I don't know why--my British-Canadian instincts to root for the underdog, perhaps?--but I have been haunted for a long time by stories of psychiatric patients and their abuses not just in the Soviet Gulag in the middle of the last century, but more recently, and in a supposedly "enlightened" and free country like the US--or Canada or the UK. The stories that remain with me are those of patients deemed and treated as though they are beyond reach--and this seems primarily to encompass people labeled "psychotic" or "schizophrenic."
I have read stories of clinicians who were unwilling to simply write such people off, or consign them to subsisting in heavily drugged states in institutions, but have tried to reach, and even to heal, them, via psychotherapy. There are four such clinicians I have some familiarity with. What follows are just some initial reflections based on learnings gleaned from each of them. (I am not mounting a defense of all of them, or even each of them singly in every one of their views; nor am I conceiving of a grand theory of anything here.)
I think the first clinician I encountered was R.D. Laing. About three years ago, reading of him somewhere and finding what I read interesting (alongside his Glaswegian heritage, which is that of my mother and maternal grandparents, who were born in and around Glasgow and lived up and down the River Clyde before emigrating to Canada), I got a copy of his semi-autobiographical Wisdom, Madness, and Folly: The Making of a Psychiatrist and read it with not just interest but real horror also, learning in there of certain techniques used less than a century ago with certain patients--e.g., insulin comas--alongside the often callous dismissal and virtual medical imprisonment of patients labeled psychotic and/or schizophrenic.
Incidentally, numerous films and documentaries have been made about Laing, and Amazon Prime has the most recent, Mad to be Normal, which I watched with great interest. It gives no background to Laing, and only perfunctory (but damning) coverage of his shoddy treatment of his family and his many affairs and resultant children, but focuses almost entirely on the "experimental" community he founded and ran from 1965-70 in London at Kingsley Hall, a place where patients could live without judgment and enforced treatment--which was not unproblematic!
Freud (without much experience) claimed--and everyone else seems mindlessly to have repeated--that psychosis and schizophrenia were impossible to treat with psychotherapy. Laing and a few others would show Freud to be wrong on this point. Laing was not successful with every patient, to be sure, but with enough that we must, if we are dispassionate clinicians of truly open minds weighing the findings of (loaded phrase!) an "evidence base" to consider his efforts seriously and give him credit--no matter the problems that come with some of his views, and certainly with his destructive conduct towards his children and wives.
He writes about his clinical work in his earliest book, which I have just finished: The Divided Self: An Existential Study in Sanity and Madness. In this book, Laing writes of debts I did not know he had, including to Jock Sutherland (author of the interesting study Fairbairn's Journey into the Interior), Charles Rycroft, and the great D.W. Winnicott.
True to his subtitle, Laing immediately dives into a claim--derived from Freud's Civilization and its Discontents--that what we call "psychosis" may be a sign of a serious split from the unbearable parts of our world, and thus have more of an external-social "cause" than an internal-biomedical one. He also notes that people locked in a psychotic state may--a theme also found, he notes, in Frieda Fromm-Reichmann (about whom see below)--be helped by the presence of a patient clinician: "since relatedness is potentially present in everyone, then he may not be wasting his time in sitting for hours with a silent catatonic who gives every evidence that he does not recognize his existence" (26). Fromm-Reichman says this, and so, as we shall see, does Christopher Bollas.
A little later he returns to this theme, noting that the clinician must, at a minimum, make every effort to "know how the patient is experiencing himself and the world, including oneself. If one cannot understand him, one is hardly in a position to love him in any effective way" (34).
Laing recounts an interesting claim of a patient in group therapy who felt another patient was threatening his existence and so the first patient became very argumentative precisely, he claimed, to preserve his existence. This leads Laing later in the chapter to caution (pace his earlier claim) that with some patients the therapist needs to be very careful not to extend love because it might in fact be more feared from and in the therapist than the latter's hatred. Themes of engulfment and annihilation abound here, as they will later in George Atwood, discussed below. But even more than in Atwood, Laing focuses on the necessity of a sense of autonomy in the patient, whose delusions may come about in part as a function of feeling that autonomy is under attack.
