss, and it’s this which reveals for us the delusional quality of the act. For if something’s properly said to be ‘done in retaliation’, that which is suffered must be understood by the revenging party to be something done to her by the one on whom revenge is taken. It’s by bringing the breakage under the description of ‘revenge’ whilst not providing any such understanding for us that Minkowski helps us appreciate the short-circuiting, delusional, character of that which here confronts us. Yet whilst we can’t enter empathically into this act qua rational act – i.e. whilst we’ve no idea how to make ‘because I lost two of my hats’ into a genuine reason for breaking two of one’s mother’s cups – we can nevertheless psychologically grasp the act’s motivated character: the act functions to restore mental equilibrium.
Near the beginning of this chapter we met three patients, the first of whom was Elena who hallucinates and delusionally believes that her father, ‘all black and completely nude’, frequently comes to her bed thrusting ‘a spear into her lower abdomen and dancing about in a very peculiar fashion’. This, Bleuler tells us, is the same father who does in fact frequently abuse her sexually. At the start of her psychosis she hallucinates her mother complaining about her to her father. When she speaks of his abuse her tone is embarrassed and objective, but when she articulates her hallucination and delusion she wears a ‘completely erotic expression’. This all provides a clue to the nature of what would have been more comprehensively repressed had her mind not been so damaged by her abusive upbringing and illness. Her natural heterosexual desires, that is, are awakened by her father, but since she is, like many a healthy teenager, still too sunk into the predicament of the inevitability yet impermissibility of oedipal desires, they can’t take a straightforward mentalized form. They instead take a symbolic shape, but do so when she’s in a state of waking dream, with the result that she neither straightforwardly believes, nor wishfully imagines, but instead delusionally believes, that her naked black father thrusts his spear into her abdomen.
Following Elena we met Ms R whose father was oppressive in his expectations, obtuse about his daughter’s difficulties, and utterly unrealistic about her ability to find or cope with a job or marriage. Like Elena, Ms R is too sunk into her predicament and so can’t develop fully mentalized feelings – at first about her father’s impossible expectations, and later about the ward staff’s equally unhelpful expectations of her progress. The feelings therefore remain merely potential or ‘unconscious’ – ‘trapped’, as it were, within the very structure of her relationships rather than condensing out into discrete sufferable experiences. And like Elena, Ms R – due to whatever predisposition she carries, along with the unbearableness of the home situation – becomes psychotic. Nevertheless the general drive toward psychological symbolization still remains in her, and because she’s lost touch with reality it now naturally manifests in delusion: ‘a large man is sitting on top of my head’. In someone who had not lost reality contact this thought would naturally be seen as a metaphor, one more naturally expressed in the form of a simile: ‘It is for me as if a large man were sitting on my head’. Yet, at least in the ambit of her waking dream, the metaphorical/literal distinction no longer finds instantiation in Ms R’s mind – and so to treat her expression as metaphorical would be to commit the pre/trans fallacy. Luckily for Ms R, a psychotherapist sensitive to the meanings of psychological symbolization is able to help the ward staff understand that this large man ‘is’ her father. Which ‘is’ is to say: her delusional expression is a psychological symbolization of the stifling predicament she is in, a predicament which, were she able to extricate herself from it for a moment so as to bring it into view, would naturally be expressed in such terms as ‘my father is oppressing me’. The ward staff can now take a mentalising attitude toward Ms R, one which conveys an accepting understanding of her experience, which refrains from repeating the oppression, and which, in making clear that such experiences can be discussed, allows Ms R to begin to mentalize her own suffering.
After Ms R we encountered Jonas, the ‘masturbating hebephrenic, who … finds a high peak in a mountain range so shocking that he gets into a fight with his companion and has to return home.’ The analogy, writes Bleuler, ‘can hardly be called pathological. But what is … pathological is [Jonas’] interpretation of the analogy in the sense of the real sexual organ and the correspondingly violent reaction.’ Such examples abound in the literature, and testify to the impact of an unintegrated sexuality and unsatisfactory sexual life on psychopathology.
Jonas, let’s imagine, struggles both to integrate his sexual desires and to tolerate the shame and frustration of their unfulfilment. He is shy, unconfident, awkward, and doesn’t know how to go about finding and attracting a sexual partner. Such a predicament is, after all, not humanly unknown, perhaps especially amongst those at risk of developing mental illness. For Jonas, we hypothesize, the predicament is simply too much to bear. He is lost in it; it courses through him, determining his actions – rather than being something he can pull into view or get a handle on. He can only move dynamically in the world – go walking in the Alps with a companion, say – by rigidly defending against his sexual fears and frustrations. At times mere repression and distraction serve the purpose, but at other times the affective load of his predicament is too great: now he simultaneously dissociates and loses his footing in reality. Yet now that he’s slipped into a delusional mode, the frustrating situation can at least take some kind of expressive form: a mountain peak offers an opportunity for Jonas to develop outrage. Unbearable inner turmoil now takes an outward shape; relief is thereby obtained; ersatz sense is made. Such outrage is however impossible to empathically grasp in the terms in which it expresses itself. We could make something of it were it not a mountain peak but an exposed sexual characteristic that was under discussion. We could make something of it too if Jonas were using a metaphor to articulate himself. In the absence of these, however, empathic intelligibility in Jaspers’s sense is unavailable. We don’t come to understand Jonas in his predicament and in his delusion by grasping his speaker’s meaning, since his outraged expression conveys none. Instead we come to understand him by grasping psychologically how the breakdown of such meaning bespeaks the diremptive power of such complexes as are betrayed by his delusional symbolization.
Before concluding the discussion it’s important that we consider the
dangers for the patient of openly translating their psychological
symbolization to them. This chapter began with mention of Angela who, you
will recall, told me, at the end of the 20th century, that she had just
been released from Belsen (which was liberated in 1945). Interpreting her
as using a metaphor (for being discharged from the psychiatric hospital,
as indeed she had been) provoked in her a reaction of bafflement and
disturbance. This already shows how caution is required when interpreting
symbolically freighted psychopathology in the absence of a containing
therapeutic relationship. The patient needs to be treated with (moral)
understanding even when her discourse is (rationally) ununderstandable –
yet it can be deeply undoing to receive the kind of (psychological)
understanding which renders them defence-less. Showing psychological
understanding is often lauded, and indeed is essential for any
psychotherapy that not only helps a patient through his psychosis but also
helps him work through his underlying complexes and ameliorate his
underlying vulnerability. Even so, and especially for the patient whose
psychosis is itself a flight from intolerable shame, knowing oneself to be
psychologically understood can be a fearful business. To return once again
to Schopenhauer: if ‘such painful knowledge or reflection is so harrowing
that it becomes positively unbearable, and the individual would succumb to
it, then nature, alarmed in this way, seizes upon madness as the last
means of saving life.’ Carelessly undoing this can then constitute an
assault on life itself.
