REFLECTIONS
George E. Atwood, Ph.D.
What follows are some reflections on my experiences as a psychotherapist, and also on the personal philosophy to which these experiences have led. The material is organized into a series of thought trains centering around my work in the area of severe psychological disturbances.
1. Studying madness
As a young man, having just discovered the world of psychoanalysis, it occurred to me that the study of very severe psychological disturbances might lead to an understanding of the foundational constituents of human nature. Nothing could be more interesting, I thought, than to search for a new and deeper knowledge of the human condition as a psychotherapist. I have had the good fortune to pursue this quest for half a century.
One may ask the question: what really is madness? Here is how I would sum it up. Madness is not an illness or disease, it is not a condition existing somehow inside a person, and it is not a thing of any kind having objective existence. Madness is an experience a person may have, one involving in its essential core a fall into nonbeing. Madness is the dissolution of all order and a descent into chaos. It is the greatest catastrophe of subjectivity that can happen to a person. The felt reality of the world disintegrates and the enduring solidity and integrity of one’s sense of selfhood – the ongoing experience of ‘I am’ – becomes tenuous, unstable, and even vanishes. Madness is the abyss and there is nothing more frightening, not even death.
Our minds can generate meanings and images of our deaths: we can picture the world surviving us, and we can identify with those that come later or otherwise try to immortalize ourselves through our works. We can rage against the dying of the light, and we can look forward to reunions with lost loved ones in the afterworld. We can think about the meaninglessness of human existence and its finitude. We can be relieved that all our sorrows will soon be over. We can even admire ourselves for being the only creatures in existence, as far as we know, who perceive their own wretched destiny to be extinguished. The abyss of madness offers no such possibilities: it is the end of all possible responses and meanings, the erasure of a world in which there is anything coherent to respond to, the melting away of anyone to engage in a response. It is much more scary than death, and this is proven by the fact that people in annihilation fear – the terror of madness – so often commit suicide rather than allow themselves to be engulfed by it.
In working with madness as a psychotherapist, one draws close to a realm in which there are no orienting landmarks, no coherent purposes and desires that point to a meaningful future, no organized recollections establishing a continuous past. The ordering structures of existence itself collapse, all sense of personal identity becomes erased, and one may fear being pulled out of one’s sanity and into the nothingness. This is the terror of madness, and it affects all those who come into its vicinity.
How can we, as explorers of the human soul, enter this dark territory? I think we need a map of that chaos, a picture of the variations we will encounter, and some general guidelines as to how we might respond to the disastrous human situations that are encountered. Also needed are protections from how we are ourselves perceived. A terrible toll may be taken on the clinician who may be viewed as a persecutor, as a god, or even as a persecuting god. An even greater injury may be inflicted on the patient, someone already in the deepest trouble who now faces being seen as insane.
Psychotherapy is a world within the world, one in which patient and therapist gaze into each other’s eyes and see themselves reflected in ways that may clash profoundly with what they feel is true or most deeply need. The mismatching of such images leads to all manner of difficulties for both parties, often spiraling into chronic impasses and the loss of the possibility of a healing connection.
How can we as therapists be shielded against the terror of being drawn into the madness and against the potential violence to ourselves of the interplay with those who are lost in chaos? What protections can there be that will not operate as well at the expense of the patient? The key lies in one thing only: the power of human understanding. We must understand annihilation states and all the signs and symptoms expressing a person’s struggle with such experiences. We must know the symbols typically used to represent these states of mind, images that are often concretized or reified, i.e., treated as tangible, substantial realities. We must use our understanding then to discover responses to our patients’ crises that will help them refind a personal center and feel included again in the human community. This is the work of clinical psychotherapy research, a field now on the threshold of a new age as the older ideas about objectified “mental illnesses” recede and a new emphasis on phenomenology arises.
Let me offer a thought on systems of psychiatric diagnosis, which everyone who enters our field encounters. Sometimes these systems turn into dragons that consume the minds of those who use them. There is nothing wrong with careful studies of the symptoms and signs of psychological disturbances, and with efforts to classify the richly varied phenomena one sees in this realm of study. Ordering principles need to be applied, so that we are not just left adrift in a sea of confusion. A problem arises however when the classifications we impose on the variations that are observed become reified and objectified, turned into mental diseases imagined as existing somehow inside the people we seek to understand. Our patients in extreme distress reify their fantasies, generally in order to substantiate personal realities that have come under assault and are threatened with dissolution. We in parallel often reify our diagnostic concepts, ascribing the chaotic manifestations confronting us to a disease process inside the patient. Such a locating of the problem in the internal, not grounded in any actual scientific knowledge, basically takes the clinician off the hook. He or she is not implicated in what is seen; instead the clinician sits high and dry, observing and classifying from a position of serene detachment, wrapped in a cordon sanitaire. This shields us from feeling responsible for how we are experienced and utterly neutralizes the power of the patient’s attributions to attack or displace our own ways of defining ourselves. The problem is that the clinician is implicated: what people show us depends in part on how we are responding to them. Human experience is always embedded in a relational context. If that response organizes itself around an objectifying psychiatric diagnosis, one can expect to see reactions to the distancing and invalidation that is involved. If those very reactions are then ascribed again to the supposed mental illness, the distancing is deepened and the disjunction rigidifies. It is important to learn about diagnostic systems, but we must not let them become our commanding, reifying viewpoints. One should be guided instead by attention to the patients’ experiences and by reflections on one’s own. We are still at the beginning of exploring this strange and complicated country.
2. Secrets of the mind
In my youthful enthusiasm long ago, I imagined that a careful analysis of the fragments into which psychiatric patients disintegrate might disclose the basic elements of human nature. Although I have tried to follow through on this quest, I cannot say that I have succeeded in any literal sense. There is however one central discovery that has occurred as a result of this journey: myself. Amidst the shattered hearts, the broken minds, the annihilations, it is as if the pattern of my own life was somehow inscribed. Exploring the souls of my patients therefore has led me again and again to the depths and origins of my own lifeworld. Could it be that the study of madness presents us all with opportunities to discover who we actually are? Could it also be that the effort to assist those who come to us presents us a chance to heal our own wounds as well?
I shall tell about one of my own early experiences in this connection. My first seriously challenging patient, a young woman I met decades ago, believed with all her heart that she was a part of the Holy Trinity and that she was one with God. Her story is given in the first chapter of my book, The Abyss of Madness (2011). She and I, over the tumultuous course of our early relationship, came to an understanding of her situation as centrally relating to a catastrophe that had occurred in her childhood: the sudden suicide of her beloved father. I saw how the tragic loss had bisected her youth into before and after, into father and no father. As our shared journey continued and her healing began, I became witness to a gradual smoothing out of the traumatic bifurcation with the emergence of feelings of furious rage, of heartbreaking sorrow, of annihilating invalidation. At some point along the way – I cannot say precisely when – it dawned on me that in looking at her life I was also seeing an image of my own. You see, my childhood also was divided into a before and an after, the separation caused by the sudden death of my mother when I was a young boy. In coming to the tragedy that had disastrously affected my patient’s development, I had been returned to the tragedy of my own. In witnessing her slow healing and recovery, in turn, my own healing – continuing down to the present day – had a chance to begin. The great German philosopher-historian Wilhelm Dilthey (1926) famously proclaimed that in the study of persons in the so-called human sciences, all understanding is a matter of “the rediscovery of the I in the Thou.” It follows from this elegant idea, to my mind anyway, that in the discovery of the Thou, we find a mirror in which our own souls are made visible.
Here are some additional thoughts that come forward as I think about the goal of finding out the secrets of human nature from the study of madness. I shall introduce them by describing the adventures of a young man I knew many years ago. He came to me just before a long psychiatric hospitalization. He said he had discovered the secret, not of human nature, but of the universe as a whole: the key to all of creation. I asked him to tell me about this amazing secret. He said it was revealed to him in a vision in which he saw the interrelatedness of all things. The vision encompassed the whole of the cosmos in a single image, abolishing all separateness and isolation in an overpowering, radiant unity. He had discovered the heart and soul of existence itself, and repeatedly shouted the secret out: “ALL IS ONE, ALL IS ONE, ALL IS ONE!”
I was curious about the personal context of this unifying vision. His life story was a sad one, involving a world in which the center failed to hold. He had been a golden child, a precocious genius who from an early age had shown stunning abilities in both science and the arts. His parents considered him to be a gift from God, filling their otherwise rather empty lives with a transcendent meaning. Complying with their expectations, the boy grew up with A-plus achievements in every endeavor, and the parents believed they had brought a great man into the world. The breakdown occurred on the eve of his graduation from college, a summa cum laude on the threshold of glorious success in life. One little problem tripped him up: a girlfriend he had become very attached to decided to end their relationship. His love for her, such as it was, expressed a part of him that contained, tenuously, his personal truth. Being a stellar achiever had always come easy and fit perfectly into his parents’ needs. Losing the girlfriend was different; it was a disaster beyond imagining for a boy who had so little he could call truly his own. It was the end of a life that had scarcely begun. Unspeakable agonies followed the loss, a suffering beyond all comprehension in which everything that had seemed together was now torn asunder.
This was when the vision of cosmic oneness supervened. Every atom and subatomic particle, and every galaxy supercluster came together before him, in a vast network of interdependent relations. It was a breathtakingly beautiful tapestry encompassing the totality of all existing things. People in this young man’s social world – family, friends, college teachers – thought he had gone crazy and the decision was made to hospitalize him. What he was doing, however, was putting the world back together again, reconnecting all that had fallen apart.
I came to the idea that his vision was utterly, profoundly a true one. He had indeed encountered a secret of the universe, one that has been thoroughly hidden from us in this age of atomism. We think of our own lives as a matter of isolated minds existing alongside each other, little separate unit-selves dropped into the world out of their mothers’ wombs. We imagine our minds as having interiors, filled with all manner of mental contents (thoughts, desires, memories, etc.), but subsisting somehow separately from a surrounding external environment. The estrangement between internal and external is paralleled by a dualism between our bodies and our minds. The universe itself, in turn, we visualize as a vast space populated by all things great and small, some of them causally interacting with one another but each of them having its own separate and solitary existence. We are hypnotized by this alienating and fragmenting atomism, regarding it as just the way things are rather than as the ontology that it is. My young man, propelled by a catastrophic experience of the disintegration of the world, broke through the trance of this philosophy to a sudden recognition of the unity of all beings. I found his thinking to be powerful, although at the time I met him he was unable to do much with it other than to cry and shout.
Working with those who dwell in the extreme range of psychological disorder presents us with dramatic signs of how our very selfhood and sense of the reality of the world are embedded in contexts shared with other human beings. One sees, for example, how the “symptoms” of so-called mental illness do not emanate from a wholly internal condition afflicting the isolated individual, but instead vary as a function of the response that person encounters from others. When responses felt as objectification and invalidation are supplanted by experiences of being understood and included in the community of others, striking shifts occur in delusions and hallucinations, and chronic annihilation states recede. C.G. Jung, the great psychiatrist, acknowledged this in his famous words: “Schizophrenics cease to be schizophrenic at the moment they feel understood” (Laing, 1959). We, as clinicians, are therefore involved in the psychological disturbances we are called upon to treat, and the wounds requiring healing in our patients are matched by the wounds we carry in our own hearts.
