By Michael Guy Thompson, PhD
One of the things that haunts me about our all too human condition is how much pain we have to suffer in the ordinary conduct of our lives. Who do we turn to when we are in such despair that we don’t know where to turn? I believe all of us suffer from occasional feelings of fear, alienation, depression, confusion. Some suffer from these symptoms more than others, but we are all otherwise more or less the same in how vulnerable we can be. I try to connect with your deepest existential issues and help you get to know yourself intimately, in order to bring the passion and happiness than has been missing back into your life… or perhaps, for the first time?
For more than thirty years I have worked with the full spectrum of distress and consternation that inspires many of us to seek psychotherapy. My approach is existential, which is a penetrating yet personal approach to therapy. I also work with borderline and psychotic symptoms, getting to the bottom of why a happy life of love and wonder is so elusive.
I am among the few psychoanalysts who integrate their work with the existential perspective, rooted in my training with R. D. Laing. I have published several books and numerous articles about my work over the past thirty years. You can access these publications as well as unpublished lectures under the PUBLICATIONS menu elsewhere on this website and download them for free.
My Way to Existential Psychoanalysis
By Michael Guy Thompson
There has been considerable attention paid to the formulation of theory throughout the history of psychoanalysis and many of the arguments waged pertain to the presumed correctness of one theory over the other. Perhaps this is why there is an uncommon proliferation of theoretical formulations that seem so convoluted that they remind one of the age-old argument as to how many angels can dance on the head of a pin! The most prevalent arguments today concern advances that are said to have been made in the way that analysts are treating their patients and the theoretical underpinning that justify their techniques. Admittedly, I have been less than successful over the course of my professional career — going back some thirty-five years or so, first in London and more recently in San Francisco — with couching my views in such a fashion as to fit into one psychoanalytic school or other.
Though one’s penchant for theory can be gratifying as an end in itself, it has been my observation that theories have never played a significant role in the formulation of what psychoanalysts or psychotherapists actually do. Moreover, their tendency to generalize from the particular assumes a universality that strikes me as fundamentally foreign to the clinical situation. Practitioners learn from experience, and what they in turn derive from their experience are principles that guide them in their clinical activity. This means that principles have priority over theories because theories are derived from the experiences that principles presuppose. How are the two interrelated?
According to the Oxford English Dictionary a theory is a conception or mental scheme of something to be done, or of the method of doing it. It is also a systematic statement of rules or principles to be followed, or a statement of what are held to be the general laws, principles, or causes of something known or observed, as distinct from the practice of it. Finally, a theory is a hypothesis that is proposed as an explanation, a mere hypothesis, speculation, conjecture. You can see from this list of definitions that theories derive from principles that, in turn, serve as the source from which a theory may be formulated. Moreover, a theory, strictly speaking, is “merely conjecture, speculation, hypothesis,” it is neither the data (in this case, one’s experience) on which one’s views are founded nor is it the basis on which one’s knowledge is conceived. If an analyst doesn’t derive his theory from experience then he is obliged to borrow from the experiences of others. His clinical formulations are like castles in the air, pretty to look at but without a foundation. In contrast, a principle is depicted as a beginning, source, and foundation, that from which something originates or derives, or the ultimate basis for the existence of something. It can also be understood as a fundamental truth or proposition on which other propositions depend. In other words, principles are fundamental to what may ultimately become theoretical formulations, or they may serve as ends in themselves, depending on how wedded to theory the practitioner happens to be.
Put another way, a principle is the origin of what we know. In the context of psychoanalysis, principles and technique are necessarily interdependent because the one relies on the other for the development and articulation of each. A hundred years ago Freud’s experience as a clinician gave rise to principles of technique from which his theoretical formulations were derived. Yet there is no necessary relationship between the theories Freud formulated and the principles upon which they are founded. This is what is both maddening and unique about psychoanalysis. It does not especially lend itself to theory because it pertains to experiences, both those of analysts and their patients, that are unpredictable, unrepeatable, and where the unconscious is concerned, unfathomable. Freud had no theories when he began his career and he was tinkering with them until the day he died.