In this chapter we also met both the notable psychiatrist Frieda Fromm-Reichmann and her patient Joanne Greenberg whom she treated for four years at Chestnut Lodge. In Greenberg’s words now: “People would tell you what perceptive things a patient had said. The thing is I want to choose my perceptions. I don’t want them to come out of some kind of unconscious soup. I want it to be something I choose to say, not something that says me.” She adds here too how being understood in that state can feel horrifically dangerous. Whilst Fromm-Reichmann’s instruction that “you must take me with you” was welcome to her, it felt “horrifically dangerous” to be understood thus. ‘I don’t know how Frieda got around that. I remember the danger. . . . It’s bigger than you are. It’s more powerful. It can kill.’
In the first extract (from ch. 1 of On Madness) I elucidate how I see reference to matters motivational as belonging not simply to an empirical psychoanalytic theory of what happens to make for mental illness, but instead as central to our very understanding of the ill mind.
Maintenance and motivation
In thinking on what it is for illness to be ‘of the mind’ we’ve so far
encountered one negative and two positive defining criteria. The negative,
exclusionary, criterion is that it’s not itself brain disease. (It may
involve altered brain function, it may even be triggered by brain disease,
and someone may be unlucky enough to suffer both; even so it's not of the
essence of mental illness that it is itself such a disease.) The positive
ones are that true mental illness involves some kind of radical
disturbance of agency, and some kind of disturbance to a person’s rational
relationship with reality. Three further criteria of mental illness will
be adumbrated below: the self-maintaining character of the disturbance,
the motivation at play within it, and the suffering from which it emerges
and which remains implicated within it.
The next of our criteria for mental illness - its self-maintaining character - has to do with it not being maintained by a purely environmental cause. Mental illness may be caused by disturbing experiences, whether these are one-off traumas or ongoingly disturbed relationships. Even so, what makes talk of illness, rather than simply of distress, apt is that genuine illness doesn’t cease just when the source of distress is removed. Hot environments may provoke discomfort, yet we only talk of heatstroke once the body’s thermoregulation is overwhelmed and an enduring malaise persists despite returning to the shade. Taking to one’s bed doesn’t immediately make one well. In this way is ‘illness’ distinguished from ‘reaction’.
So too with mental illness. The dynamic systems theory notion of the personality as a self-regulating system that can get trapped in particular ‘attractor basins’ captures something of this. Savanna, desert and forest, for example, are alternative stable ecosystem states; intermediary states move towards one of these, and once formed are not easily destabilized. So too we may consider everyday mood states to be self-maintaining since they exercise a constraining force on the kinds of thoughts, memories and action tendencies that are readily available, and in this way maintain themselves. When in a depressed mood, for example, we think dismal thoughts, become sedentary, lose interest in our lives, and can’t access hope - and this all maintains the mood. So too when we’re giddily happy or anxious: emotions come and go as we adapt to new situations, but moods are not ongoing flexible adaptations to our lives, but have their own inner dynamism. We can become trapped in them for a while, especially if we’re somewhat emotionally blocked. Even so it’s in the nature of ordinary mood to shift after a sleep or a significant sustained change in activity or environment. Mood becomes mental illness when it becomes a more deeply entrenched pattern. Also relevant here is the notion of ‘internalization’. A child may have occasional experience of an abusive relationship without internalising it. If however the experience is protracted, the situation may become ‘trapped’ inside the child. Now she either comes to fearfully expect all others to be abusive, or tacitly casts the abuse as deserved and becomes unwarrantedly self-deprecating, or becomes abusive herself. The point of mentioning such possibilities here is not to lapse into a merely empirical psychology, but only to make clear what it is for mental illness to be self-maintaining.
The fifth criterion has it that essential to much true mental illness is that it’s at least partly intelligible in motivational terms. To borrow Aristotle’s terminology again: essential to much mental illness is that somewhere on the scene are final causes. What distinguishes much mental illness as such is that in it the will turns against, rather than supports, contact with reality, at least in some limited domain of that contact. Such a perversion of its own natural function informs key aspects of the analogical extrapolation from ordinary to mental illness, and in particular is what informs our intuition that in mental illness the mind has in some sense itself become ill. The significance of motivation is registered in different terms by different psychological systems – whether we’re thinking of the behaviourist’s ‘avoidance’ or the psychoanalyst’s ‘defence mechanisms’ – but ultimately it belongs not to a contingent aspect of these systems’ empirical science but rather to the essential nature of that which they here theorize. This motivation is of course not well described as ‘to become mentally ill’, or ‘to become psychotically depressed’. Nor is it aptly thought of as conscious - i.e. as being readily avowable by the mentally ill subject. Instead it shows itself in a reflexive avoidance of anxiety, anguish, terror and overwhelm in order to preserve inner equilibrium. Contrast here such (‘organic’) disorders as merely affect the mind with those (‘functional’) disorders which are mental illnesses proper. In the latter cases the symptoms enjoy a form of intelligibility (i.e. perform a ‘function’) related to their sufferers’ unconscious attempts to preserve selfhood, reduce overwhelm and flee angst. That these attempts may sometimes eventuate in even worse psychotic terrors, or in cutting off not only what was terrifying but also what was nourishing in reality contact, does not itself speak against the idea of such reflexive avoidance being criterial of mental illness. (Compare: Fever may be our body’s way of dealing with bacterial infection; this doesn’t mean it won’t damage you if it goes too far. Or: you take benzodiazepines to reduce your anxiety, but over time your chemical dependency makes your anxiety worse. … Welcome to the motivated yet hapless human world of temporary, compelling, and ultimately damaging fixes ascending over the far harder won delayed gratification of sustainable change.)
‘Mental illness’ is often taken as synonymous with ‘mental disorder’. It is however in the former’s allusions to a self-maintaining state, to suffering, and to the motivated avoidance of such suffering by psychotic or neurotic retreat, that it reveals itself as a more specific concept. (Consider too that the concept of 'mental disorder’ includes not only mental illnesses but also developmental disabilities.) Yet despite the fact that motivation is an essential ingredient of our understanding of mental illness, it’s not the case that it’s always to be found. As suggested above, ‘mental illness’ is a family resemblance concept, and sometimes we may call a ‘mental illness’ a condition which is unmarked by such motivation.