As one comes to love a person diagnosed as schizophrenic, Laing counsels reading Kierkegaard, especially The Sickness Unto Death (which was my introduction to the Danish philosopher in high-school), saying that the clinician must first understand real despair (and Kierkegaard is an excellent guide to it) before understanding his schizophrenic patient, for the latter is nothing if not mired in despair.
The middle section of The Divided Self is really focused on the schizoid personality, and the splitting characteristic of it. Here Laing's debts to Winnicott and Fairbairn are very clear. As we get into the final section, he deals more directly with schizophrenia, and provides in some chapters very extensive clinical material. He notes, however, something I have also found: "it is never easy to obtain an adequate account of a schizophrenic's early life. Each investigation into the life of any single schizophrenic patient is a laborious piece of original research" (179).
Laing notes something other authors have: violent fantasies and delusions, including of murder, are common in schizophrenics and reflect their sense of "having murdered their selves." He calls these delusions, but immediately says they "contain existential truth" (149).
Those in psychotic states are often known to speak what others regard as incomprehensible gibberish, but Laing notes that this is a deliberate defense mechanism: the "deliberate use of obscurity and complexity" reflects the fact that the patient is trying to scare away the doctor because the patient "is terrified of love" (163) and wants to "avoid at all costs the possibility of being held responsible for a single coherent idea or intention" (164).
Such are some of the gleanings from Laing which I will continue to think about. Many of them, as we will see presently, are very similar to those of George Atwood and Bollas again.
Having finished Laing's The Divided Self, I have lined up next to read Daniel Burston's biography of Laing, The Wing of Madness: the Life and Work of R.D. Laing. (I interviewed Burston last year about his newest book.) Biographies have long been my go-to genre for bedtime reading, and I will get to this as soon as I finish another one currently underway, viz., Helen Swick Perry, Psychiatrist of America: the Life of Harry Stack Sullivan.
In addition to Laing, the other person who tried with some success to reach those often labeled as hopeless cases is Frieda Fromm-Reichmann. I have discussed her life and work here, so I will not say more about that now. She, too, remains a greatly admirable inspiration.
Instead, let me turn to a clinician who is still alive: the retired Rutgers psychologist George Atwood, author of the recent book The Abyss of Madness. It is an enjoyable book, though the last chapter (focused entirely on 'existentialist' philosophers) seems rather tacked on and not at all integrated into the rest of the book, which mixes much good clinical sense with interesting case material. Atwood early on notes that "psychotherapy is always a dialogue between two universes, one that transforms both" (35).
A little later in the book he comes to his titular focus, saying that "Madness is not an illness, and it is not a disorder. Madness is the abyss. It is the experience of utter annihilation" (41). Madness gains its terror, he suggests, because it raises the specter of falling into nonbeing. And madness should not be thought some rare and singular phenomenon that happens to others. Rather, Atwood suggests (and here he puts me in mind of Christopher Bollas, who has suggested that all of us cycle into and out of periods of 'madness' at some point, to greater or lesser degrees, but only a few of us get stuck there long enough to need or attract clinical attention), "the abyss is a universal possibility" (43).
Much of the book is spent attempting to understand delusions, which at one point he regards as an attempt to restore a "lost connection to someone life-giving," a point he illustrates with an especially harrowing case study of a child devastated by paternal suicide (44). He found working with this severely delusional woman that it was necessary for him as a psychotherapist to feel and show her that he had a real "understanding of the horror" and saw his job as helping her return from the land of horrors. Doing this, he says, does not require a "diagnosis," which he sees as not just objectifying but reifying the delusion. Instead, she needed from him "validation and mirroring" (45).
Much later in the book he returns to working out a definition of delusion, noting succinctly that it is "a belief, any belief, about the validity of which there can be no discussion" (p.99). Given that no discussion is possible, Atwood advises against making any comparisons between the delusion and "reality" for this will not help the patient. Instead, in an interesting turn of phrase earlier used in the book, such a comparison will awaken an "epistemological trauma" in the patient. (This phrase, and the way Atwood describes it, are very close to the great moral philosopher Alasdair MacIntyre's 1977 article on "Epistemological Crises, Dramatic Narrative, and the Philosophy of Science," which I have often used with my students over the years.)
Given that delusions admit of no debate, Atwood advises that the clinician discuss these delusions as one would discuss dreams, about which he has an entire very interesting chapter. (He counsels the wisdom of something I learned both from my own experience as an analysand, and also from Nina Coltart: pay attention to the first reported dream at the outset of treatment for it may well concern "the deepest theme of the treatment that is to come" [89].)