What he never wavered from, however, were the principles upon which his clinical work and the theories he derived from them were based. These principles have changed little in the century that has followed since their conception. The history of psychoanalysis may be characterized as a Babel of tongues (theories) that have endeavored (to a considerable degree, unsuccessfully) to make sense of what experience tells us. What are these principles and what is the source of their power?
Let’s begin with the fundamental rule of psychoanalysis, the pledge to be honest as articulated by Freud and, with modifications, remains so today. My method is to examine these technical principles and their tributaries phenomenologically, which is to say, from the analyst’s lived experience, by exploring their internal consistency as they emerge from a clinical context. This is the basis of my conception of an existentially based approach to psychoanalysis. Let me explain what I take phenomenology to mean and how I employ this term in my work.
Whereas the term, phenomenology, is invoked in a common sense sort of way with increasing frequency in the psychoanalytic literature, the way I conceive it is rooted in the philosophical discipline that was initiated by Edmund Husserl and subsequently modified by Martin Heidegger. Typically taken to mean that which pertains to the person’s experience, phenomenology is a discipline that arose around the same time Freud was formulating his treatment philosophy. Its method is devoted to subverting the over-conceptualization of human existence with which the modern era is identified by bracketing theoretical explanations and returning us, in our naiveté, to the ground of our native experience. According to Edie (1962),
Phenomenology is neither a science of objects nor a science of the subject; it is a science of experience. It does not concentrate exclusively on either the objects of experience or on the subject of experience, but on the point of contact where being and consciousness meet. It is, therefore, a study of consciousness as intentional, as directed towards objects, as living in an intentionally constituted world [i.e., one founded on intersubjectivity]. (p. 19)
Phenomenological inquiry differs from conventional scientific investigation in that science is not concerned with nor is it able to study experience; its manner of investigation is directed instead to objects of perception, the nature of which is said to exist independently of the person who conducts the investigation and whose reality is presumed to exist independently of the investigator. This is why science is unable to account for the experience of the person who engages in research because the person’s experience is (alleged to be) separated from and, consequently, inaccessible to the object of scientific investigation, no matter what the object may be, whether material, conceptual, imaginary, or interpersonal.
Diametrically opposed to this standard of investigation, phenomenology seeks to examine the nature of the world as experienced, whatever the object of inquiry may be, including one’s self, one’s thoughts, and one’s experience of others. In other words, instead of applying a theory that presumes to account for what is happening “in” the patient one is treating, the phenomenologist goes directly to the person himself, by examining his experience of his relationship with this person. This is not a matter of speculation but of determining the ground of experience at the moment it is transformed through the interhuman bond shared with others.
Following Husserl’s call to return to “the things themselves,” a generation of phenomenologists, including Martin Heidegger, Max Scheler, Jean-Paul Sartre, Maurice Merleau-Ponty, Paul Ricoeur, and Immanuel Levinas set out to investigate their experience of the world in a radically different manner than the one to which scientists or philosophers were accustomed. According to Safranski (1998), Husserl and his followers
[W]ere on the lookout for a new way of letting the things approach them, without covering them up with what they already knew. Reality should be given an opportunity to “show” itself. That which showed itself, and the way it showed itself, was called “the phenomenon” by the phenomenologists. (p. 72)
Ironically, phenomenology resists definition because, like experience itself, its method is antithetical to theoretical and causal explanation. Its point of departure is its rejection of the conceptualizing tendencies of the hard, human, and even social sciences. In the preface to his Phenomenology of Perception, Merleau-Ponty (1964) suggested that phenomenology is necessarily difficult to define because it,
[R]emains faithful to its nature by never knowing where it is going. The unfinished nature of phenomenology and the inchoative atmosphere that has surrounded it are not to be taken as a sign of failure; they were inevitable because phenomenology’s task was to reveal the mystery of the world and of reason. (p. xxi)
Phenomenology shares with psychoanalysis the view that explanation is inadequate to the task of understanding what is given to experience and shares with psychoanalytic treatment the task of determining the nature of suffering in a manner that does not objectify or categorize the sufferer. In other words, instead of posing the scientific question of what causes one to be this way or that, the phenomenologist asks, “What does it mean that I experience the world this way or that?” Once the meaning-question is substituted for that of causation one enters the realm of phenomenology, because in raising this question one accepts the inherent mystery of our existence, the puzzle of which has never been solved and is not likely to be. This feature of phenomenology (that the object of experience can never be decisively separated from the subject who experiences it) is both intentional and intersubjective, because my experience of the other person must remain unremittingly mine, with all its attendant ambiguity and baggage.