Suffering
Ordinary illness will, unless interrupted early, at some point result in suffering. The suffering will most usually be registered as pain, fatigue or discomfort, although some illnesses damage dignity more than cause unpleasant sensation. Many mental illnesses such as melancholia and anxiety disorders present clear instances of distress and dysphoria: anxiety and angst, panic, inner torment, mental pain, etc. Yet when we think on certain paradigmatic mental illnesses (say a manic or schizophrenic psychosis) we may be struck by how their sufferers - sometimes even those who concurrently suffer such physical illness as would normally result in pain - don’t always complain of such suffering. Retrospectively, of course, a subject may - as Ilse did - acknowledge the deep mental distress that in some sense she was nevertheless in at the time. And whilst we can readily see the damage to her dignity – damage which the concept of illness will itself be called on to ameliorate – and how in this sense she suffers, she may well not be able to see this at the time, a fact which naturally compounds the injury.
At this point it may be tempting to appeal to the ‘family resemblance’ character of the suffering criterion and suggest that, whilst it’s essential to some instances of mental illness, it need not always be present. Perhaps this is sometimes the case; even so, the appeal moves too quickly. Consider how, when discussing disturbances to agency above, it was suggested that whilst paradigmatic mental illnesses may seem to evince no ‘failure in getting on and doing things’, the criterion is met with if taken in a radicalized rather than ordinary form. The failure, that is, is not to ordinarily exercise of will, but is instead met with in that very will’s derangement: it’s not the absence of the fact of, but the continued possibility of speaking meaningfully about, ‘ordinary doing’ that’s here negated. The parallel suggestion now is that whilst the psychotic subject may feel no conscious suffering, the very form of his thought now radically embodies suffering. The suffering which is here expressed in his thought and action is not that which he consciously feels, but instead than which has broken his ability to stay in touch with painful reality. Suffering’s lostness to him here is, we might say, a symptom of his own greater lostness to suffering. If we clinicians and theorists deflect from the difficulty of reality that madness presents us, and take taxonomic refuge instead in terms like ‘mental disorder’ which carry no essential reference to suffering, we overlook how someone may be so broken by anguish that they’re no longer alive to it.
None of this is to say that there’s not also often a great deal of ordinary emotional suffering in mental illness. Instead it’s to urge that paradigm cases of it are those in which the greatest suffering now manifests in the collapse not only of agency but also of subjectivity - where by ‘subjectivity’ is meant, in part, the capacity to consciously suffer. Unfulfilled intention and unsoothed distress cannot now, as it were, be successfully suffered by the mind. Now, when the mind buckles, its disappointment and emotional pain instead become inscribed in its very form, rather than being felt as such. Should this collapsed subject become able to tolerate emotional reality again she will by that token once again become able to truly experience, rather than collapse into, her anguish. In the meantime we might detect it simmering in the restless agitation underlying a manic patient’s flight from anguish, or covered over by the insouciance accompanying the hebephrenic’s delusion. We intuitively sense that the paranoiac’s delusion provides, as Freud wrote, ‘a patch over the place where originally a rent had appeared in the ego’s relation to the external world’, whilst the catatonic has frozen himself out of existence itself because of that anguish which temporal existence now engenders for him. A patient called Joan described it thus:
In thinking on what it is for illness to be ‘of the mind’ we’ve so far
encountered one negative and two positive defining criteria. The negative,
exclusionary, criterion is that it’s not itself brain disease. (It may
involve altered brain function, it may even be triggered by brain disease,
and someone may be unlucky enough to suffer both; even so it's not of the
essence of mental illness that it is itself such a disease.) The positive
ones are that true mental illness involves some kind of radical
disturbance of agency, and some kind of disturbance to a person’s rational
relationship with reality. Three further criteria of mental illness will
be adumbrated below: the self-maintaining character of the disturbance,
the motivation at play within it, and the suffering from which it emerges
and which remains implicated within it.The next of our criteria for mental illness - its self-maintaining character - has to do with it not being maintained by a purely environmental cause. Mental illness may be caused by disturbing experiences, whether these are one-off traumas or ongoingly disturbed relationships. Even so, what makes talk of illness, rather than simply of distress, apt is that genuine illness doesn’t cease just when the source of distress is removed. Hot environments may provoke discomfort, yet we only talk of heatstroke once the body’s thermoregulation is overwhelmed and an enduring malaise persists despite returning to the shade. Taking to one’s bed doesn’t immediately make one well. In this way is ‘illness’ distinguished from ‘reaction’.
So too with mental illness. The dynamic systems theory notion of the personality as a self-regulating system that can get trapped in particular ‘attractor basins’ captures something of this. Savanna, desert and forest, for example, are alternative stable ecosystem states; intermediary states move towards one of these, and once formed are not easily destabilized. So too we may consider everyday mood states to be self-maintaining since they exercise a constraining force on the kinds of thoughts, memories and action tendencies that are readily available, and in this way maintain themselves. When in a depressed mood, for example, we think dismal thoughts, become sedentary, lose interest in our lives, and can’t access hope - and this all maintains the mood. So too when we’re giddily happy or anxious: emotions come and go as we adapt to new situations, but moods are not ongoing flexible adaptations to our lives, but have their own inner dynamism. We can become trapped in them for a while, especially if we’re somewhat emotionally blocked. Even so it’s in the nature of ordinary mood to shift after a sleep or a significant sustained change in activity or environment. Mood becomes mental illness when it becomes a more deeply entrenched pattern. Also relevant here is the notion of ‘internalization’. A child may have occasional experience of an abusive relationship without internalising it. If however the experience is protracted, the situation may become ‘trapped’ inside the child. Now she either comes to fearfully expect all others to be abusive, or tacitly casts the abuse as deserved and becomes unwarrantedly self-deprecating, or becomes abusive herself. The point of mentioning such possibilities here is not to lapse into a merely empirical psychology, but only to make clear what it is for mental illness to be self-maintaining.
The fifth criterion has it that essential to much true mental illness is that it’s at least partly intelligible in motivational terms. To borrow Aristotle’s terminology again: essential to much mental illness is that somewhere on the scene are final causes. What distinguishes much mental illness as such is that in it the will turns against, rather than supports, contact with reality, at least in some limited domain of that contact. Such a perversion of its own natural function informs key aspects of the analogical extrapolation from ordinary to mental illness, and in particular is what informs our intuition that in mental illness the mind has in some sense itself become ill. The significance of motivation is registered in different terms by different psychological systems – whether we’re thinking of the behaviourist’s ‘avoidance’ or the psychoanalyst’s ‘defence mechanisms’ – but ultimately it belongs not to a contingent aspect of these systems’ empirical science but rather to the essential nature of that which they here theorize. This motivation is of course not well described as ‘to become mentally ill’, or ‘to become psychotically depressed’. Nor is it aptly thought of as conscious - i.e. as being readily avowable by the mentally ill subject. Instead it shows itself in a reflexive avoidance of anxiety, anguish, terror and overwhelm in order to preserve inner equilibrium. Contrast here such (‘organic’) disorders as merely affect the mind with those (‘functional’) disorders which are mental illnesses proper. In the latter cases the symptoms enjoy a form of intelligibility (i.e. perform a ‘function’) related to their sufferers’ unconscious attempts to preserve selfhood, reduce overwhelm and flee angst. That these attempts may sometimes eventuate in even worse psychotic terrors, or in cutting off not only what was terrifying but also what was nourishing in reality contact, does not itself speak against the idea of such reflexive avoidance being criterial of mental illness. (Compare: Fever may be our body’s way of dealing with bacterial infection; this doesn’t mean it won’t damage you if it goes too far. Or: you take benzodiazepines to reduce your anxiety, but over time your chemical dependency makes your anxiety worse. … Welcome to the motivated yet hapless human world of temporary, compelling, and ultimately damaging fixes ascending over the far harder won delayed gratification of sustainable change.)