But there is more. The universe exists in such a way as to generate the possibility of our own coming into being, and a profound argument can be made that it is as it is in part because we are here to be aware of it. Human beings are implicated in the way in which the world becomes manifest, and at the same time the study of the cosmos is the universe becoming conscious of itself. The observer and the observed, in both the natural sciences and the human sciences, are inseparable from each other, and the constituents of reality, on smaller and smaller scales, turn out to be interdependent, entangled phenomena rather than fully separable units somehow subsisting in ontological solitude.
In other words, my young man was absolutely right. One might wonder what happened to him. It is sad. He was diagnosed on the basis of the grandiose euphoria he showed: manic-depressive illness was the Dx. The treatment provided to him included multiple hospitalizations, extensive electroconvulsive therapy, and an ever-varying succession of antipsychotic drugs. The last time I saw him, fifteen years into this so-called treatment, he was doing poorly – depressed, confused, unable to work, obese, and… no girlfriend. I wonder what the outcome might have been if someone instead had been able to sit down with him – for a day, or a year, or a decade – and discuss what it meant that all is one. Is it not possible that good things might have emerged from such conversations?
A final thought regarding the story I have been telling: how is it that this young man, in captivity to his parents but also in a struggle to render a shattered universe whole, was a mirror in which I could find a reflection of myself? When I was a young college student, I made a discovery of my own that was very similar. In the context of an exposure to Zen Buddhism, it came to me that all dualism is false: every one of the great contrasts in our culture’s history and philosophy – internal/external, matter/spirit, masculine/ feminine, good/evil, freedom/determinism, I/You – were illusory, and our belief in them was a trance from which we needed to awaken. Looking back, I see the philosophy of monistic adualism I then adopted as importantly related to the shattering trauma of my mother’s death. I also see it as a precursor to the unifying theories and philosophical ideas in which I have come to believe.
3. Joy and suffering
The intensive psychotherapy of severe mental illness, so-called, offers two intertwining opportunities. On the one hand, one has a chance to give help to a fellow human being who is in trouble, perhaps the deepest psychological trouble that there is; on the other hand, one encounters phenomena that are at the far extreme of human experience, showing fundamental issues of all our lives with extravagant clarity and drama. This is the heart and soul of psychoanalysis, ever since it first appeared in the thinking of Sigmund Freud. Psychoanalysis is and always has been an approach to the healing of the wounded soul, and also an exploring of the depths of human existence and human nature. At the age of 17, I saw these twin pathways of the psychoanalytic enterprise, and I could not hold back from making a total commitment to the work. Is there anything that could possibly be as interesting or important? There are great rewards to be found in working clinically in the realm of madness, but often enough there can also be great suffering. To engage with people in the extremes of psychological disorder is to cast oneself into the chaos – it means to embark upon a journey without an outcome that is certain, often with harrowing developments along the way, always requiring a commitment that is absolute. Sometimes this journey eventuates in a healing and a thriving; in other instances all our efforts may fail and we are consigned then to bear witness to someone’s devastation. Therein lies the suffering, in the knowledge that nothing is assured and that catastrophe is always at hand. On the other side, our commitment, being absolute, means there also is hope for healing and recovery, and there is something utterly wonderful about pursuing this hope with nothing held back. If things do not work out, and perhaps there is a suicide or some other incontrovertible disaster, we die a thousand deaths. If on the other hand a better way is found, the Phoenix rises from the ashes, and one then has the sense of having participated in the sacred.
During my college years I had a professor who repeatedly warned his students away from pursuing individual psychotherapy as a career. “How many people can you hope to help in a lifetime,” he asked, “twenty-five or thirty as a maximum, right?” It was his idea that our field should devote itself to the prevention of psychological disorders, through various social engineering programs based on behaviorist principles of reinforcement. I found his thoughts bleak and very depressing, because he was attacking the dream that brought me into psychology in the first place. I was too young to be able to offer much of a coherent response, but I knew I disliked what he was saying intensely. I now think that individual psychotherapy is itself the single most powerful preventive measure one could possibly find, because it has become apparent to me that giving help to one person can save the whole world. Psychological disorders arise out of personal histories of traumatic experience, histories that are in turn embedded in complex intergenerational cycles. Traumas that remain unprocessed, that perhaps are not even recognized as having happened, are inevitably passed on to the next generation, and the next; and so it goes, as chains of historical causation reach across the years and even the decades and the centuries.
Consider the potential then that lies within even a single instance of individual psychotherapy that works out well, as the incomparable power of human understanding is brought to bear on a life that otherwise might have unfolded as just another destructive link in the historical sequence. The chain is broken, and rather than darkness being delivered down upon one’s descendants, an illumination is bequeathed as the effects of the healing are transmitted instead. What my teacher failed to take into account is that healing is contagious, radiating into the human surround and having repercussions that flow indefinitely into the future. How limited he was! And yet, we could ask what were his traumas, and why did he imagine he could fix them by his vast program of behaviorist engineering? As I meditate upon these questions, a picture of his unacknowledged despair comes into view. Behaviorism was like that: an intellectual movement turning toward the purely physical but predicated ultimately on the loss of hope for human connection. There is also the intellectual joy that comes with understanding a life. I will give a single example. This is about the famous actress, Patty Duke, a person whose experiences interested me some years ago. Picture the following: as a young woman she set off on a mission to rescue America from foreign influences, which she believed had infiltrated the highest offices of our government. A disastrous effort to travel to the White House in Washington DC and personally eject the imaginary foreign agents was followed up by a devastating depression. In studying Duke’s delusional mission and its background in her life history, I discovered that her earliest years were ones of enslavement to the entertainment industry: her parents essentially surrendered her to television agents who made her a nationally acclaimed star, but at the price of a stolen childhood. It seemed apparent that the intruders in the White House were symbols of the controlling agendas of the public entertainment world. An autobiography was eventually written, describing her development and her breakdowns (A Brilliant Madness, Duke & Hochman, 1992). This record of the journey of her soul, however, had a peculiar feature: half of the chapters, interposed between those that she herself authored, were written by a science journalist representing medical psychiatry and chronicle her evolution as a victim of a biologically based mental disease (so-called manic-depressive illness). Her account thus oscillates between two positions: one being that of telling her story as she experienced it and in her own words, and the other involving a surrender to medical authority. The chapters written embodying the psychiatric viewpoint were like the invaders in the White House, whereas in her own chapters her soul shines forth in freedom – or tries to. The early history of her life being taken over by the agendas of others, the delusion about foreign infiltrators inserting themselves into our country’s self-government, and the strange structure of the autobiography thus display a repeating thematic pattern, centering around a heartbreaking, often losing battle to establish the integrity and inviolability of her own unique selfhood. The disparate elements here interrelate and form a tapestry that is beautiful, in its sad order and symmetry.
Human lives are like that: they display an invariant thematic structure, once apprehended in sufficient depth. I am not saying all our worlds are organized around a battle for self-integrity, as in the story of Patty Duke; I am saying that our individual life histories leave unique signatures on our personal universes. My life exhibits such patterns, and so does everyone’s. A sense of intense and sometimes thrilling satisfaction accompanies the recognition of these unifying themes, in oneself and in others, as initially disparate elements become woven together and apparent chaos gives way to crystallizing order. There is joy in the unveiling of such things. In extending the ideas on which these analyses draw to the larger field of human existence as a whole, we recognize that the themes of the individual lives we encounter belong to a network of possibilities shared by us all.
4. The future of our field
Our time is one of immense change and loss. We are witness to the progressive falling away of traditional answers to the question of the ultimate, as the solid foundations that once gave our lives meaning disappear in a whirlwind of available facts and diverse contexts and perspectives. Our time is also though one of great possibility. As the strictures of reassuring faith have dissolved, we have been cast into an open space, one that can only be filled in by our own creativity. Anxiety and uncertainty are inevitable companions in this journey, but so is the joy of anticipating what is to come. I want to imagine an emerging worldview that has been preparing itself for more than one hundred years, and that is already having important consequences for our field. Three features seem to me salient in this new way of interpreting the meaning of human existence: Interdependence, Self-reflection, and Responsibility.
1. A person is of his or her world, natural and social. The world that we experience is part of our very being, making us who and what we are. That constitutive world, at the same time, is what we make of it. A new mindset of radical interdependence is appearing, within which these statements do not stand in contradiction to each other.
2. Reflective awareness of the many contexts that shape our lives has in our time become pervasive, meaning that we are aware that all our beliefs and values - philosophical, religious, political, scientific – are embedded in our personal existence. One might say that the age of absolutes standing outside the circle of reflection is over. The yearning for ultimate answers and eternal foundations, however, seems likely to be a part of who we are forever.
3. Recognizing that all human beings are siblings in the same darkness (Stolorow, 2011), we are at last embracing the idea that we are our brothers’ and sisters’ keepers. We have also taken up the task of being guardians of the Earth and all its living creatures. I foresee a world in which these responsibilities are considered sacred. One might wonder how I can be so sanguine, in an age of terrorism and fanaticism. I regard these things as the death throes of religious ideologies that are giving way to a new humanism.
The theme of interdependence leads to a reconceptualization of what it means to be an individual person. One might say: there is no such thing as a person. I am obviously not claiming that people don’t exist; it is rather that their existence is not one of being an isolated object, subsisting in a state of ontological separateness and solitude. The new worldview opens us to seeing our irreducible relatedness to our worlds and to others. This changes everything in how one understands so-called psychopathology. I will illustrate what I am saying with a clinical story.
A woman, 24 years old, was brought to a hospital by her father and mother after she had been arrested for trying to break into a well-known country musician’s home. I happened to be on the clinical staff and so met this young person. She was mute, and scarcely moving. The word “catatonia” was used by two of our psychiatrists, engaging in diagnostic deliberations at the time, but I have never thought much of such labels. I sat quietly by her side on a daily basis in the first weeks of my work with her, hoping she would eventually begin to speak to me. Finally she did, telling of a secret world in which she had lived for several years. This world was ruled by a famous country music star, and contained a number of other figures who regularly talked to her in the mornings and in the nights. They were like the chorus in a Greek tragedy. A love affair had developed between her and the star, conducted via telepathy, and she had been able for a long time to function in her world (she had been a part-time student in college) while dwelling much of the time in the secret realm.
Disaster came when she finally made an effort to have physical contact with her lover. The police had arrested her when she went to his actual home. The voices of the chorus, originally loving and sweet, had in the meantime turned increasingly critical and aggressive. Such idealized delusional companions often turn into persecutors, and the imaginary realm that has been found then becomes an unbearable hell. This patient was very similar to Joanne Greenberg, who wrote a classic work in the literature of madness: I Never Promised You a Rose Garden (1964). Joanne also inhabited a secret world, initially a place of magic and love but then that turned dark and monstrous.