In recent years a so-called paradigm-shift is said to have shaken the foundations of psychoanalysis and altered its course. I refer to the emergence in the American psychoanalytic community of the relational and intersubjective perspectives that posture their views as advances over Freud’s technical formulations. It is claimed that a two-person psychology is distinct from a one-person paradigm and a relational perspective can be distinguished from a biological one. I perceive these developments as essentially theoretical in nature and so offer nothing novel or original in the way of technical innovation, despite claims to the contrary. In as much as this model is depicted as a departure from the classical drive perspective, I perceive in Freud’s technical formulations a sensibility that faithfully approximates a phenomenological orientation, even when his theories contradict his clinical intuition.
Approached from this angle, psychoanalysis is already phenomenological — which is to say, personal — in its latency because it has always favored interpretation over explanation, and because it relies on the experience of the patient to guide the treatment, not what the psychoanalyst presumes to know. Yet despite the phenomenological nature of psychoanalytic inquiry, there has always been a tendency among analysts — beginning with Freud — to extrapolate theories from experience (or from the theoretical constructs of others) that presume to explain what we are unable to see with our eyes. Whereas the phenomenologist resists engaging in speculation as a matter of course, psychoanalysts often thrive on it, in effect wanting it both ways: to offer, in one breath, interpretations that try to deepen the patient’s experience, while in the next offering explanations for what is supposed to have “caused” the patient to be the way that he is. In contrast, the phenomenologist admits from the beginning of his inquiries that he does not know where he is going and does not need to. This is why the phenomenologist’s perspective is skeptical instead of theoretical, because it is rooted in a philosophy of perpetual inquiry, one that is surprisingly compatible with Freud’s technical principles. I would even argue that Freud’s principles of technique make little sense outside of a phenomenological context.
It is my thesis that the fundamental pivot around which the psychoanalytic experience revolves is the self-disclosure that each patient affects through the act of free association. It may be surprising to note that after a century of debate and discussion, there is still no universal agreement as to what free association is, and whether it is indispensable to the therapeutic experience or superfluous. I believe that free association is not only ubiquitous to therapy (even for those practitioners who reject this principle), but that our understanding of what it entails turns on a fundamental premise that has been systematically omitted from the psychoanalytic literature since Freud introduced it: the explicit (or implicit) promise to conceal nothing from one’s therapist. I am referring to the pledge to be as honest or candid as one is capable of being throughout the duration of therapy. In a word, the pledge to be as authentic as one can be.
If the therapeutic experience may be characterized as one of lifting the veil from what we typically conceal, even from ourselves, then the practice of psychoanalysis is an inherently dangerous proposition. If we are to place ourselves at risk with what we are about to discover about ourselves — the analyst as well as the patient — then it behooves us to proceed with a measure of caution. It is one thing to say this and another to put it in effect, to be wedded to it. Since the inception of psychoanalysis Freud took pains to harness the potential for inflicting harm on one’s patients by formalizing a set of constraints that were conceived as rules, or recommendations, to follow. Between 1905 and 1915 he crafted a series of technical recommendations that were paradoxically intended to restrain psychoanalysts from the temptation of doing too much (therapeutic ambition) for their patients, while protecting themselves and their patients from the risks unavoidably encountered in this enigmatic treatment method. Instead of providing instructions about the do’s and don’t’s of the analytic experience, Freud offered nothing more palpable than a set of first principles that merely assigned the respective roles that analyst and patient should play. Although some have complained about the paucity of instructions Freud offered, most therapists today have come to appreciate from their clinical experience the limits of what practitioners can be told what to do, no matter how many years of instruction or supervision they accrue. If anything, therapy students today are over-trained. Their work is scrutinized, supervised, and evaluated by others who, try as they may, cannot possibly know what it is like to be in the room with the person the student is treating. Freud did not write a manual on how to conduct therapy because he concluded that everything of a positive (i.e., active) nature should be left to tact and the analyst’s own judgment, whereas the principles themselves should remain, like a moral fable, of a cautionary nature. In this sense, Freud’s technical recommendations are nothing less than ethical precepts, because their purpose was to formulate a working terminology with which the analyst’s experience could be articulated and communicated to colleagues. This is why the Hippocratic counsel, “do no harm,” remains the paramount consideration, not the utilitarian goal of success by any measure.