‘Mental illness’ is often taken as synonymous with ‘mental disorder’. It is however in the former’s allusions to a self-maintaining state, to suffering, and to the motivated avoidance of such suffering by psychotic or neurotic retreat, that it reveals itself as a more specific concept. (Consider too that the concept of 'mental disorder’ includes not only mental illnesses but also developmental disabilities.) Yet despite the fact that motivation is an essential ingredient of our understanding of mental illness, it’s not the case that it’s always to be found. As suggested above, ‘mental illness’ is a family resemblance concept, and sometimes we may call a ‘mental illness’ a condition which is unmarked by such motivation.
Suffering
Ordinary illness will, unless interrupted early, at some point result in suffering. The suffering will most usually be registered as pain, fatigue or discomfort, although some illnesses damage dignity more than cause unpleasant sensation. Many mental illnesses such as melancholia and anxiety disorders present clear instances of distress and dysphoria: anxiety and angst, panic, inner torment, mental pain, etc. Yet when we think on certain paradigmatic mental illnesses (say a manic or schizophrenic psychosis) we may be struck by how their sufferers - sometimes even those who concurrently suffer such physical illness as would normally result in pain - don’t always complain of such suffering. Retrospectively, of course, a subject may - as Ilse did - acknowledge the deep mental distress that in some sense she was nevertheless in at the time. And whilst we can readily see the damage to her dignity – damage which the concept of illness will itself be called on to ameliorate – and how in this sense she suffers, she may well not be able to see this at the time, a fact which naturally compounds the injury.
At this point it may be tempting to appeal to the ‘family resemblance’ character of the suffering criterion and suggest that, whilst it’s essential to some instances of mental illness, it need not always be present. Perhaps this is sometimes the case; even so, the appeal moves too quickly. Consider how, when discussing disturbances to agency above, it was suggested that whilst paradigmatic mental illnesses may seem to evince no ‘failure in getting on and doing things’, the criterion is met with if taken in a radicalized rather than ordinary form. The failure, that is, is not to ordinarily exercise of will, but is instead met with in that very will’s derangement: it’s not the absence of the fact of, but the continued possibility of speaking meaningfully about, ‘ordinary doing’ that’s here negated. The parallel suggestion now is that whilst the psychotic subject may feel no conscious suffering, the very form of his thought now radically embodies suffering. The suffering which is here expressed in his thought and action is not that which he consciously feels, but instead than which has broken his ability to stay in touch with painful reality. Suffering’s lostness to him here is, we might say, a symptom of his own greater lostness to suffering. If we clinicians and theorists deflect from the difficulty of reality that madness presents us, and take taxonomic refuge instead in terms like ‘mental disorder’ which carry no essential reference to suffering, we overlook how someone may be so broken by anguish that they’re no longer alive to it.
None of this is to say that there’s not also often a great deal of ordinary emotional suffering in mental illness. Instead it’s to urge that paradigm cases of it are those in which the greatest suffering now manifests in the collapse not only of agency but also of subjectivity - where by ‘subjectivity’ is meant, in part, the capacity to consciously suffer. Unfulfilled intention and unsoothed distress cannot now, as it were, be successfully suffered by the mind. Now, when the mind buckles, its disappointment and emotional pain instead become inscribed in its very form, rather than being felt as such. Should this collapsed subject become able to tolerate emotional reality again she will by that token once again become able to truly experience, rather than collapse into, her anguish. In the meantime we might detect it simmering in the restless agitation underlying a manic patient’s flight from anguish, or covered over by the insouciance accompanying the hebephrenic’s delusion. We intuitively sense that the paranoiac’s delusion provides, as Freud wrote, ‘a patch over the place where originally a rent had appeared in the ego’s relation to the external world’, whilst the catatonic has frozen himself out of existence itself because of that anguish which temporal existence now engenders for him. A patient called Joan described it thus:
I had to die to keep from dying. I know that sounds crazy but one time a boy hurt my feelings very much and I wanted to jump in front of a subway. Instead I went a little catatonic so I wouldn’t feel anything – I guess you had to die emotionally or your feelings would have killed you.
Another schizophrenic subject talked of how he ‘suppressed feeling as I suppressed all reality. I dug a moat around me.’ The philosopher Arthur Schopenhauer also put it well:
if such a sorrow, such painful knowledge or reflection, is so harrowing that it becomes positively unbearable, and the individual would succumb to it, then nature, alarmed in this way, seizes upon madness as the last means of saving life. The mind, tormented so greatly, destroys, as it were, the thread of memory, fills up the gaps with fictions, and thus seeks refuge in madness from the mental suffering that exceeds its strength.
In such ways the ‘mental illness’ concept provides us with a reminder to maintain contact with the mentally ill patient’s latent suffering. Ilse’s psychosis developed when she was utterly overwhelmed by her first sexual encounters and her school examinations. Whether her delusions were a mere breakdown product of a mind overwhelmed by such suffering as ‘exceeds its strength’, or whether instead she ‘seized upon madness’ by way of motivated retreat from an anguish that was ‘positively unbearable’ to her, isn’t something we can decide on from the information in the case report. But we anyway aren’t forced to choose between these: the family resemblance concept of ‘mental illness’ includes both possibilities within it.