Traditional psychiatric thinking would understand this story as involving a dreadful mental illness that erupted in this woman’s young life, an illness it calls schizophrenia. This was the diagnosis she was given during the period of her hospitalization. When looked upon within the new worldview, however, the symptoms of this so-called illness are no longer seen as emanating solely from a pathological condition somehow existing inside of her; instead, they are understood as having meaning within complex relational and historical contexts, as significantly relative to what had happened and was still happening in her social world.
Her emotional history, as I came to understand it in the long course of our contacts, centered around a theme of abiding loneliness. This context, unseen as such by members of her family of origin, was one in which she had accommodated herself to parental expectations and needs, becoming a child fulfilling their dreams through stellar academic achievements. The parents’ marriage had at the same time been a bloody chaos of tension and hostility: repeatedly, the mother and the father had fought physically and threatened to abandon each other. She had tried, with all her might, to be a shining manifestation of hope for familial cohesion, always sensitive to her mother and father, moving back and forth between them, forever striving to make them proud and happy.
The extremity of this young girl’s commitment to pleasing her parents and forestalling the disintegration of her family began at some point to lead to a division in her subjective life: on the one side were her harmonizing accommodations; on the other was an unarticulated and yet intensifying sense of hurt and of her own abandonment. There was no real recognition or validation of her pain by anyone, and therefore nowhere to go with her emerging suffering. This was the setting, following a series of separations and other changes in her living situation, in which she found her true love during her late teen years. Listening to his songs of loss and alienation, of broken hearts and searing loneliness, she saw her own experiences set to music: she had found a twin, a soul mate whose feelings precisely mirrored her own. Appearing recurrently in her dreams and reveries, his presence suddenly one day became utterly real and she immersed herself in their shared affection, magically expressed through mental telepathy. Catastrophe occurred when she finally tried to establish physical contact with him.
I worked closely with her for many years, helping her to find words for her deep feelings of isolation and loneliness, and helping her as well to resist the siren-call of her lover and the chorus of voices associated with him. That is what is needed in such cases: patience, devotion, and understanding. I don’t want to make it sound easy; it wasn’t. There were a great many back and forth movements with respect to the secret world, and there were dangerous suicide attempts in the first years of our contacts. I suffered greatly with how close she came to ending her life. But it eventually worked out well enough. She brought herself together in gradual stages and found new ways to connect with others, expressing in her life a wonderful creative spirit.
I have told this little story to illustrate what I think will become commonplace in our field within the worldview I have been talking about. This young woman’s psychological disturbance, her “schizophrenia,” is here seen as a set of reactions embedded in her life in her family, and related to her trauma history and to the absence in her background of validating recognition. Her illness was not, from this standpoint, a pathology afflicting her entirely from within; it was a personal disaster brought on by complex transactional patterns inhering in her relationships over time to all those who were important to her, both real and imagined.
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A great task facing us in the years ahead will be the thorough phenomenological redescription and reconceptualization of severe psychological disorders, and then a corresponding development of psychotherapeutic approaches embodying the new understandings that are attained. Great strides in this project have already occurred, and so we will not be starting from scratch. Among the many contributors on whose phenomenological and clinical contributions one can build, I would list: Jung, Tausk, Federn, Winnicott, Sullivan, Fromm-Reichman, Binswanger, Searles, Laing, Des Lauriers, Kohut, Karon, Stolorow, and Brandchaft.
Let me suggest some ideas that are more specific in regards to the most meaningful directions of our field in the coming decades. If I had another thirty years to live and to work, I might throw myself into the following sorts of things.
So-called schizophrenia
An influential book appeared in 1911: Eugen Bleuler’s Dementia Praecox or the Group of Schizophrenias. In addition to introducing the term “schizophrenia” to our world, this work attempted to describe and provide examples of widely differing forms of the most extreme psychological disturbances that exist. It is worth reading even today for its rich accounts of madness in its many variations, although the work does suffer from some serious limitations from our present vantagepoint. The clinical descriptions are framed within a broadly Cartesian, intrapsychic frame of reference, locating the disturbances being considered inside the patients who are then pictured in isolation from their worlds. The presentations, in addition, tend to be restricted to the patients’ symptomatology in the present moment, leaving out of account the complex histories and relational contexts in which their symptoms are embedded and have meaning. Finally, the book is written almost entirely from the perspective of the medical model, viewing psychological disturbances as disease processes occurring in the mind.
A very wonderful project, one that would require a great many years of devotion, would be the modern counterpart to Bleuler’s classic study. This would involve even more detailed descriptions and examples of madness in its many forms and variations, with the focus however always being on the subjective states that are involved. Such a phenomenological emphasis would then be accompanied by a life-historical perspective, from which the overt symptom-pictures are cast in relation to the personal backgrounds of the people concerned. There would only be one way to accomplish the immense task I am suggesting: the collaboration of a number of dedicated clinicians and thinkers. It would be required that there be long-term commitments to the patients being studied, so that the inquiry into their worlds have a grounding in deep explorations of history and also include the nature of the healing processes that can be achieved.
Bleuler proposed that the heart of what was known in his time as dementia praecox consisted in various splitting processes occurring in the mind: hence the term, schizo-phrenia. These included the disintegration of the logical associations of thought, the splitting of cognition from its associated affects, the dividing of positive and negative emotions, and the separating off of a private reality from contact with the externally real. My own view is that future phenomenological studies of patients in this range will show how these various features can be significantly understood as secondary to a sense of personal annihilation. This means that the primary disturbance would be seen in the shattering or even erasure of the experience of personal selfhood. Also central would be the dissolution of the sense of the realness of the world and the disintegration of all that we ordinarily experience as substantial and enduring. The most prominent visible symptoms of these disturbances, such as one sees in hallucinations and delusions, in this context appear as restitutive or reparative reactions, efforts to reunify all that has fallen apart and resolidify all that has melted away.
Another clinical story comes to mind that relates to the sort of understanding I am thinking of. Consider this brief account as standing for a hundred that I could provide. One of my patients from many years ago came to me after a long period in a psychiatric hospital. Twenty one years old at the time, she described herself as having always been in “pieces,” having separate and distinct “selves” that floated about in a strange space, without there being a common center. There was a sexual self, a religious self, a political self, a comical self, a professional self, and a social self. Each of these entities embodied an area of her interests and capabilities, but they were like islands suspended in the sea with no land bridges between them. It was interesting to me that a delusion haunting her during the many months of her hospitalization was a belief she was part of a world-revolution aiming to dissolve traditional nation-states and establish a universal government based on the power of all-embracing love. Out of her own personal fragmentation, it seemed, was arising a dream of world unity. She had been told by her doctors her diagnosis was that of schizophrenia, and, confused about what this meant, studied Bleuler’s derivation of the term from the Greek words for “split” and “mind.” She told me a better translation, still respecting the etymology but connecting more closely to her own familiar self-experience, would be: “torn soul.” I found her statement, obviously rooted in her feeling of being in pieces, to be one of the most astute things I have ever heard on this subject, and I told her so. We worked together for several decades and got along very well.
So-called bipolar disorder
In The Abyss of Madness, I made the claim that the most important frontier for present-day clinical psychoanalytic research is that of the psychotherapy of bipolar disorder, also known as manic-depressive illness. Of course these terms are medical-diagnostic designations, embedded in a Cartesian, objectifying worldview. How the patients so diagnosed will appear under a phenomenological lens remains to be seen, and what innovations in our approach to them will come forth are still to be defined.
A fabulous insight into the experiential core of a great many of the patients showing an oscillating pattern of mania and depression was given to us by Bernard Brandchaft. In his book Toward an Emancipatory Psychoanalysis (Brandchaft, Doctors, & Sorter, 2010), he saw a problem again involving a sense of personal annihilation, wherein the manic episode expresses a transitory liberation from annihilating ties to caregivers. The depression that ensues, in contrast, represents the reinstatement of those ties. A division has occurred between accommodative and individualizing trends in these patients’ personalities: on one side of this division, there is a compliant surrender to authority and the installation within the patient’s selfhood of others’ purposes and expectations; on the other side is a glorious overthrow of such captivity and the embrace of shining freedom. The magical emancipation, of course, cannot last, because there is nothing and no one to support it, and so it collapses into a dark despair. Here would be my questions for those who seek pathways of psychotherapy with such patients in the future. Can an experience be facilitated that establishes a new center, one in which compliance and rebellion are somehow integrated? Can the empathy of the clinician become a medium in which previously aborted developmental processes can be reinstated? Can a deep understanding of what is at stake for the patient finally make a constructive difference to his or her destiny in the continuing nightmare of bipolarity?
The great psychoanalyst, Frieda Fromm-Reichman, in 1954 published a now-classic clinical study: Its title was: “An intensive study of twelve cases of manic-depressive psychosis.” A generalization arising from this study was the notion that such patients were, in their families growing up, treated as extensions of their caregivers rather than as independent beings in their own rights. I would like to see a modern counterpart to this work, tracing carefully the subjective worlds and histories of bipolar patients and exploring the outer limits of our efficacy as therapists in arresting their destructive patterns and stabilizing their lives. The key to success in such a project will be in the new understanding flowing from Brandchaft’s insight, one highlighting the patients’ needs to find pathways of emancipation from enslaving accommodation that do not lead into the structureless chaos of the manic episode.
An amazing example of the twin-sides of bipolarity is given in another classic of the literature of madness: Kay Jamison’s An Unquiet Mind (1995). This author tells the story of her extended resistance as a young woman against her doctor on the issue of her taking mood-stabilizing drugs. Back and forth their arguments went, with her trying to defend her right to a life free of medical intrusions, and with her psychiatrist telling her she had a biologically-based mental illness that absolutely required medications in order for her to be able to function. Finally, with the greatest reluctance, Kay agreed to begin on a course of taking regular doses of lithium. However, when she went to the pharmacy to pick up her prescription, she suddenly was seized by a terrifying vision. She saw, in her mind’s eye, vast numbers of poisonous snakes approaching her vicinity and foresaw how these dangerous creatures would strike at her and all those she cared about, filling their bodies with lethal toxins. So she purchased, along with her lithium, all the snake-bite kits the pharmacy had available, hoping to use the kits to save herself and as many people as she could.
Here is my theory of what this delusion about snakes symbolized. The poison carried by these imagined creatures, about to be injected into Kay herself and the unsuspecting public, represented the diagnostic authority of her doctor, to which she was in the process of capitulating. The theme of at first fighting back willfully but then caving in and surrendering appears also in her early family life, which she describes as having been a battle against oppressive control. The side of this woman tending toward compliant surrender was accepting into her self-definition the medical attributions she had earlier resisted; the side of her wanting to protect her self-integrity from invasion and usurpation armed itself with antidotes to snake venom. There is a parallel between Kay’s desperate purchase of the life-saving snakebite kits and Patty Duke’s attempt to drive imagined foreign agents out of the White House. Remarkably, neither of these women appears to have had any awareness of such symbolic connections. So-called bipolar patients often seem to live in a world of utter concreteness, rendering subjective life strangely opaque.