Ultimately, therapists must come to terms with these principles in their own way and interpret them to the best of their ability. Yet, a typical, contemporary study of psychoanalytic technique leaves little to chance and less to the imagination, written as though it should be obvious what should — indeed, must — be done, when, and to what degree. The principles themselves are now so diluted that analysts no longer know what to make of them, let alone how to adapt them to their necessarily idiosyncratic situation. This account, however, is not an historical nature but a practical one, for my purpose is to show that psychoanalysis has not, as some insist, “progressed” over the course of the last century but, on the contrary, has lost something in the interim: I am referring to its edge.
It is my impression that psychoanalysis, like an old codger, is dying, and analysts have no one to blame but themselves. I know I am not alone in this, though I suspect this assessment will shock those who do not appreciate the gravity of the situation. American culture has turned against it, and who can blame them? In parts of Europe and South America psychoanalysis is on the cutting edge, because it still has an edge that cuts. This was always its intention, Freud’s intention, to cut, wound, elicit bleeding, if not blood then call it passion, suffering, angst. The best patient was the one whose back is against the wall, ready to take a leap over the precipice, given the chance to become who he is. Only a fool could be expected to endure what would follow. It was no, as Frieda Fromm-Reichmann suggested, bed of roses. The dreadful, as Heidegger observed, has already happened. Like Freud, I believe you must swallow the poison and pay the price if you seriously expect to change.
Yet there was a time when psychoanalysis flourished in this country when elsewhere it just managed to hang on. In Europe psychoanalysis was the pet of the intelligentsia, where it became existentialized, while in America it became medicalized and its doctors got fat with grand promises and unrealistic expectations. In America psychoanalysis has rarely been concerned, as it is in Europe, with the problem of human existence — la condition humain — that speaks to the enduring fact of our suffering and the elusive promise of liberation. Instead, its goal has become one of relieving that old saw, mental illness, diagnosable, to be sure, whose anticipated cure holds the hope that one eventually will recover, if you wait long enough. Following this model, debates have accrued around the collective myth that one can separate the good analysts from the bad, the well trained from the incompetent, the well suited from the incorrigible. By what criteria are we expected to distinguish the one from the other? Who is to serve as the judge?
It seems to me, I know this is heresy, that all the progress psychotherapy has made since Freud’s death has amounted to little, if any, improvement in our understanding of the human condition. In the last half-century or so, we have cultivated, developed, and perfected the life out of it. Its edge has dulled, a consequence of what is left of a social acceptance that fuels what remains of its diminishing popularity. There is an irony here, an anomaly between talk about its “improved” methods on the one hand and the repression of its edge on the other. Many seem to have forgot that it was Freud, in symmetry with the existentialists, who introduced us to our dark side, which is just as authentic as the face we perceive in the mirror. Is it more ethical to conceal our dark side and, thus, “protect” others from ourselves, or to be what we authentically are and go to bed with a clear conscience? This is a fundamentally ethical question, not a psychological one. It was Freud who introduced the principles of morality, character, ethics, into the fabric of psychoanalysis and inaugurated in its wake a novel conception of honesty, becoming the greatest moral essayist since Montaigne (Harold Bloom).