In the second extract (from ch. 4 of On Madness) I take issue with Eugene
Minkowski's scepticism about the significance of psychodynamics in
schizophrenia. Minkowski, recall, was the Jewish/Polish/French psychiatrist
who wrote the classic La Schizophrénie, the first edition of which appeared
in 1927. (Here, by the way, is my very rough and ready translation of
ch. 3
of the second edition.) His work is rightly called the best treatise on
schizophrenia yet written. But his reformulation of schizophrenic autism -
from motivated withdrawal to a cut-off inner domain to a non-motivated loss
of grounding vital contact with reality - seems to me to be based on a
misreading of motivation. On a reading of the psychobiological dynamism of
motivation as the reflective choosing we find in intention. Put this right
and we can once again help ourselves to an understanding of the
psychodynamics of psychosis in which the biological and the psychological
are of a piece rather than in competition. Of the various characteristics of mental illness discussed in chapter one - irrationality, suffering, a self-maintaining character, motivated avoidance of anguish - the last characteristic, motivation, was offered as essential but non-necessary. We can acknowledge cases of mental illness wherein madness is properly ascribed on the basis only of sheer overwhelm and self-maintaining rational breakdown. ‘Mental illness’, however, is a family resemblance concept, so we shouldn’t take the mere possibility of non-motivated delusionality to mean that, when a mind becomes mad to avoid anguish, it isn’t thereby manifesting an essential aspect of mental illness. In such cases talk of ‘mental illness’ signals not only suffering and disorganization in the face of overwhelm, but also the supervening of an alternative organization wherein the mind sacrifices its primary tasks of maintaining intelligibility-finding (and hence intelligible) world-involvement and of sublating inner conflict (through emotional work and personal growth) to the end of self-preservation. Whilst the self-preservation met with in ordinary illness is properly described in functional terms (‘killer-T lymphocytes function to destroy virally infected cells’), the self-preservation met with in mental illness is, as befits the psychological context, often properly described in motivational terms (‘the mind … seeks refuge in madness from the mental suffering that exceeds its strength’ (Schopenhauer).) This mind isn’t merely compromised; it’s also compromising as it beats its retreat from unbearable overwhelm to a world of its own in which reality and fantasy have collapsed together.
On this conception, then, it’s prima facie reasonable to think of someone’s schizophrenic autism as at least sometimes a function of his psychodynamics - i.e. as a result of his motivatedly, if unconsciously, distorting his mind’s own defining, reality-facing, form in order to manage his emotional equilibrium. Yet a somewhat different conception is offered us by Eugène Minkowski, the most profound of our post-Bleulerian schizophrenia interpreters, and nearly all of today’s biological psychiatry follows in his lead. For Minkowski provides an extended discussion of the personally meaningful ‘content of psychosis’ only to proceed to deprecate the significance of painful predicament and its motivated avoidance in an understanding of the essential nature of the illness.
Contending with predicament is of course often important, he opines, and naturally we owe a great debt to Jung’s depth psychological investigations of psychosis, investigations which help us grasp the obscure meanings of various individuals’ psychotic experiences in relation to their pre-psychotic predicaments. Yet the essential autistic core of schizophrenia is, he suggests, far more clearly appreciated in terms of mere deficit or defect rather than in terms of psychodynamic processes. We all, schizophrenics and non-schizophrenics alike, have our existential predicaments, and it’s therefore only to be expected that these show up in the delusional life of the schizophrenic as also in the inner life of the non-psychotic subject. But understanding what makes definitively for a schizophrenic inner life, rather than just grasping what contingently is that life’s psychology, is, he suggests, better pursued merely by reference to what now is damaged or deficient. Such damage or deficiency, he reasons, is after all what makes for illness.
From the perspective of the present work, it’s surprising to see Minkowski in effect reduce schizophrenia from a prototypical (suffering- and motivation-involving) illness to a mere disorder or disability. For sure, in doing so he follows a venerable psychiatric tradition associated especially with Emil Kraepelin. And there is of course nothing to stop anyone reserving the terms ‘schizophrenia’ and its cardinal trait of ‘autism’ for whatever disturbances of association, boundaries, and reality contact are intelligible only in non-motivational terms. What would be of concern, however, is if that decision led to core aspects of the psychotic experience being overlooked. When Barbara tells us that by ‘Riding off in the bus, I left safely behind me a mess of reality with which I was totally incapable of coping’ - or when she hallucinates the frightening Operators whose threats, unlike her real-world predicaments, at least have a thinkable and hence more manageable form - does this really just accidentally diminish her angst, or is it rather motivated by an urgent need for the angst’s abating? And when we turn to some of Minkowski’s own examples of lost reality contact, what we find is that rather than suggesting the irrelevance, they rather seem to suggest the significance, of motivation in our understanding of the loss of reality testing.
Consider first the man who, when out walking, ‘was sometimes struck with the appearance of a woman. He would then return to his house, sit down on a chair, cross his arms and take up a position as symmetrical as possible to reflect on the event. He would try to solve the problem of why a woman’s body made a particular impression on a man.’ What’s striking is that, in his treatment of the case, Minkowski gives no thought at all to the natural understanding that here we find the intolerable emotional experience of frustrated sexual desire, and the practical problem of how to achieve sexual intimacy with women, being delusionally sublimated into the bizarre intellectual problem of why heterosexual men are attracted to sexually attractive women.
|
| Minkowski |
Consider, next, Minokwski’s case of the schizophrenic woman who ‘in an advanced stage of her illness, passed the time making hats for herself. She had made 16 of them. One day, she lost two of them. As a form of retaliation against this she decided to break two of her mother’s 16 cups.’ Once again we’re hardly going out on a limb if we here risk a hypothesis about the symbolic resonance of the hats, cups and breakages – for example that the patient made hats to provide herself with her own version of that which she enviously felt her mother to both cherish and unfairly withhold, so that, following her loss, she was driven to even the score by breaking two of mother’s cups. Of course, we don’t know the details, so must indeed here be content with mere hypothesis. But what’s evident, and what’s already registered in Minkowski’s mention of retaliation, is that matters motivational are not incidental to the case.
Throughout his text Minkowski keeps a careful eye on the distinction between delusion’s motivated, symbolic, content and delusional form so as to not lose sight of the latter. Yet whilst the distinction between content and form is important, what gets lost is the above-articulated Sartrean notion that it’s in fact not just the content, but the form, of the delusional world that is sought by she who finds the discord between the real and the desired world too painful to handle. To live in one’s own world becomes for Minkowski merely a matter of being detached from reality, and psychological functions such as wish or imagination, shame and guilt, repose and confidence become mere content-providers for a mind the alternative form of which is to be understood otherwise. Yet from the alternative perspective offered here, matters biographical and formal do not keep to their own enclaves any more for psychotic delusion than for everyday mood. To insist that they do is, far from exercising a clear-sighted restraint, to risk colluding with the delusional subject’s efforts to dismantle his reality contact in the domain of his disquiet. For, as we already know, we often become moody when we fail to tolerate, process, understand, or get to grips with our specific emotional predicaments. Our worlds are now encountered under a formally altered aspect, an aspect that resolves when (amongst other possible resolutions) we find a way to own, acknowledge or fathom the specific significance of our situated encounters. When mood resolves, and we find a way to once again meaningfully suffer what we experience, predicament once more becomes thinkable in its particularity. Delusion can here be understood as a further step on from unbearable mood, the mood’s form resolving not into thinkable content but into the merely ersatz thoughts of a quasi-dreaming mind. Something like, but by definition not, thinkability in its specificity is now restored, albeit at the cost of reality contact.