Madness and Creative Genius
Another favorite subject of mine, one that I hope will be taken up in our field in coming years, pertains to creativity and its complex relationships to madness and trauma. It is my view that the events and circumstances of our lives that hurt us most deeply, sometimes that even take us into an experience of personal annihilation, are implicated as also being among the factors leading to great achievements of creative imagination.
I taught an advanced seminar at my college for a long time, a class in which each year we would select a person for study showing great creativity but also signs of madness. A generalization unexpectedly emerged from the long series of analyses that took place: in almost every case there was evidence of a profound, irreconcilable conflict in the personality of the creator, one that threatened to lead to fragmentation and madness but that seemed to be integrated by the acts of creation. The specific content of the division varied from instance to instance, but the presence of such a duality seemed not to. Four such divided geniuses are described and discussed in the final chapter of The Abyss of Madness: Soren Kierkegaard, Friedrich Nietzsche, Martin Heidegger, and Ludwig Wittgenstein.
I would be very interested in a much more inclusive exploring of major figures in art, philosophy, and science in order to see just how truly general this apparent pattern is. It would also be important to study carefully how it is that the creative activity brings the warring trends in the creator’s soul into a unity. I am thinking that a thorough understanding of such matters could lead to innovative psychotherapeutic approaches with people otherwise fated to lives of paralysis and despair. Would it not be a beautiful development in our field if ways could be found to transform delusions and hallucinations into works of art?
I shall offer a single instance of the analyses conducted in my college seminar, that of the great German poet Rainer Maria Rilke. Rilke’s writings abound with a concern with spirits and ghosts. He was himself inhabited by the soul of a sister who died, a short period before he was born. His mother, broken-hearted by her loss, raised her son to be the dead child’s reincarnation. Consider his name, as it was given to him by his mother: Rene Karl Wilhelm Josef Maria Rilke. The name “Rainer,” which one normally associates with him, does not appear in this sequence. It is a masculinization of “Rene,” originally given as his first name. He changed it under the influence of his muse and lover, Lou Andreas Salome.
Rilke’s given names form a sequence of male designations bounded at the beginning and the end by female ones. His mother, having lost her daughter, enclosed his name, and his soul, in a vision of a resurrected female. She dressed him in girl’s clothes, encouraged his playing with dolls, and interpreted his early interests in drawing and watercolors as essentially feminine preoccupations. Born a boy, he was raised from birth to be a girl.
The soul of the dead sister took up residence inside the young boy. Although the female spirit never became the whole of him, she did alternate in his experience with the male child he also became. Sometimes her presence was felt as a mystical mask he would put on; the problem arose when this mask began to melt into his face and displace his identity as a boy. Or was it the girl he was raised to be whose identity was displaced by the mask of a boy? At other times, the alien spirit erupted from within, draining away all vitality and pursuing its own independent agendas (Rilke, 1910). This spirit might have been, again, the girl emerging from within the boy, or the boy erupting from the depths of the girl his mother saw him as being. With Rilke, it is always both/and, and never either/or. The key to the genius of his poetry lies in his ability to embrace both sides of his androgenous nature, and this ability also shielded him from madness.
In the journey of the creator, there is almost always a division within the soul, one that – left unaddressed – carries the possibility of madness within its depths. The act of creation provides a pathway in which the division can be transcended and unified, and is a protection against psychological destruction. There are countless examples one can find in the life histories of artists, philosophers, and scientists. The need to bring together that which has been torn asunder establishes an everlasting tension, one that leads to a spiraling of creativity. This is a theme one could spend a lifetime studying.
5. The lost childhood of the therapist
There is a traumatic condition that has developed early in the lives of almost every psychotherapist I have known, or at least in the lives of those who become committed to working with very serious disorders. I will call this the situation of the lost childhood. There are two basic pathways along which it seems to occur.
The first and most frequent story is one in which a child is enlisted at a young age to support and sustain a depressed or otherwise emotionally troubled parent. I am speaking here of something extreme, wherein a reversal of roles takes place and the parent comes to depend on the child rather than the other way about. The identity of the son or daughter then crystallizes around making nurturing provisions, the activity of caregiving being the only way open to maintaining bonds of secure connection in the family. There has generally been an emotional void in the parent’s own background, and the child is then given the task of filling it. A compromise of the child’s autonomy and authenticity occurs as the little “psychotherapist” materializes, a slave to the needs of the mother and/or father. Impulses to disengage and pursue a separate life in this context are felt by the parent as unbearable injuries, always producing reactions of great distress and sometimes of rage. When the child tries in some way to be a person in his or her own right, the parental response may be: “Why are you killing me?” This is a pathway closely resembling the one described by Alice Miller in her very fine book, The Drama of the Gifted Child (1982). The “gift” to which she was referring here is the natural sensitivity and empathy of certain children that lead a wounded parent to draw them into this role. Miller’s original title for her book was Prisoners of Childhood, a very apt description of the imprisoning effect of such an upbringing, which includes the dissociation of important sectors of the child’s personality as the child is not allowed to become the person he or she might otherwise have been. The most natural thing in the world for such an individual, later grown up, is to seek out a career in counseling and psychotherapy. Their training for the work has been occurring from an early age. Thus is generated what I call a Type 1 Clinician, one seen especially frequently in the field of psychoanalysis.
The second situation leading to this career is based not on serving the needs of a troubled parent, but rather on an experience of traumatic loss. Here too there is an imprisonment that takes place, and a resultant lost childhood that compromises the full development of the individual’s own unique personality.
The story runs as follows. A fundamentally loving relationship with one or both parents is in place in early life, a bond within which the emerging identity of the developing child is supported and the stability of family life is felt to be secure. An irrevocable change then occurs, something making it seem that formerly secure ties are lost, leaving the child bereft. A parent may grow ill and die, vanish for reasons unknown, be perceived as having disappointed or betrayed the child unforgivably, or undergo an emotional breakdown from which there is no recovery. The early world, now missing, becomes idealized in memory, contrasting sharply and painfully with the desolation that has taken its place. The longing for the parent who has inexplicably changed or disappeared intensifies and becomes unbearable. The loss of the mother or father at this point is restituted by an identification process, one in which the child becomes the one who has gone missing. A transformation of personal identity has thus taken place, in which the loving, rescuing qualities of the longed-for parental figure now reappear as aspects of the child’s own selfhood. By the magical act of turning oneself into the absent beloved one, the trauma of loss is undone and the shattered, chaotic world is set right. In this way a loving parental attitude is installed within the child’s personality, and his or her subsequent relationships in every sphere of life come to be dominated by a theme of caregiving. Any breakdown of the identification with the idealized figure leads to a resurgence of the chaos and pain of the original loss.
This too can eventuate in a most terrible captivity, for the trajectory of the child’s own development here has been interrupted and frozen by the need to stand in for the parent who has been lost. Who that child might have been or wanted to become as a distinctive person is thereby sidelined as the identification solidifies. One can appreciate how easy it would be for such a person to fall into a career as a psychotherapist. This is the situation of a Type 2 Clinician.
There would also be mixed cases, in which the early developmental history of the psychotherapist included both kinds of experiences, traumatic emotional exploitation by a disturbed parent and traumatic loss. I am myself an example of the second type, with the central loss being that of my mother when I was a boy. The great theorist D. W. Winnicott, if I have understood him correctly, was a clinician of the first type, affected most importantly by a mother who suffered from severe depressions. Obviously there may be other pathways to choosing a life of service to the emotionally disturbed, but almost all of the clinicians I have known fall into one or both of my categories. My friend and colleague, Robert Stolorow, on hearing about these ideas, suggested that he is himself “a mild case of Type 1.” At first, I agreed with this notion, although I wasn’t so sure about the supposed mildness. On further reflection I came to think he is a mixed case, with an early pattern of caregiving to wounded parents intertwined with issues of emotional desertion and loss that were magnified by devastating tragedy in his adult years (see Atwood & Stolorow, 2014, chapter 7).
It runs through my mind that the great German philosopher Friedrich Nietzsche exemplifies the life theme I have called Type 2. He lost his beloved father at the age of 4, and reacted to the death by becoming his father once more; in the process however the child he had been disappeared as an active presence in his life. That is the downfall of this solution to loss: identifying with and thereby substituting for the missing parent leads to the disincarnation of the original child, whose independent hopes and dreams never have a chance to crystallize or be pursued. Nietzsche, catapulted at a young age into a precocious paternal maturity, became a psychotherapist for civilization itself, a kind of father figure (Zarathustra) for all humanity in its journey into an uncertain future. His prodigious creativity spiraled forth from the tensions generated by his personal tragedy, and so did his eventual madness
The division between the two pathways I have described is not absolute and may be pictured too sharply. Those who are drawn into the role of soothing and healing a wounded parent are not strangers to the experience of disruptive separation and loss; correspondingly, those bereft children who identify with a lost mother or father are often doing so, in part, to heal a family that has been shattered by tragedy. Perhaps one could think of my Type 1 and Type 2 clinicians as opposite sides of the same coin, differing in individual lives only in their relative salience.
Anyone embarking on a career aiming to help people come to terms with their traumatic life situations and histories needs to do everything possible to address his or her own. In the early history of psychoanalysis, a requirement was established that analysts in training complete their own personal analyses before they could be officially certified. This seemed like a good idea at the time, decreed by Freud and Jung. These fathers of our field, however, exempted themselves from this requirement, which I think should upset analysts tremendously. Here is the problem. The analyst’s unprocessed trauma, like the parent’s, is inevitably passed on to the next generation. Freud and Jung, by refraining from applying their injunction to themselves, guaranteed that specific areas of their unconsciousness – those pertaining to their unhealed wounds - would be visited upon their descendants. This is why our field’s continuing interest in the lives of its progenitors is so important. Identifying zones of incompleteness in their self-analyses holds out the possibility of our emancipation from all they were unable to understand.
Clinicians must be aware of what has happened in their lives and grieve the losses they have incurred. Nothing else will do. The healing of the traumas of which I am speaking is a lifetime project, and so the important thing is that the journey commences. Mourning needs to occur, both for the parent who was lost or was never there in the first place, and as well for the unobstructed childhood that never had a chance to unfold. The psychotherapist’s healing will be a theme in all of his or her work, most often in the background, but included nevertheless in any constructive developments that take place. Psychotherapy is not a procedure performed upon one person by another; it is a dialogue between personal universes, and it transforms both. Our field has not caught up to this idea, but the time is coming in which it will be regarded as axiomatic.
REFERENCES
Atwood, G.E. (2011) The Abyss of Madness. New York: Routledge.
Atwood, G.E. & Stolorow, R.D. (2014) Structures of Subjectivity: Explorations in Psychoanalytic Phenomenology and Contextualism, 2nd Edition. New York: Routledge.
Bleuler, E. (1911) Dementia Praecox or the Group of Schizophrenias. Madison, CT: International Universities Press, 1950.
Brandchaft, B., Doctors, S. & Sorter, D. (2010) Toward an Emancipatory Psychanalysis. New York: Routledge.
Dilthey, W. (1926) Meaning in History. Ed. H. Rickman London: Allen & Unwin: London, 1961.
Duke, P. & Hochman, G. (1992) A Brilliant Madness. New York: Bantam Books.