The similarities between dreams and delusions are threefold: neither follows laws of logic and rationality; both engage in condensation and concretization; and both can, with time, fade and be forgotten.
I confess I wish I had finished this part of Atwood's book even a day earlier, for it would have come in handy with someone whose delusions I mistakenly tried repeatedly to challenge, without any discernible effect--other than making this person acutely uncomfortable and distant which, in turn, gave rise to a counter-transference image in my mind of a ship with a damaged rudder being blown in circles in the South Atlantic.
Atwood reports additional case material, including of a patient whose delusions about coming from a "family of vampires" made a lot of sense once the patient's history was known. The sense was derived not from comparing the delusion to some notion of reality, but instead by asking what the internal meaning for the patient might be. Here as in most other cases reported, the "madness" this patient suffered was a "result of the failure of sustaining human relationships" and, usually, "disastrous trauma," sometimes visible but sometimes not (55).
What are reported as "delusions" in children, Atwood suggests, may well be potent vehicles for some truth hitherto hidden or denied. When they express themes of murder and violence this may indicate not necessarily literal violence earlier in their life, but nonetheless a strong sense of having had something precious killed.
When he turns to schizophrenia, Atwood notes that patients carrying this diagnosis "often do not experience themselves as existing. They live in a felt state of nonbeing" (58-59). As a result of this claim, Atwood at several points cautions the clinician to remember, and remind the patient, that we all live in a common world as experiencing beings, but that our experiences can and do differ. Saying such a thing to such patients helps may help them feel less estranged and threatened.
Commendably, in When the Sun Bursts, he notes some limitations at the outset: the book is not a textbook on schizophrenia but is simply based on his extensive clinical work, in England and the US, going back decades. Even with this, however, he lays no claim to be an expert in schizophrenia or anything else. As he rightly puts it, "no human life is long enough to allow any clinician to claim that he or she has truly grasped the meaning of any of the 'disorders'" (2-3).
By the time I reached the end of the book, I had come back again to this realization with renewed gratitude. We do not need, and should rightly question, anyone--no matter how distinguished--laying down the law about what Disorder X, Y, or Z means in definitive terms. Bollas eschews all of that, and it allows the reader freedom to think and to disagree. There were parts I questioned, and by the end realized that it is not necessary for me to have an over-arching and comprehensive theory that explains all psychotic phenomena, or all patients thought to be schizophrenic: instead, it is enough that this one book helped me very considerably with one case at the moment, and gratefully to receive its gifts while remaining open to and awaiting others (noted at the end of this essay).
Bollas starts off with a blunt assertion, which, in my very limited experience so far, I fully share: "no one a psychoanalyst meets is more compelling than the schizophrenic" (p.2). Like Laing and Atwood and others, Bollas is horrified by the "throw away the key" approach we have seen in too many instances of schizophrenic diagnosis (p.8). His own approach is team-based, working with physicians and others to provide community-based care that, where possible, avoids heavy drug use and institutionalization.
He suggests that the schizophrenic might bear more than a passing resemblance to the child who finds his or her own mind more puzzling and incomprehensible than just about anything else. With time, and "good enough" parenting, they learn how to decipher parts of their mind, and to be able to bear it. But "when defenses against the complexities of the mind break down there can be a breakthrough of too much. Selves cave in" (p.8).
At the end of the introduction, Bollas is quite insistent that if you can catch someone--especially an adolescent--at the outset of what seems to be a schizophrenic episode, then the "crucial factor that is vital to whether the person has a chance to survive and reverse the process" is that "there is someone for the person to talk to for long periods of time" over many days and weeks. If this is provided "there is a good chance that clinicians will see transformations back to non-psychotic functioning" (8-9).
As we move into ch.1, we get some fascinating glimpses of autobiography, taking us back to Bollas' early training and work in California in the 1960s at a school with a lot of severely disturbed children. More of this emerges in ch. 3. One valuable lesson he learned then, which has remained with him all these years, is that "almost all psychotic behavior was comprehensible if one could discover the underlying logic of thought" (20). (This is a point made by Sofia Jeppson in her new article, "Psychosis and Intelligibility," Philosophy, Psychiatry, and Psychology 28 [2021]: 233--249.)