Perhaps the principal reason Minkowski struggles to find a place for motivation in his understanding of autism is his tendency, widespread also in today’s biological psychiatry, to judge the attribution of motivation to the schizophrenic autist to be too much of a stretch only because of a prior conflation of motivation with intention. He’s surely right to think it wrong-headed to suppose that the overwhelmed subject typically intends to enter a delusional world. Even taken to it’s extreme, the ‘policy of the ostrich’ - i. e. putting one’s head in the sand - is not, as Minkowski notes, a good model for entering a delusional world. But unconscious motivation is properly ascribed to subjects on the basis of the shape of their behaviour, thought and feeling over time - rather than on the self-ascriptions they’re disposed to make at the time. And the avoidance of anguish by flight to a delusional world is best understood as having a reflex character, and as motivated in a similar way to much animal behaviour. Retrospectively, however, the patient may be able to own the motivated character of their flight from reality; thus Minkowski himself cites a patient who reports of himself that ‘I suppressed feeling as I suppressed all reality. I dug a moat around myself.’
Notwithstanding, it’s plausible to suggest that the schizophrenic person’s motivated autistic retreat exploits his schizotaxic disposition – i.e. his non-motivationally-intelligible weakened reality contact, loose cognitive associations, and unstable ego boundaries. So too the bipolar patient’s psychosis may exploit the abnormal ease with which his self-conception separates from his emotional life. And this in turn may explain why many can suffer hideous tormenting conflicts without yet going psychotic: their (non-schizotaxic) constitution ruling it out as a live option for them. Yet whilst such dispositions may be necessary for schizophrenic illness, they’re insufficient (for we at least need suffering before we shall talk properly of mental illness), and they obtain also in those who haven’t become ill. Furthermore we have the observation (of Bleuler and Jung amongst others) that, when we’re considering mental illness, autism and accessory symptoms such as delusion prevail in the ambit of emotionally charged complexes. In short Minkowski does not provide good reason to doubt that the patient is not only thrown, but also take flight, into his own world. And especially when we consider the retrospective testimony of the patient, and take note of his psychodynamics and the relief that delusionality affords his complex-ridden person, we can surely find a place for the motivational element within our understanding of his autism.
Against the above it might be suggested that to read motivational dynamics into the very core of our understanding of schizophrenic illness gives the psychological discipline of psychoanalysis an ontological promotion it hasn’t earned; and that the autistic core of schizophrenia is in any case better explicated in ‘basic’ neurobiological terms rather than in terms of ‘higher level’ motivational factors. Let’s consider these in turn.
As for the first suggestion, we may counter that the concept of motivational dynamics belongs not first and foremost to the science of psychoanalysis, but rather to both our pre-psychoanalytic articulation of the more difficult moments of our daily lives and our psychopathological system quite generally. If psychoanalysis here builds on our insight into what we already latently grasp then all well and good. But when it comes to our understanding of mental illness it takes a curiously blunted psychopathological sensibility to read the psychodynamics out of our intuitive grasp of what we encounter, and not any particular schooling in psychoanalysis to read them there where they’re to be found.
As against the second consideration – that the fundamental nature of schizophrenic autism is such as to invite neurobiological rather than psychodynamic explanation – we may ask why these accounts should be thought to compete. After all, it’s part of the design of such motivational concepts as the drive or the need state that they sit rather closer to matters physiological than do other psychological concepts. (They are, we may say, ‘psychobiological’ in character.) And the basic conflicts which psychoanalytic investigation tracks – to do with sexual desire, social affiliation, competition, aggression, attachment, etc. – and the basic affects here in play – of interest, lust, love, rage, fear, anxiety, terror, etc. – do not float free of the brain but are all – as affective neuroscience well describes – directly anchored in distinct neural circuitry. Without taking a stand on matters empirical, it’s surely at least imaginable that unless there is, say, sufficiently complex cortical activity to allow competing drive activations to be negotiated, then the clashing of such activations may constitute an overwhelming degree of that inner push-pull tension we call ‘anxiety’. And if someone is sufficiently schizotaxic to not be inexorably tethered to the world, it’s conceivable that such anxiety will propel him into orbiting a different, this time psychotic, sun. In short, shouldn’t we need positive reason to suppose that matters neurological and affective are here not of a piece, rather than have that assumption of brain/affect dualism be our starting point and then have to justify a psychodynamic understanding of schizophrenic autism?
In the final extract (from On Madness ch. 9) I offer a retheorisation of the psychoanalytic concept of symbolisation:
The psychology of psychological symbolization
The above examples give us a sense of how symbolization dares venture in terrains where mentalization fears to tread. A patient recounting his dreams, a child in her play, and a Sunday painter in the field give symbolic articulation to feelings which they may as yet be unable to mentalize. The examples also make clear how far the notion of psychological symbolization is from the traditional notion of symbolic production: the ordinary symbol stands for or represents that which it symbolizes, whereas a subject’s symbolization of his experience involves his use of a medium wherein his experience may itself begin to take determinate shape.
It’s easy enough to see why someone looking at the above examples may be drawn to say that the child, artist, dreamer, or woman in labour is using symbols to represent experience that already enjoys determinate form. If, that is, we take the notion of a symbol in its ordinary sense - namely ‘something that stands for, represents, or denotes something else’ - and if we take as our paradigm of emotional experience those mature feelings which are already clearly structured and apt for avowal, then the relation of a moment of child’s play or of a painted figure’s facial expression to particular emotions will naturally appear as one of representation. Yet this appears a clear instance of a pre/trans fallacy: a state which is prior to mentalization is here conflated with one which presupposes it to have already obtained.
We may even here hazard an error theory as to why Freudian psychoanalysis has typically considered psychological symbolization in terms of substitution. On that conception the mind in conflict represses out of awareness emotions or urges which nevertheless lie determinately within it, and in a moment of bad faith offers up for itself substitutes which provide at least some of the gratification which the repressed emotions or urges would, in happier circumstances, themselves have provided. This conception, if it’s not to straightway fall foul of the contradictions inherent in the very idea of a mind which must somehow know what it yet disavows, must also make use: of an inner ‘censor’, of inner mental ‘partitions’ to keep the repressed feeling apart from the self-knowing subject, and of some kind of ‘introspective’ faculty for enabling access to the symbolic substitute – all of which quickly leads us into a complexified, reified and alienated characterization of mental life. If, however, we consider unconscious emotion not as extant yet hidden, but instead as an inchoate dispositional force which has not yet taken shape (either partly in symbolization or fully in mentalization) – then we may avoid a conception of the symbol as a substitute for that which is ‘known yet repressed’. Any notion of substitution, or of a determinate unconscious content for which the symbol is substituted, may now be seen to pertain not to the symbolising subject but instead merely to the form of our representation of her predicament. An ‘unconscious’ feeling now becomes that which, along with a high load of anxiety, would unfold in a determinate manner were certain defensive strategies not deployed – rather than something extant but somehow squirreled away within the recesses of a self-concealing mind. And a symbol now becomes not a stand-in for an emotional thought extant yet gone into hiding, but instead a somewhat inarticulate expression of unconscious feeling. Affect is now mobilized, even though its expression doesn’t take a mentalising shape and so doesn’t voice that thought which a subject better able to metabolize her predicament would voice (‘I’m frightened of father’), but instead voices something analogous (‘This toy monster terrorizes this doll’).