Fromm-Reichman, F. (1954) An intensive study of twelve cases of manic-depressive psychosis. In Psychoanalysis and Psychotherapy: Selected Papers, pp 227-274, Chicago: University of Chicago Press.
Greenberg, J. (1964) I Never Promised You a Rose Garden. Orlando, FLA: Holt, Rinehart, & Winston.
Jamison, K. (1995) An Unquiet Mind. New York: Alfred A. Knopf.
Laing, R.D. (1959) The Divided Self. London: Tavistock Publications.
Miller, A. (1982) The Drama of the Gifted Child. New York: Basic Books.
Rilke, R.M. (1910) The Notebooks of Malte Laurids Brigge. New York: W.W. Norton., 1992.
Stolorow, R.D. (2011) World, Affectivity, Trauma: Heidegger and Post-Cartesian Psychoanalysis. New York: Routledge.
George E. Atwood, Ph.D.
What follows are some reflections on my experiences as a psychotherapist, and also on the personal philosophy to which these experiences have led. The material is organized into a series of thought trains centering around my work in the area of severe psychological disturbances.
1. Studying madness
As a young man, having just discovered the world of psychoanalysis, it occurred to me that the study of very severe psychological disturbances might lead to an understanding of the foundational constituents of human nature. Nothing could be more interesting, I thought, than to search for a new and deeper knowledge of the human condition as a psychotherapist. I have had the good fortune to pursue this quest for half a century.
One may ask the question: what really is madness? Here is how I would sum it up. Madness is not an illness or disease, it is not a condition existing somehow inside a person, and it is not a thing of any kind having objective existence. Madness is an experience a person may have, one involving in its essential core a fall into nonbeing. Madness is the dissolution of all order and a descent into chaos. It is the greatest catastrophe of subjectivity that can happen to a person. The felt reality of the world disintegrates and the enduring solidity and integrity of one’s sense of selfhood – the ongoing experience of ‘I am’ – becomes tenuous, unstable, and even vanishes. Madness is the abyss and there is nothing more frightening, not even death.
Our minds can generate meanings and images of our deaths: we can picture the world surviving us, and we can identify with those that come later or otherwise try to immortalize ourselves through our works. We can rage against the dying of the light, and we can look forward to reunions with lost loved ones in the afterworld. We can think about the meaninglessness of human existence and its finitude. We can be relieved that all our sorrows will soon be over. We can even admire ourselves for being the only creatures in existence, as far as we know, who perceive their own wretched destiny to be extinguished. The abyss of madness offers no such possibilities: it is the end of all possible responses and meanings, the erasure of a world in which there is anything coherent to respond to, the melting away of anyone to engage in a response. It is much more scary than death, and this is proven by the fact that people in annihilation fear – the terror of madness – so often commit suicide rather than allow themselves to be engulfed by it.
In working with madness as a psychotherapist, one draws close to a realm in which there are no orienting landmarks, no coherent purposes and desires that point to a meaningful future, no organized recollections establishing a continuous past. The ordering structures of existence itself collapse, all sense of personal identity becomes erased, and one may fear being pulled out of one’s sanity and into the nothingness. This is the terror of madness, and it affects all those who come into its vicinity.
How can we, as explorers of the human soul, enter this dark territory? I think we need a map of that chaos, a picture of the variations we will encounter, and some general guidelines as to how we might respond to the disastrous human situations that are encountered. Also needed are protections from how we are ourselves perceived. A terrible toll may be taken on the clinician who may be viewed as a persecutor, as a god, or even as a persecuting god. An even greater injury may be inflicted on the patient, someone already in the deepest trouble who now faces being seen as insane.
Psychotherapy is a world within the world, one in which patient and therapist gaze into each other’s eyes and see themselves reflected in ways that may clash profoundly with what they feel is true or most deeply need. The mismatching of such images leads to all manner of difficulties for both parties, often spiraling into chronic impasses and the loss of the possibility of a healing connection.
How can we as therapists be shielded against the terror of being drawn into the madness and against the potential violence to ourselves of the interplay with those who are lost in chaos? What protections can there be that will not operate as well at the expense of the patient? The key lies in one thing only: the power of human understanding. We must understand annihilation states and all the signs and symptoms expressing a person’s struggle with such experiences. We must know the symbols typically used to represent these states of mind, images that are often concretized or reified, i.e., treated as tangible, substantial realities. We must use our understanding then to discover responses to our patients’ crises that will help them refind a personal center and feel included again in the human community. This is the work of clinical psychotherapy research, a field now on the threshold of a new age as the older ideas about objectified “mental illnesses” recede and a new emphasis on phenomenology arises.
Let me offer a thought on systems of psychiatric diagnosis, which everyone who enters our field encounters. Sometimes these systems turn into dragons that consume the minds of those who use them. There is nothing wrong with careful studies of the symptoms and signs of psychological disturbances, and with efforts to classify the richly varied phenomena one sees in this realm of study. Ordering principles need to be applied, so that we are not just left adrift in a sea of confusion. A problem arises however when the classifications we impose on the variations that are observed become reified and objectified, turned into mental diseases imagined as existing somehow inside the people we seek to understand. Our patients in extreme distress reify their fantasies, generally in order to substantiate personal realities that have come under assault and are threatened with dissolution. We in parallel often reify our diagnostic concepts, ascribing the chaotic manifestations confronting us to a disease process inside the patient. Such a locating of the problem in the internal, not grounded in any actual scientific knowledge, basically takes the clinician off the hook. He or she is not implicated in what is seen; instead the clinician sits high and dry, observing and classifying from a position of serene detachment, wrapped in a cordon sanitaire. This shields us from feeling responsible for how we are experienced and utterly neutralizes the power of the patient’s attributions to attack or displace our own ways of defining ourselves. The problem is that the clinician is implicated: what people show us depends in part on how we are responding to them. Human experience is always embedded in a relational context. If that response organizes itself around an objectifying psychiatric diagnosis, one can expect to see reactions to the distancing and invalidation that is involved. If those very reactions are then ascribed again to the supposed mental illness, the distancing is deepened and the disjunction rigidifies. It is important to learn about diagnostic systems, but we must not let them become our commanding, reifying viewpoints. One should be guided instead by attention to the patients’ experiences and by reflections on one’s own. We are still at the beginning of exploring this strange and complicated country.
2. Secrets of the mind
In my youthful enthusiasm long ago, I imagined that a careful analysis of the fragments into which psychiatric patients disintegrate might disclose the basic elements of human nature. Although I have tried to follow through on this quest, I cannot say that I have succeeded in any literal sense. There is however one central discovery that has occurred as a result of this journey: myself. Amidst the shattered hearts, the broken minds, the annihilations, it is as if the pattern of my own life was somehow inscribed. Exploring the souls of my patients therefore has led me again and again to the depths and origins of my own lifeworld. Could it be that the study of madness presents us all with opportunities to discover who we actually are? Could it also be that the effort to assist those who come to us presents us a chance to heal our own wounds as well?
I shall tell about one of my own early experiences in this connection. My first seriously challenging patient, a young woman I met decades ago, believed with all her heart that she was a part of the Holy Trinity and that she was one with God. Her story is given in the first chapter of my book, The Abyss of Madness (2011). She and I, over the tumultuous course of our early relationship, came to an understanding of her situation as centrally relating to a catastrophe that had occurred in her childhood: the sudden suicide of her beloved father. I saw how the tragic loss had bisected her youth into before and after, into father and no father. As our shared journey continued and her healing began, I became witness to a gradual smoothing out of the traumatic bifurcation with the emergence of feelings of furious rage, of heartbreaking sorrow, of annihilating invalidation. At some point along the way – I cannot say precisely when – it dawned on me that in looking at her life I was also seeing an image of my own. You see, my childhood also was divided into a before and an after, the separation caused by the sudden death of my mother when I was a young boy. In coming to the tragedy that had disastrously affected my patient’s development, I had been returned to the tragedy of my own. In witnessing her slow healing and recovery, in turn, my own healing – continuing down to the present day – had a chance to begin. The great German philosopher-historian Wilhelm Dilthey (1926) famously proclaimed that in the study of persons in the so-called human sciences, all understanding is a matter of “the rediscovery of the I in the Thou.” It follows from this elegant idea, to my mind anyway, that in the discovery of the Thou, we find a mirror in which our own souls are made visible.
Here are some additional thoughts that come forward as I think about the goal of finding out the secrets of human nature from the study of madness. I shall introduce them by describing the adventures of a young man I knew many years ago. He came to me just before a long psychiatric hospitalization. He said he had discovered the secret, not of human nature, but of the universe as a whole: the key to all of creation. I asked him to tell me about this amazing secret. He said it was revealed to him in a vision in which he saw the interrelatedness of all things. The vision encompassed the whole of the cosmos in a single image, abolishing all separateness and isolation in an overpowering, radiant unity. He had discovered the heart and soul of existence itself, and repeatedly shouted the secret out: “ALL IS ONE, ALL IS ONE, ALL IS ONE!”
I was curious about the personal context of this unifying vision. His life story was a sad one, involving a world in which the center failed to hold. He had been a golden child, a precocious genius who from an early age had shown stunning abilities in both science and the arts. His parents considered him to be a gift from God, filling their otherwise rather empty lives with a transcendent meaning. Complying with their expectations, the boy grew up with A-plus achievements in every endeavor, and the parents believed they had brought a great man into the world. The breakdown occurred on the eve of his graduation from college, a summa cum laude on the threshold of glorious success in life. One little problem tripped him up: a girlfriend he had become very attached to decided to end their relationship. His love for her, such as it was, expressed a part of him that contained, tenuously, his personal truth. Being a stellar achiever had always come easy and fit perfectly into his parents’ needs. Losing the girlfriend was different; it was a disaster beyond imagining for a boy who had so little he could call truly his own. It was the end of a life that had scarcely begun. Unspeakable agonies followed the loss, a suffering beyond all comprehension in which everything that had seemed together was now torn asunder.
This was when the vision of cosmic oneness supervened. Every atom and subatomic particle, and every galaxy supercluster came together before him, in a vast network of interdependent relations. It was a breathtakingly beautiful tapestry encompassing the totality of all existing things. People in this young man’s social world – family, friends, college teachers – thought he had gone crazy and the decision was made to hospitalize him. What he was doing, however, was putting the world back together again, reconnecting all that had fallen apart.
I came to the idea that his vision was utterly, profoundly a true one. He had indeed encountered a secret of the universe, one that has been thoroughly hidden from us in this age of atomism. We think of our own lives as a matter of isolated minds existing alongside each other, little separate unit-selves dropped into the world out of their mothers’ wombs. We imagine our minds as having interiors, filled with all manner of mental contents (thoughts, desires, memories, etc.), but subsisting somehow separately from a surrounding external environment. The estrangement between internal and external is paralleled by a dualism between our bodies and our minds. The universe itself, in turn, we visualize as a vast space populated by all things great and small, some of them causally interacting with one another but each of them having its own separate and solitary existence. We are hypnotized by this alienating and fragmenting atomism, regarding it as just the way things are rather than as the ontology that it is. My young man, propelled by a catastrophic experience of the disintegration of the world, broke through the trance of this philosophy to a sudden recognition of the unity of all beings. I found his thinking to be powerful, although at the time I met him he was unable to do much with it other than to cry and shout.