In the third chapter, Bollas speaks of "negative hallucinations" as those things that negate "the presence of objects that are present in the world around them [i.e., psychotic patients]" (45). This was a helpful phrase for me in trying to understand a particular case right now.
Though he doesn't call them this, Bollas scatters throughout the book some "techniques" that he uses and seems to recommend. These include:
- finding out from the person what has been helpful, what "self-therapy techniques" they have successfully used to date, if any (47);
- try talking about "everyday reality" rather than inner disturbances in order to give the patient a sense of safety and anchoring (50);
- allying himself with Harold Searles, Hanna Segal, and Wilfred Bion (inter alia), Bollas advocates "listening to the free associations and unconscious communications" of the schizophrenic (50), a point he reiterates seveal times throughout the book;
- a comfortable use of silence throughout sessions (67-78).
It is in the seventh chapter that we get the story of the book's title. Bollas says that very often "those on the verge of schizophrenia may experience profound changes in their way of seeing, hearing, and thinking" (75). A little later he names these "apocalyptic moments in which the person's worldview is changed" (80). One young male patient named David in his early 20s went through a series of shocks and changes, and described them to Bollas as being the point in his life when the sun burst.
What are some signs of such changes? Bollas lists several, including dehumanization and ritualization in which real acting persons are replaced with people playing roles. Real people are too untrustworthy and dangerous, so now they are forced into a narrative or a "play" in which they have fixed roles. The patient does so as a way of keeping people away from him. Fragmentation here is tolerable, but self-fulfillment and self-unity are not: "a self fulfilled is a self endangered" (81).
The second part of the book opens with a claim from a patient who insisted he knew things of his life before birth. I found this startling insofar as I once knew someone who made a very similar claim. Such a person creates what Bollas calls a "mythic personality" one of whose hallmarks is often a "metasexuality" marked by "frenzied connectedness" (91). Later in the chapter he returns to this, speaking of the experience of some patients in manifesting a "rapaciously deranged sexuality" (96).
This takes us into the tenth chapter which is devoted to metasexuality. Here Bollas speaks of the schizophrenic tendency toward "sexualizing everything" in order to eradicate "the specificity of erotic fantasy life and the reality of sexual engagement with a specific other" (97). Why might a person do this?
For Bollas, one answer might be that "the mania of sexual omnipotence aims to re-situate a failing self within a position of power" (98), but such a self is situated in a "profoundly solitary position" (101).
Chapter 11 is devoted to "Hearing Voices," and Bollas here notes that in addition to voices, some schizophrenics also have very acute and prominent experiences of colours. He counsels that we first recognize the voices come from the inner child, and that we must also treat these voices with great respect. We should neither judge them nor critically compare them to reality, but instead simply "ask what each voice is saying and to ask for further details," confident that in doing so we will be listening to voices whose main task is to disguise and protect the self.
Bollas says that instead of frontally challenging voices (which I have done, to utterly no avail at all!), we should both (clinician and patient) puzzle over them, asking: what can they mean? The task here is not challenge or dispute, but translation. If you ask the patient to talk about the voices, Bollas says the effect is often profound. Ask the patient to try to explain to you what the voices mean. Treat them with dignity (109). (I found this very helpful in one case after having earlier failed by challenging the delusions. It occurs to me that this is a "technique" that might admit of wider application in, e.g., our infamous political problems now with conspiracy theories about vaccines, stolen elections, etc.)
As a psychoanalyst, Bollas notes that voices cannot free-associate and if the patient can come to see this, it may change everything. It may, in fact, provoke the kind of "epistemological crisis" we noted earlier: the supposedly all-powerful voices can do little more than repeat their claims ad nauseam, never being able to elaborate upon their points in any intellectually compelling manner. They speak for the split-off parts of the personality, but do a poor job of it, and if their poverty can be seen and accepted by the patient, this may be the beginning of the dissolution of the voices' power.