Consider too the different senses of ‘articulate’. One sense considers articulation to be the voicing of that which is already structured. Another considers it to be the development of such discrete structuration. A third considers it in terms of such jointedness as now permits movement. It’s these second and third senses which are relevant when we’re considering what’s meant by psychological symbolization. A subject too sunk into her predicament to be able to give it voice, too identified with it to be able to develop feelings about it, develops instead some feelings in relation to what we naturally consider its analogue. Through imaginative involvement in play, through ritual, dreaming, or artistic production, she imaginatively bodies forth feelings in articulate form and becomes more given to flexible response in the face of her predicament. Now the ghost will be killed with a knife, the denizens of Muu’s abode will be defeated, the cypress will be cleared from the roof of the house, and angry attacking impulses will be allowed their breathing space alongside loving and tender feelings. As a consequence, agitation decreases, labour or mourning proceed, artistic vision is rendered incarnate – and life once again unfolds without inhibition.
Psychotic symbolization
Having elucidated the collapse of the literal and the metaphoric in
psychotic thought, and outlined the nature of psychological symbolization,
we’re now in a position to bring these together in a fresh understanding
of psychotic symbolization. This understanding, if it’s to be of value,
should allow us to make reflective sense of what’s readily intuitively
grasped in the following:One of our hebephrenics had to be returned to the hospital twice because, in addition to other things, she cut branches off a Quittenbaum (quince tree) in order to signify that she was “quits” with the pastor. She threw these branches into the creek; they were her sins which would be carried down to the sea.
Here Bleuler’s patient engages in an act which, superficially at least, resembles a rite. Yet by contrast with our appreciation of religious acts, we readily recognize it as psychotic. Regularly encountered explanations for this difference include: i) religious acts are in fact themselves essentially psychotic, but because we’re attached or habituated to them we give them a special pleading they’ve not earned; ii) religious acts are necessarily participated in by many people, and are not just individual inventions, and it’s this which makes it incorrect to consider them psychotic; iii) what in a religious rite is treated metaphorically is here treated literally, and this is what makes it right to designate it psychotic. Yet if the understanding of psychosis and of psychological symbolism advanced in this chapter is right, we can begin to see our way to an alternative understanding of such acts.
To make clear the character of this understanding, let’s invent a plausible empirical setting for the Quittenbaum delusion. Thus let’s imagine that here we meet with an unhappily married woman who has become erotically attached to her caring pastor. She now finds herself in intolerable conflict - both because her desire is unrequited and because her conscience can’t condone it. Rather than being able to develop this predicament in clear thought, allowing both for a lucid articulation of the desire and for the acknowledgement of the impossibility of its fulfilment, Bleuler’s patient is instead overwhelmed and becomes psychotic. That’s to say, her thought is no longer rooted in and calibrated by reality, so she enters a ‘waking dream’ in which her thoughts no more belong properly either to imagination or to judgement but instead manifest a collapse of the two into each other. Her concrete equation of the quince branches and her sins is not a matter of her treating literally what a non-psychotic rite participant would treat as metaphor. What has instead happened is that she has psychologically symbolized her predicament, i.e. given it a non-mentalistic verbal elaboration, whilst in a psychotic state. Her acts cannot be seen by her as play, art or ritual, nor can either she or we clearly approach her thought and experience using the categories of the literal or the metaphorical, for her state of mind is such as to make such distinctions void.
Or consider this:
Another schizophrenic in an advanced stage of her illness, passed the time making hats for herself. She had made 16 of them. One day, she lost two of them. As a form of retaliation against this she decided to break two of her mother’s 16 cups.
Let’s again invent a backstory to psychologically fill out this brief clinical report. Imagine then that, when young, the patient’s mother suffered an insufficient degree of reliable nurture and emotional containment. She’s unable to mentalize this deprivation, but finds refuge in collecting symbolic substitutes for (what psychoanalysis calls) the ‘absent breast’. With these cups she can feed herself; they enable her to become self-satisfying; unlike the absent breast, they’re reassuringly within her control, hanging as they do on the dresser hooks. Nevertheless, her impoverishing early experience, and her self-involvement, in turn impair her capacity to provide adequate emotional containment to her daughter. To tolerate her own exclusion from the domain of care symbolized by the mother’s relationship with her precious cups, the daughter in turn creates her own substitute ‘breast’ – i.e. she knits herself a hat for each of her mother’s 16 cups. With these hats for comfort, she can avoid becoming angry at her mother’s emotional neglect. Losing two of them, however, threatens the fragile emotional balance they provide. She can mentalize none of the emotional meaning, but her painful loss is nevertheless mitigated by breaking two of her mother’s cups: this breakage perfectly demonstrates what we might call the ‘logic’ of delusional symbolization.
There’s no such thing as our developing here a rational (or what Jaspers called ‘empathic’) understanding of the patient’s breaking of her mother’s cups, since this poor patient is not engaged in a rational act. She might say ‘I broke them because I lost two of my hats’ - yet this, qua reason, makes no sense. Minkowski - the author of this report - articulates her vandalism as something done ‘in retaliation for’ the loss, and it’s this which reveals for us the delusional quality of the act. For if something’s properly said to be ‘done in retaliation’, that which is suffered must be understood by the revenging party to be something done to her by the one on whom revenge is taken. It’s by bringing the breakage under the description of ‘revenge’ whilst not providing any such understanding for us that Minkowski helps us appreciate the short-circuiting, delusional, character of that which here confronts us. Yet whilst we can’t enter empathically into this act qua rational act – i.e. whilst we’ve no idea how to make ‘because I lost two of my hats’ into a genuine reason for breaking two of one’s mother’s cups – we can nevertheless psychologically grasp the act’s motivated character: the act functions to restore mental equilibrium.