Working with those who dwell in the extreme range of psychological disorder presents us with dramatic signs of how our very selfhood and sense of the reality of the world are embedded in contexts shared with other human beings. One sees, for example, how the “symptoms” of so-called mental illness do not emanate from a wholly internal condition afflicting the isolated individual, but instead vary as a function of the response that person encounters from others. When responses felt as objectification and invalidation are supplanted by experiences of being understood and included in the community of others, striking shifts occur in delusions and hallucinations, and chronic annihilation states recede. C.G. Jung, the great psychiatrist, acknowledged this in his famous words: “Schizophrenics cease to be schizophrenic at the moment they feel understood” (Laing, 1959). We, as clinicians, are therefore involved in the psychological disturbances we are called upon to treat, and the wounds requiring healing in our patients are matched by the wounds we carry in our own hearts.
But there is more. The universe exists in such a way as to generate the possibility of our own coming into being, and a profound argument can be made that it is as it is in part because we are here to be aware of it. Human beings are implicated in the way in which the world becomes manifest, and at the same time the study of the cosmos is the universe becoming conscious of itself. The observer and the observed, in both the natural sciences and the human sciences, are inseparable from each other, and the constituents of reality, on smaller and smaller scales, turn out to be interdependent, entangled phenomena rather than fully separable units somehow subsisting in ontological solitude.
In other words, my young man was absolutely right. One might wonder what happened to him. It is sad. He was diagnosed on the basis of the grandiose euphoria he showed: manic-depressive illness was the Dx. The treatment provided to him included multiple hospitalizations, extensive electroconvulsive therapy, and an ever-varying succession of antipsychotic drugs. The last time I saw him, fifteen years into this so-called treatment, he was doing poorly – depressed, confused, unable to work, obese, and… no girlfriend. I wonder what the outcome might have been if someone instead had been able to sit down with him – for a day, or a year, or a decade – and discuss what it meant that all is one. Is it not possible that good things might have emerged from such conversations?
A final thought regarding the story I have been telling: how is it that this young man, in captivity to his parents but also in a struggle to render a shattered universe whole, was a mirror in which I could find a reflection of myself? When I was a young college student, I made a discovery of my own that was very similar. In the context of an exposure to Zen Buddhism, it came to me that all dualism is false: every one of the great contrasts in our culture’s history and philosophy – internal/external, matter/spirit, masculine/ feminine, good/evil, freedom/determinism, I/You – were illusory, and our belief in them was a trance from which we needed to awaken. Looking back, I see the philosophy of monistic adualism I then adopted as importantly related to the shattering trauma of my mother’s death. I also see it as a precursor to the unifying theories and philosophical ideas in which I have come to believe.
3. Joy and suffering
The intensive psychotherapy of severe mental illness, so-called, offers two intertwining opportunities. On the one hand, one has a chance to give help to a fellow human being who is in trouble, perhaps the deepest psychological trouble that there is; on the other hand, one encounters phenomena that are at the far extreme of human experience, showing fundamental issues of all our lives with extravagant clarity and drama. This is the heart and soul of psychoanalysis, ever since it first appeared in the thinking of Sigmund Freud. Psychoanalysis is and always has been an approach to the healing of the wounded soul, and also an exploring of the depths of human existence and human nature. At the age of 17, I saw these twin pathways of the psychoanalytic enterprise, and I could not hold back from making a total commitment to the work. Is there anything that could possibly be as interesting or important? There are great rewards to be found in working clinically in the realm of madness, but often enough there can also be great suffering. To engage with people in the extremes of psychological disorder is to cast oneself into the chaos – it means to embark upon a journey without an outcome that is certain, often with harrowing developments along the way, always requiring a commitment that is absolute. Sometimes this journey eventuates in a healing and a thriving; in other instances all our efforts may fail and we are consigned then to bear witness to someone’s devastation. Therein lies the suffering, in the knowledge that nothing is assured and that catastrophe is always at hand. On the other side, our commitment, being absolute, means there also is hope for healing and recovery, and there is something utterly wonderful about pursuing this hope with nothing held back. If things do not work out, and perhaps there is a suicide or some other incontrovertible disaster, we die a thousand deaths. If on the other hand a better way is found, the Phoenix rises from the ashes, and one then has the sense of having participated in the sacred.
During my college years I had a professor who repeatedly warned his students away from pursuing individual psychotherapy as a career. “How many people can you hope to help in a lifetime,” he asked, “twenty-five or thirty as a maximum, right?” It was his idea that our field should devote itself to the prevention of psychological disorders, through various social engineering programs based on behaviorist principles of reinforcement. I found his thoughts bleak and very depressing, because he was attacking the dream that brought me into psychology in the first place. I was too young to be able to offer much of a coherent response, but I knew I disliked what he was saying intensely. I now think that individual psychotherapy is itself the single most powerful preventive measure one could possibly find, because it has become apparent to me that giving help to one person can save the whole world. Psychological disorders arise out of personal histories of traumatic experience, histories that are in turn embedded in complex intergenerational cycles. Traumas that remain unprocessed, that perhaps are not even recognized as having happened, are inevitably passed on to the next generation, and the next; and so it goes, as chains of historical causation reach across the years and even the decades and the centuries.
Consider the potential then that lies within even a single instance of individual psychotherapy that works out well, as the incomparable power of human understanding is brought to bear on a life that otherwise might have unfolded as just another destructive link in the historical sequence. The chain is broken, and rather than darkness being delivered down upon one’s descendants, an illumination is bequeathed as the effects of the healing are transmitted instead. What my teacher failed to take into account is that healing is contagious, radiating into the human surround and having repercussions that flow indefinitely into the future. How limited he was! And yet, we could ask what were his traumas, and why did he imagine he could fix them by his vast program of behaviorist engineering? As I meditate upon these questions, a picture of his unacknowledged despair comes into view. Behaviorism was like that: an intellectual movement turning toward the purely physical but predicated ultimately on the loss of hope for human connection. There is also the intellectual joy that comes with understanding a life. I will give a single example. This is about the famous actress, Patty Duke, a person whose experiences interested me some years ago. Picture the following: as a young woman she set off on a mission to rescue America from foreign influences, which she believed had infiltrated the highest offices of our government. A disastrous effort to travel to the White House in Washington DC and personally eject the imaginary foreign agents was followed up by a devastating depression. In studying Duke’s delusional mission and its background in her life history, I discovered that her earliest years were ones of enslavement to the entertainment industry: her parents essentially surrendered her to television agents who made her a nationally acclaimed star, but at the price of a stolen childhood. It seemed apparent that the intruders in the White House were symbols of the controlling agendas of the public entertainment world. An autobiography was eventually written, describing her development and her breakdowns (A Brilliant Madness, Duke & Hochman, 1992). This record of the journey of her soul, however, had a peculiar feature: half of the chapters, interposed between those that she herself authored, were written by a science journalist representing medical psychiatry and chronicle her evolution as a victim of a biologically based mental disease (so-called manic-depressive illness). Her account thus oscillates between two positions: one being that of telling her story as she experienced it and in her own words, and the other involving a surrender to medical authority. The chapters written embodying the psychiatric viewpoint were like the invaders in the White House, whereas in her own chapters her soul shines forth in freedom – or tries to. The early history of her life being taken over by the agendas of others, the delusion about foreign infiltrators inserting themselves into our country’s self-government, and the strange structure of the autobiography thus display a repeating thematic pattern, centering around a heartbreaking, often losing battle to establish the integrity and inviolability of her own unique selfhood. The disparate elements here interrelate and form a tapestry that is beautiful, in its sad order and symmetry.
Human lives are like that: they display an invariant thematic structure, once apprehended in sufficient depth. I am not saying all our worlds are organized around a battle for self-integrity, as in the story of Patty Duke; I am saying that our individual life histories leave unique signatures on our personal universes. My life exhibits such patterns, and so does everyone’s. A sense of intense and sometimes thrilling satisfaction accompanies the recognition of these unifying themes, in oneself and in others, as initially disparate elements become woven together and apparent chaos gives way to crystallizing order. There is joy in the unveiling of such things. In extending the ideas on which these analyses draw to the larger field of human existence as a whole, we recognize that the themes of the individual lives we encounter belong to a network of possibilities shared by us all.
4. The future of our field
Our time is one of immense change and loss. We are witness to the progressive falling away of traditional answers to the question of the ultimate, as the solid foundations that once gave our lives meaning disappear in a whirlwind of available facts and diverse contexts and perspectives. Our time is also though one of great possibility. As the strictures of reassuring faith have dissolved, we have been cast into an open space, one that can only be filled in by our own creativity. Anxiety and uncertainty are inevitable companions in this journey, but so is the joy of anticipating what is to come. I want to imagine an emerging worldview that has been preparing itself for more than one hundred years, and that is already having important consequences for our field. Three features seem to me salient in this new way of interpreting the meaning of human existence: Interdependence, Self-reflection, and Responsibility.
1. A person is of his or her world, natural and social. The world that we experience is part of our very being, making us who and what we are. That constitutive world, at the same time, is what we make of it. A new mindset of radical interdependence is appearing, within which these statements do not stand in contradiction to each other.
2. Reflective awareness of the many contexts that shape our lives has in our time become pervasive, meaning that we are aware that all our beliefs and values - philosophical, religious, political, scientific – are embedded in our personal existence. One might say that the age of absolutes standing outside the circle of reflection is over. The yearning for ultimate answers and eternal foundations, however, seems likely to be a part of who we are forever.
3. Recognizing that all human beings are siblings in the same darkness (Stolorow, 2011), we are at last embracing the idea that we are our brothers’ and sisters’ keepers. We have also taken up the task of being guardians of the Earth and all its living creatures. I foresee a world in which these responsibilities are considered sacred. One might wonder how I can be so sanguine, in an age of terrorism and fanaticism. I regard these things as the death throes of religious ideologies that are giving way to a new humanism.
The theme of interdependence leads to a reconceptualization of what it means to be an individual person. One might say: there is no such thing as a person. I am obviously not claiming that people don’t exist; it is rather that their existence is not one of being an isolated object, subsisting in a state of ontological separateness and solitude. The new worldview opens us to seeing our irreducible relatedness to our worlds and to others. This changes everything in how one understands so-called psychopathology. I will illustrate what I am saying with a clinical story.
A woman, 24 years old, was brought to a hospital by her father and mother after she had been arrested for trying to break into a well-known country musician’s home. I happened to be on the clinical staff and so met this young person. She was mute, and scarcely moving. The word “catatonia” was used by two of our psychiatrists, engaging in diagnostic deliberations at the time, but I have never thought much of such labels. I sat quietly by her side on a daily basis in the first weeks of my work with her, hoping she would eventually begin to speak to me. Finally she did, telling of a secret world in which she had lived for several years. This world was ruled by a famous country music star, and contained a number of other figures who regularly talked to her in the mornings and in the nights. They were like the chorus in a Greek tragedy. A love affair had developed between her and the star, conducted via telepathy, and she had been able for a long time to function in her world (she had been a part-time student in college) while dwelling much of the time in the secret realm.