In chs. 12 and 13 (but really throughout the book) Bollas makes excellent and very enlightening use of object relations theory to help us conceptualize what is going on in a schizophrenic mind. External objects become invested with profound meaning, speaking for and representing parts of the self that must, for several reasons, be disowned and even disdained: "Mental processes may be housed in objects that perform them." In extreme form this can result in "schizophrenic emptiness" (135-36) as the patient puts the self into various objects, retaining little to nothing for and of himself. In doing so, the patient ensures that "action defeats thinking" (142) for thinking has been made too dangerous and intolerable. The clinician who attempts to "interpret" these projections into objects is on precarious terrain here for the patient may regard such actions at tantamount to theft and react with alarm or even violence.
A little later Bollas argues that "schizophrenics are often precocious as children, frequently speaking early and developing language skills to a very high order" (163). He does not here mention, but I naturally immediately thought of Winnicott's famous essay (which I discussed here) on precocious children, "Mind and Its Relation to the Psyche-Soma." (Bollas later in the book talks about the somatization of certain schizophrenic phenomena.) Such children, he notes, may often be "highly sensitive to colour, light, and sound" and may become experts on certain physical objects (this has been confirmed in my clinical experience.)
As the book gathers itself towards a conclusion, Bollas circles back to make something of a plaidoyer once more for several techniques he has successfully used.
1) Got a Comprehensive History:
He stresses repeatedly the need to get a good history, saying that places like Finland this has long been understood and practiced. Involve the family. Almost all cases reveal there was some kind of "apocalyptic" moment, some kind of abrupt shift and change that led to schizophrenic symptoms beginning. If you catch this early enough you may be able to prevent the patient from falling into a full-blown disorder.
One additional crucial task a history does is allow for the "restoration of human temporality itself" (179) in a mind increasingly slipping far into the past or future.
2) Narrate the Quotidian:
Ask the patient to narrate in as much detail as possible the events leading up to the painful break or moment. Do so in a way that engages the self, the I, and allows the patient to see and recover a sense of agency and subjectivity. This he says is "crucial. If he has not given up, there is time to get him to shore" (171).
Additionally, part of the task here is to re-narrate that event, to restructure it in the mind, so that it is no longer destructive, persecutory, etc.
3) Ease the Annihilatory Defenses:
Help to decrease the anxiety about the self and begin to work towards the restoration of the subjective voice. Before (or simultaneous with) this, however, you may need to engage in the next step, often for some time.
4) Talk to the Patient About Commonplace Matters:
They may watch you to figure out how you navigate the world, how you are not overwhelmed by the experiences that they are, and how you seem to make sense of objects in ways that differ from their use of them. Tell them about the weather, or a movie you saw, etc.
5) Ask for Examples:
How does the patient structure his mind? What heuristics does he use? What assumptions about people and the world exist? What core convictions does he have? Where are there unthought knowns? Here is where a free-association type method (and the reverie and associations it evokes in the therapist) may be useful as these things may be discovered by simply listening to and watching the patient not just talk but also interact with the environment
6) Remember the Poets:
Bollas ends this hugely insightful and helpful book by turning to W.B. Yeats and a passage from his autobiography. This leads Bollas on to claim--without, just a few pages earlier, at all disdaining the need for psychotropic medications and hospitals in some cases--that perhaps the "poets may have more to teach us about schizophrenia than psychiatry and psychopharmacology. After all, they have learned how to descend...to the sensorial, imaginary, and symbolic in such a way as to convey our unconscious knowledge. Perhaps poets come close to the mental intersections experienced by the schizophrenic. Who knows how this happens?" (197).
I reach the end of When the Sun Bursts: the Enigma of Schizophrenia with that familiar sense one has of having been greatly enriched by a book, but a little saddened that this enjoyable and deeply edifying conversation has come to an end--though this is a book that will repay careful reading, I am sure. Its lasting gift to me has been twofold: first, to take a disorder out of the shadows and to strip it of the fear surrounding it that I have felt as I watched it seize control of two family friends over the years; and, second, to reveal to me that this is a population I would very much like to work with.
Next up (but not until next month, when my academic semester is over!) I hope to read Harold Searles, Harry Stack Sullivan, and Silvano Arieti (this latter introduced to me on Twitter by Mark Ruffalo, whom I thank for this kindness. He also put me on to MIchael H. Stone's useful piece, "The History of Psychoanalytic Treatment of Schizophrenia," Journal of the American Academy of Psychoanalysis 27 [1999]: 583-601.). Other suggestions of still more authors I should read are welcome in the comments.
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