Near the beginning of this chapter we met three patients, the first of whom was Elena who hallucinates and delusionally believes that her father, ‘all black and completely nude’, frequently comes to her bed thrusting ‘a spear into her lower abdomen and dancing about in a very peculiar fashion’. This, Bleuler tells us, is the same father who does in fact frequently abuse her sexually. At the start of her psychosis she hallucinates her mother complaining about her to her father. When she speaks of his abuse her tone is embarrassed and objective, but when she articulates her hallucination and delusion she wears a ‘completely erotic expression’. This all provides a clue to the nature of what would have been more comprehensively repressed had her mind not been so damaged by her abusive upbringing and illness. Her natural heterosexual desires, that is, are awakened by her father, but since she is, like many a healthy teenager, still too sunk into the predicament of the inevitability yet impermissibility of oedipal desires, they can’t take a straightforward mentalized form. They instead take a symbolic shape, but do so when she’s in a state of waking dream, with the result that she neither straightforwardly believes, nor wishfully imagines, but instead delusionally believes, that her naked black father thrusts his spear into her abdomen.
Following Elena we met Ms R whose father was oppressive in his expectations, obtuse about his daughter’s difficulties, and utterly unrealistic about her ability to find or cope with a job or marriage. Like Elena, Ms R is too sunk into her predicament and so can’t develop fully mentalized feelings – at first about her father’s impossible expectations, and later about the ward staff’s equally unhelpful expectations of her progress. The feelings therefore remain merely potential or ‘unconscious’ – ‘trapped’, as it were, within the very structure of her relationships rather than condensing out into discrete sufferable experiences. And like Elena, Ms R – due to whatever predisposition she carries, along with the unbearableness of the home situation – becomes psychotic. Nevertheless the general drive toward psychological symbolization still remains in her, and because she’s lost touch with reality it now naturally manifests in delusion: ‘a large man is sitting on top of my head’. In someone who had not lost reality contact this thought would naturally be seen as a metaphor, one more naturally expressed in the form of a simile: ‘It is for me as if a large man were sitting on my head’. Yet, at least in the ambit of her waking dream, the metaphorical/literal distinction no longer finds instantiation in Ms R’s mind – and so to treat her expression as metaphorical would be to commit the pre/trans fallacy. Luckily for Ms R, a psychotherapist sensitive to the meanings of psychological symbolization is able to help the ward staff understand that this large man ‘is’ her father. Which ‘is’ is to say: her delusional expression is a psychological symbolization of the stifling predicament she is in, a predicament which, were she able to extricate herself from it for a moment so as to bring it into view, would naturally be expressed in such terms as ‘my father is oppressing me’. The ward staff can now take a mentalising attitude toward Ms R, one which conveys an accepting understanding of her experience, which refrains from repeating the oppression, and which, in making clear that such experiences can be discussed, allows Ms R to begin to mentalize her own suffering.
After Ms R we encountered Jonas, the ‘masturbating hebephrenic, who … finds a high peak in a mountain range so shocking that he gets into a fight with his companion and has to return home.’ The analogy, writes Bleuler, ‘can hardly be called pathological. But what is … pathological is [Jonas’] interpretation of the analogy in the sense of the real sexual organ and the correspondingly violent reaction.’ Such examples abound in the literature, and testify to the impact of an unintegrated sexuality and unsatisfactory sexual life on psychopathology.
Jonas, let’s imagine, struggles both to integrate his sexual desires and to tolerate the shame and frustration of their unfulfilment. He is shy, unconfident, awkward, and doesn’t know how to go about finding and attracting a sexual partner. Such a predicament is, after all, not humanly unknown, perhaps especially amongst those at risk of developing mental illness. For Jonas, we hypothesize, the predicament is simply too much to bear. He is lost in it; it courses through him, determining his actions – rather than being something he can pull into view or get a handle on. He can only move dynamically in the world – go walking in the Alps with a companion, say – by rigidly defending against his sexual fears and frustrations. At times mere repression and distraction serve the purpose, but at other times the affective load of his predicament is too great: now he simultaneously dissociates and loses his footing in reality. Yet now that he’s slipped into a delusional mode, the frustrating situation can at least take some kind of expressive form: a mountain peak offers an opportunity for Jonas to develop outrage. Unbearable inner turmoil now takes an outward shape; relief is thereby obtained; ersatz sense is made. Such outrage is however impossible to empathically grasp in the terms in which it expresses itself. We could make something of it were it not a mountain peak but an exposed sexual characteristic that was under discussion. We could make something of it too if Jonas were using a metaphor to articulate himself. In the absence of these, however, empathic intelligibility in Jaspers’s sense is unavailable. We don’t come to understand Jonas in his predicament and in his delusion by grasping his speaker’s meaning, since his outraged expression conveys none. Instead we come to understand him by grasping psychologically how the breakdown of such meaning bespeaks the diremptive power of such complexes as are betrayed by his delusional symbolization.
Before concluding the discussion it’s important that we consider the
dangers for the patient of openly translating their psychological
symbolization to them. This chapter began with mention of Angela who, you
will recall, told me, at the end of the 20th century, that she had just
been released from Belsen (which was liberated in 1945). Interpreting her
as using a metaphor (for being discharged from the psychiatric hospital,
as indeed she had been) provoked in her a reaction of bafflement and
disturbance. This already shows how caution is required when interpreting
symbolically freighted psychopathology in the absence of a containing
therapeutic relationship. The patient needs to be treated with (moral)
understanding even when her discourse is (rationally) ununderstandable –
yet it can be deeply undoing to receive the kind of (psychological)
understanding which renders them defence-less. Showing psychological
understanding is often lauded, and indeed is essential for any
psychotherapy that not only helps a patient through his psychosis but also
helps him work through his underlying complexes and ameliorate his
underlying vulnerability. Even so, and especially for the patient whose
psychosis is itself a flight from intolerable shame, knowing oneself to be
psychologically understood can be a fearful business. To return once again
to Schopenhauer: if ‘such painful knowledge or reflection is so harrowing
that it becomes positively unbearable, and the individual would succumb to
it, then nature, alarmed in this way, seizes upon madness as the last
means of saving life.’ Carelessly undoing this can then constitute an
assault on life itself.In this chapter we also met both the notable psychiatrist Frieda Fromm-Reichmann and her patient Joanne Greenberg whom she treated for four years at Chestnut Lodge. In Greenberg’s words now: “People would tell you what perceptive things a patient had said. The thing is I want to choose my perceptions. I don’t want them to come out of some kind of unconscious soup. I want it to be something I choose to say, not something that says me.” She adds here too how being understood in that state can feel horrifically dangerous. Whilst Fromm-Reichmann’s instruction that “you must take me with you” was welcome to her, it felt “horrifically dangerous” to be understood thus. ‘I don’t know how Frieda got around that. I remember the danger. . . . It’s bigger than you are. It’s more powerful. It can kill.’
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