Disaster came when she finally made an effort to have physical contact with her lover. The police had arrested her when she went to his actual home. The voices of the chorus, originally loving and sweet, had in the meantime turned increasingly critical and aggressive. Such idealized delusional companions often turn into persecutors, and the imaginary realm that has been found then becomes an unbearable hell. This patient was very similar to Joanne Greenberg, who wrote a classic work in the literature of madness: I Never Promised You a Rose Garden (1964). Joanne also inhabited a secret world, initially a place of magic and love but then that turned dark and monstrous.
Traditional psychiatric thinking would understand this story as involving a dreadful mental illness that erupted in this woman’s young life, an illness it calls schizophrenia. This was the diagnosis she was given during the period of her hospitalization. When looked upon within the new worldview, however, the symptoms of this so-called illness are no longer seen as emanating solely from a pathological condition somehow existing inside of her; instead, they are understood as having meaning within complex relational and historical contexts, as significantly relative to what had happened and was still happening in her social world.
Her emotional history, as I came to understand it in the long course of our contacts, centered around a theme of abiding loneliness. This context, unseen as such by members of her family of origin, was one in which she had accommodated herself to parental expectations and needs, becoming a child fulfilling their dreams through stellar academic achievements. The parents’ marriage had at the same time been a bloody chaos of tension and hostility: repeatedly, the mother and the father had fought physically and threatened to abandon each other. She had tried, with all her might, to be a shining manifestation of hope for familial cohesion, always sensitive to her mother and father, moving back and forth between them, forever striving to make them proud and happy.
The extremity of this young girl’s commitment to pleasing her parents and forestalling the disintegration of her family began at some point to lead to a division in her subjective life: on the one side were her harmonizing accommodations; on the other was an unarticulated and yet intensifying sense of hurt and of her own abandonment. There was no real recognition or validation of her pain by anyone, and therefore nowhere to go with her emerging suffering. This was the setting, following a series of separations and other changes in her living situation, in which she found her true love during her late teen years. Listening to his songs of loss and alienation, of broken hearts and searing loneliness, she saw her own experiences set to music: she had found a twin, a soul mate whose feelings precisely mirrored her own. Appearing recurrently in her dreams and reveries, his presence suddenly one day became utterly real and she immersed herself in their shared affection, magically expressed through mental telepathy. Catastrophe occurred when she finally tried to establish physical contact with him.
I worked closely with her for many years, helping her to find words for her deep feelings of isolation and loneliness, and helping her as well to resist the siren-call of her lover and the chorus of voices associated with him. That is what is needed in such cases: patience, devotion, and understanding. I don’t want to make it sound easy; it wasn’t. There were a great many back and forth movements with respect to the secret world, and there were dangerous suicide attempts in the first years of our contacts. I suffered greatly with how close she came to ending her life. But it eventually worked out well enough. She brought herself together in gradual stages and found new ways to connect with others, expressing in her life a wonderful creative spirit.
I have told this little story to illustrate what I think will become commonplace in our field within the worldview I have been talking about. This young woman’s psychological disturbance, her “schizophrenia,” is here seen as a set of reactions embedded in her life in her family, and related to her trauma history and to the absence in her background of validating recognition. Her illness was not, from this standpoint, a pathology afflicting her entirely from within; it was a personal disaster brought on by complex transactional patterns inhering in her relationships over time to all those who were important to her, both real and imagined.
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A great task facing us in the years ahead will be the thorough phenomenological redescription and reconceptualization of severe psychological disorders, and then a corresponding development of psychotherapeutic approaches embodying the new understandings that are attained. Great strides in this project have already occurred, and so we will not be starting from scratch. Among the many contributors on whose phenomenological and clinical contributions one can build, I would list: Jung, Tausk, Federn, Winnicott, Sullivan, Fromm-Reichman, Binswanger, Searles, Laing, Des Lauriers, Kohut, Karon, Stolorow, and Brandchaft.
Let me suggest some ideas that are more specific in regards to the most meaningful directions of our field in the coming decades. If I had another thirty years to live and to work, I might throw myself into the following sorts of things.
So-called schizophrenia
An influential book appeared in 1911: Eugen Bleuler’s Dementia Praecox or the Group of Schizophrenias. In addition to introducing the term “schizophrenia” to our world, this work attempted to describe and provide examples of widely differing forms of the most extreme psychological disturbances that exist. It is worth reading even today for its rich accounts of madness in its many variations, although the work does suffer from some serious limitations from our present vantagepoint. The clinical descriptions are framed within a broadly Cartesian, intrapsychic frame of reference, locating the disturbances being considered inside the patients who are then pictured in isolation from their worlds. The presentations, in addition, tend to be restricted to the patients’ symptomatology in the present moment, leaving out of account the complex histories and relational contexts in which their symptoms are embedded and have meaning. Finally, the book is written almost entirely from the perspective of the medical model, viewing psychological disturbances as disease processes occurring in the mind.
A very wonderful project, one that would require a great many years of devotion, would be the modern counterpart to Bleuler’s classic study. This would involve even more detailed descriptions and examples of madness in its many forms and variations, with the focus however always being on the subjective states that are involved. Such a phenomenological emphasis would then be accompanied by a life-historical perspective, from which the overt symptom-pictures are cast in relation to the personal backgrounds of the people concerned. There would only be one way to accomplish the immense task I am suggesting: the collaboration of a number of dedicated clinicians and thinkers. It would be required that there be long-term commitments to the patients being studied, so that the inquiry into their worlds have a grounding in deep explorations of history and also include the nature of the healing processes that can be achieved.
Bleuler proposed that the heart of what was known in his time as dementia praecox consisted in various splitting processes occurring in the mind: hence the term, schizo-phrenia. These included the disintegration of the logical associations of thought, the splitting of cognition from its associated affects, the dividing of positive and negative emotions, and the separating off of a private reality from contact with the externally real. My own view is that future phenomenological studies of patients in this range will show how these various features can be significantly understood as secondary to a sense of personal annihilation. This means that the primary disturbance would be seen in the shattering or even erasure of the experience of personal selfhood. Also central would be the dissolution of the sense of the realness of the world and the disintegration of all that we ordinarily experience as substantial and enduring. The most prominent visible symptoms of these disturbances, such as one sees in hallucinations and delusions, in this context appear as restitutive or reparative reactions, efforts to reunify all that has fallen apart and resolidify all that has melted away.
Another clinical story comes to mind that relates to the sort of understanding I am thinking of. Consider this brief account as standing for a hundred that I could provide. One of my patients from many years ago came to me after a long period in a psychiatric hospital. Twenty one years old at the time, she described herself as having always been in “pieces,” having separate and distinct “selves” that floated about in a strange space, without there being a common center. There was a sexual self, a religious self, a political self, a comical self, a professional self, and a social self. Each of these entities embodied an area of her interests and capabilities, but they were like islands suspended in the sea with no land bridges between them. It was interesting to me that a delusion haunting her during the many months of her hospitalization was a belief she was part of a world-revolution aiming to dissolve traditional nation-states and establish a universal government based on the power of all-embracing love. Out of her own personal fragmentation, it seemed, was arising a dream of world unity. She had been told by her doctors her diagnosis was that of schizophrenia, and, confused about what this meant, studied Bleuler’s derivation of the term from the Greek words for “split” and “mind.” She told me a better translation, still respecting the etymology but connecting more closely to her own familiar self-experience, would be: “torn soul.” I found her statement, obviously rooted in her feeling of being in pieces, to be one of the most astute things I have ever heard on this subject, and I told her so. We worked together for several decades and got along very well.
So-called bipolar disorder
In The Abyss of Madness, I made the claim that the most important frontier for present-day clinical psychoanalytic research is that of the psychotherapy of bipolar disorder, also known as manic-depressive illness. Of course these terms are medical-diagnostic designations, embedded in a Cartesian, objectifying worldview. How the patients so diagnosed will appear under a phenomenological lens remains to be seen, and what innovations in our approach to them will come forth are still to be defined.
A fabulous insight into the experiential core of a great many of the patients showing an oscillating pattern of mania and depression was given to us by Bernard Brandchaft. In his book Toward an Emancipatory Psychoanalysis (Brandchaft, Doctors, & Sorter, 2010), he saw a problem again involving a sense of personal annihilation, wherein the manic episode expresses a transitory liberation from annihilating ties to caregivers. The depression that ensues, in contrast, represents the reinstatement of those ties. A division has occurred between accommodative and individualizing trends in these patients’ personalities: on one side of this division, there is a compliant surrender to authority and the installation within the patient’s selfhood of others’ purposes and expectations; on the other side is a glorious overthrow of such captivity and the embrace of shining freedom. The magical emancipation, of course, cannot last, because there is nothing and no one to support it, and so it collapses into a dark despair. Here would be my questions for those who seek pathways of psychotherapy with such patients in the future. Can an experience be facilitated that establishes a new center, one in which compliance and rebellion are somehow integrated? Can the empathy of the clinician become a medium in which previously aborted developmental processes can be reinstated? Can a deep understanding of what is at stake for the patient finally make a constructive difference to his or her destiny in the continuing nightmare of bipolarity?
The great psychoanalyst, Frieda Fromm-Reichman, in 1954 published a now-classic clinical study: Its title was: “An intensive study of twelve cases of manic-depressive psychosis.” A generalization arising from this study was the notion that such patients were, in their families growing up, treated as extensions of their caregivers rather than as independent beings in their own rights. I would like to see a modern counterpart to this work, tracing carefully the subjective worlds and histories of bipolar patients and exploring the outer limits of our efficacy as therapists in arresting their destructive patterns and stabilizing their lives. The key to success in such a project will be in the new understanding flowing from Brandchaft’s insight, one highlighting the patients’ needs to find pathways of emancipation from enslaving accommodation that do not lead into the structureless chaos of the manic episode.
An amazing example of the twin-sides of bipolarity is given in another classic of the literature of madness: Kay Jamison’s An Unquiet Mind (1995). This author tells the story of her extended resistance as a young woman against her doctor on the issue of her taking mood-stabilizing drugs. Back and forth their arguments went, with her trying to defend her right to a life free of medical intrusions, and with her psychiatrist telling her she had a biologically-based mental illness that absolutely required medications in order for her to be able to function. Finally, with the greatest reluctance, Kay agreed to begin on a course of taking regular doses of lithium. However, when she went to the pharmacy to pick up her prescription, she suddenly was seized by a terrifying vision. She saw, in her mind’s eye, vast numbers of poisonous snakes approaching her vicinity and foresaw how these dangerous creatures would strike at her and all those she cared about, filling their bodies with lethal toxins. So she purchased, along with her lithium, all the snake-bite kits the pharmacy had available, hoping to use the kits to save herself and as many people as she could.
Here is my theory of what this delusion about snakes symbolized. The poison carried by these imagined creatures, about to be injected into Kay herself and the unsuspecting public, represented the diagnostic authority of her doctor, to which she was in the process of capitulating. The theme of at first fighting back willfully but then caving in and surrendering appears also in her early family life, which she describes as having been a battle against oppressive control. The side of this woman tending toward compliant surrender was accepting into her self-definition the medical attributions she had earlier resisted; the side of her wanting to protect her self-integrity from invasion and usurpation armed itself with antidotes to snake venom. There is a parallel between Kay’s desperate purchase of the life-saving snakebite kits and Patty Duke’s attempt to drive imagined foreign agents out of the White House. Remarkably, neither of these women appears to have had any awareness of such symbolic connections. So-called bipolar patients often seem to live in a world of utter concreteness, rendering subjective life strangely opaque.
Madness and Creative Genius
Another favorite subject of mine, one that I hope will be taken up in our field in coming years, pertains to creativity and its complex relationships to madness and trauma. It is my view that the events and circumstances of our lives that hurt us most deeply, sometimes that even take us into an experience of personal annihilation, are implicated as also being among the factors leading to great achievements of creative imagination.
I taught an advanced seminar at my college for a long time, a class in which each year we would select a person for study showing great creativity but also signs of madness. A generalization unexpectedly emerged from the long series of analyses that took place: in almost every case there was evidence of a profound, irreconcilable conflict in the personality of the creator, one that threatened to lead to fragmentation and madness but that seemed to be integrated by the acts of creation. The specific content of the division varied from instance to instance, but the presence of such a duality seemed not to. Four such divided geniuses are described and discussed in the final chapter of The Abyss of Madness: Soren Kierkegaard, Friedrich Nietzsche, Martin Heidegger, and Ludwig Wittgenstein.
I would be very interested in a much more inclusive exploring of major figures in art, philosophy, and science in order to see just how truly general this apparent pattern is. It would also be important to study carefully how it is that the creative activity brings the warring trends in the creator’s soul into a unity. I am thinking that a thorough understanding of such matters could lead to innovative psychotherapeutic approaches with people otherwise fated to lives of paralysis and despair. Would it not be a beautiful development in our field if ways could be found to transform delusions and hallucinations into works of art?
I shall offer a single instance of the analyses conducted in my college seminar, that of the great German poet Rainer Maria Rilke. Rilke’s writings abound with a concern with spirits and ghosts. He was himself inhabited by the soul of a sister who died, a short period before he was born. His mother, broken-hearted by her loss, raised her son to be the dead child’s reincarnation. Consider his name, as it was given to him by his mother: Rene Karl Wilhelm Josef Maria Rilke. The name “Rainer,” which one normally associates with him, does not appear in this sequence. It is a masculinization of “Rene,” originally given as his first name. He changed it under the influence of his muse and lover, Lou Andreas Salome.
Rilke’s given names form a sequence of male designations bounded at the beginning and the end by female ones. His mother, having lost her daughter, enclosed his name, and his soul, in a vision of a resurrected female. She dressed him in girl’s clothes, encouraged his playing with dolls, and interpreted his early interests in drawing and watercolors as essentially feminine preoccupations. Born a boy, he was raised from birth to be a girl.
The soul of the dead sister took up residence inside the young boy. Although the female spirit never became the whole of him, she did alternate in his experience with the male child he also became. Sometimes her presence was felt as a mystical mask he would put on; the problem arose when this mask began to melt into his face and displace his identity as a boy. Or was it the girl he was raised to be whose identity was displaced by the mask of a boy? At other times, the alien spirit erupted from within, draining away all vitality and pursuing its own independent agendas (Rilke, 1910). This spirit might have been, again, the girl emerging from within the boy, or the boy erupting from the depths of the girl his mother saw him as being. With Rilke, it is always both/and, and never either/or. The key to the genius of his poetry lies in his ability to embrace both sides of his androgenous nature, and this ability also shielded him from madness.
In the journey of the creator, there is almost always a division within the soul, one that – left unaddressed – carries the possibility of madness within its depths. The act of creation provides a pathway in which the division can be transcended and unified, and is a protection against psychological destruction. There are countless examples one can find in the life histories of artists, philosophers, and scientists. The need to bring together that which has been torn asunder establishes an everlasting tension, one that leads to a spiraling of creativity. This is a theme one could spend a lifetime studying.
5. The lost childhood of the therapist
There is a traumatic condition that has developed early in the lives of almost every psychotherapist I have known, or at least in the lives of those who become committed to working with very serious disorders. I will call this the situation of the lost childhood. There are two basic pathways along which it seems to occur.
The first and most frequent story is one in which a child is enlisted at a young age to support and sustain a depressed or otherwise emotionally troubled parent. I am speaking here of something extreme, wherein a reversal of roles takes place and the parent comes to depend on the child rather than the other way about. The identity of the son or daughter then crystallizes around making nurturing provisions, the activity of caregiving being the only way open to maintaining bonds of secure connection in the family. There has generally been an emotional void in the parent’s own background, and the child is then given the task of filling it. A compromise of the child’s autonomy and authenticity occurs as the little “psychotherapist” materializes, a slave to the needs of the mother and/or father. Impulses to disengage and pursue a separate life in this context are felt by the parent as unbearable injuries, always producing reactions of great distress and sometimes of rage. When the child tries in some way to be a person in his or her own right, the parental response may be: “Why are you killing me?” This is a pathway closely resembling the one described by Alice Miller in her very fine book, The Drama of the Gifted Child (1982). The “gift” to which she was referring here is the natural sensitivity and empathy of certain children that lead a wounded parent to draw them into this role. Miller’s original title for her book was Prisoners of Childhood, a very apt description of the imprisoning effect of such an upbringing, which includes the dissociation of important sectors of the child’s personality as the child is not allowed to become the person he or she might otherwise have been. The most natural thing in the world for such an individual, later grown up, is to seek out a career in counseling and psychotherapy. Their training for the work has been occurring from an early age. Thus is generated what I call a Type 1 Clinician, one seen especially frequently in the field of psychoanalysis.
The second situation leading to this career is based not on serving the needs of a troubled parent, but rather on an experience of traumatic loss. Here too there is an imprisonment that takes place, and a resultant lost childhood that compromises the full development of the individual’s own unique personality.
The story runs as follows. A fundamentally loving relationship with one or both parents is in place in early life, a bond within which the emerging identity of the developing child is supported and the stability of family life is felt to be secure. An irrevocable change then occurs, something making it seem that formerly secure ties are lost, leaving the child bereft. A parent may grow ill and die, vanish for reasons unknown, be perceived as having disappointed or betrayed the child unforgivably, or undergo an emotional breakdown from which there is no recovery. The early world, now missing, becomes idealized in memory, contrasting sharply and painfully with the desolation that has taken its place. The longing for the parent who has inexplicably changed or disappeared intensifies and becomes unbearable. The loss of the mother or father at this point is restituted by an identification process, one in which the child becomes the one who has gone missing. A transformation of personal identity has thus taken place, in which the loving, rescuing qualities of the longed-for parental figure now reappear as aspects of the child’s own selfhood. By the magical act of turning oneself into the absent beloved one, the trauma of loss is undone and the shattered, chaotic world is set right. In this way a loving parental attitude is installed within the child’s personality, and his or her subsequent relationships in every sphere of life come to be dominated by a theme of caregiving. Any breakdown of the identification with the idealized figure leads to a resurgence of the chaos and pain of the original loss.
This too can eventuate in a most terrible captivity, for the trajectory of the child’s own development here has been interrupted and frozen by the need to stand in for the parent who has been lost. Who that child might have been or wanted to become as a distinctive person is thereby sidelined as the identification solidifies. One can appreciate how easy it would be for such a person to fall into a career as a psychotherapist. This is the situation of a Type 2 Clinician.
There would also be mixed cases, in which the early developmental history of the psychotherapist included both kinds of experiences, traumatic emotional exploitation by a disturbed parent and traumatic loss. I am myself an example of the second type, with the central loss being that of my mother when I was a boy. The great theorist D. W. Winnicott, if I have understood him correctly, was a clinician of the first type, affected most importantly by a mother who suffered from severe depressions. Obviously there may be other pathways to choosing a life of service to the emotionally disturbed, but almost all of the clinicians I have known fall into one or both of my categories. My friend and colleague, Robert Stolorow, on hearing about these ideas, suggested that he is himself “a mild case of Type 1.” At first, I agreed with this notion, although I wasn’t so sure about the supposed mildness. On further reflection I came to think he is a mixed case, with an early pattern of caregiving to wounded parents intertwined with issues of emotional desertion and loss that were magnified by devastating tragedy in his adult years (see Atwood & Stolorow, 2014, chapter 7).
It runs through my mind that the great German philosopher Friedrich Nietzsche exemplifies the life theme I have called Type 2. He lost his beloved father at the age of 4, and reacted to the death by becoming his father once more; in the process however the child he had been disappeared as an active presence in his life. That is the downfall of this solution to loss: identifying with and thereby substituting for the missing parent leads to the disincarnation of the original child, whose independent hopes and dreams never have a chance to crystallize or be pursued. Nietzsche, catapulted at a young age into a precocious paternal maturity, became a psychotherapist for civilization itself, a kind of father figure (Zarathustra) for all humanity in its journey into an uncertain future. His prodigious creativity spiraled forth from the tensions generated by his personal tragedy, and so did his eventual madness
The division between the two pathways I have described is not absolute and may be pictured too sharply. Those who are drawn into the role of soothing and healing a wounded parent are not strangers to the experience of disruptive separation and loss; correspondingly, those bereft children who identify with a lost mother or father are often doing so, in part, to heal a family that has been shattered by tragedy. Perhaps one could think of my Type 1 and Type 2 clinicians as opposite sides of the same coin, differing in individual lives only in their relative salience.
Anyone embarking on a career aiming to help people come to terms with their traumatic life situations and histories needs to do everything possible to address his or her own. In the early history of psychoanalysis, a requirement was established that analysts in training complete their own personal analyses before they could be officially certified. This seemed like a good idea at the time, decreed by Freud and Jung. These fathers of our field, however, exempted themselves from this requirement, which I think should upset analysts tremendously. Here is the problem. The analyst’s unprocessed trauma, like the parent’s, is inevitably passed on to the next generation. Freud and Jung, by refraining from applying their injunction to themselves, guaranteed that specific areas of their unconsciousness – those pertaining to their unhealed wounds - would be visited upon their descendants. This is why our field’s continuing interest in the lives of its progenitors is so important. Identifying zones of incompleteness in their self-analyses holds out the possibility of our emancipation from all they were unable to understand.
Clinicians must be aware of what has happened in their lives and grieve the losses they have incurred. Nothing else will do. The healing of the traumas of which I am speaking is a lifetime project, and so the important thing is that the journey commences. Mourning needs to occur, both for the parent who was lost or was never there in the first place, and as well for the unobstructed childhood that never had a chance to unfold. The psychotherapist’s healing will be a theme in all of his or her work, most often in the background, but included nevertheless in any constructive developments that take place. Psychotherapy is not a procedure performed upon one person by another; it is a dialogue between personal universes, and it transforms both. Our field has not caught up to this idea, but the time is coming in which it will be regarded as axiomatic.
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