Psychoanalysis has always been and is even today about truth, about disclosing what we dare about ourselves to another person. In fact, it is concerned with no other question. Not the truth of science or jurisprudence, but the truth (even the law) of the jungle, and of the price we invariably pay when we suppress it. This is why psychoanalysis was always supposed to be radical from the start, because it championed the act of lifting the veil and giving voice to what lurks beneath our protestations to the contrary. Despite all the talk about the parameters of effective treatment methodology, or the emergence of cutting edge theories into practice, we are still, a century after trying, more or less at sea with the patients we encounter each day. We are still, no matter how much we protest to the contrary, no matter how many years of experience we have accrued, flying by the seat of our pants. There is nothing wrong with this because that was always as it should be, as in looking through a glass darkly. How effective, skilled, or adept any of us are or may eventually become as practitioners is just as difficult or impossible to assess today as it was a century ago, no matter how much supervision, oversight, or scrutiny we are subjected to. All that we have to go on, as a beacon in the darkness ahead, are what we had in our discipline’s infancy: a set of first principles that, if sufficiently elastic, guide us in that necessarily isolated, unremittingly lonely, universe of the treatment situation.
My work over the past thirty-five years has been devoted to showing how the essential, albeit unpopular, features of psychoanalysis are in danger of being forgotten, overlooked, and suppressed by successive generations of therapists who, ironically, have the most invested in its survival. In this endeavor I hope to counter the common wisdom that characterizes psychoanalysis as the epitome of what is erroneously depicted as aloof and disengaged, whose real purpose bears little, if any, relation to so-called analytic orthodoxy.
The context of therapeutic work and its objectives are and always will be the problem of what a human being suffers and what, if anything, the relationship between two people can do about it. With these observations in mind, I hope I have succeeded in depicting what existential psychoanalysis is by speaking to its essential latency. By returning to the thing of psychotherapy itself, the what and wherefore from whence it came, I hope you are able to take a small step toward reclaiming the possibility of enjoying your own experience with it, as it moves around, within, and potentially between us.
March 22, 2014
Edie J. (1962) Introduction. In Thevanaz, P., What is phenomenology? And other essays. Chicago: Quadrangle Books, 1962.
Merleau-Ponty, M. (1964) Phenomenology of perception. (trans. Colin Smith) London: Routledge & Kegan Paul.
Safranski (1998) Martin Heidegger: Between good and evil. Cambridge, MA: Harvard University Press.
Working with Schizophrenia
and the argument for ongoing psychotherapy
By Michael Guy Thompson
What is schizophrenia? The fact is that none of us knows. It is a word, a label, that we confer on a person who we believe has lost his mind, or is acting crazy and perhaps dangerously so, and that in turn frightens us. Psychiatrists associate this condition with certain symptoms that are supposed to be obvious, such as delusional thinking — e.g., paranoia — or hallucinations — e.g., hearing voices — or speaking in a manner that is impossible to follow because it doesn’t make any sense, at least to us.
It can be scary to witness a person we have known all our lives begin to act crazy and accusing us of trying to put thoughts into his head, by insisting that he hears voices that are telling him what to do, and isn’t behaving the way he ordinarily does, or that we think is normal. When my communication with him becomes impossible to rely on, it’s as though all semblance of order has broken down and I don’t know what to do. Whom do I turn to for help, counsel, or advice?
Typically, we take this person to the hospital, to their crisis unit, and they will take control of the situation by effecting a mental status examination. And if this person is indeed exhibiting signs of schizophrenia or some other, similar psychotic condition, they will medicate him with the drug or drugs that they believe will diminish those disturbing symptoms by sedating him. Indeed, they will not release that person until those symptoms have abated.
Unfortunately, this is not the end of our story. This is when the heartache really begins. Medicating drugs, a misnomer if there ever was one, do not actually “treat” the condition they are prescribed for. Unlike, say, antibiotics, they do not eradicate the so-called illness that we believe schizophrenia is. They don’t cure anything. What they do, like narcotics, is mask the symptoms that are so disturbing to the person experiencing them, and the people around him. They act as sedatives, which is to say, they render us senseless. Granted, this may seem like an improvement over the delusions, hallucinations, or other disturbing behavior that this person was exhibiting. But as everyone knows who has had a loved one go through this, medication rarely returns this person to a normal, viable way of dealing with the world and other people.
Many of the people who complain about taking such drugs (e.g., Thorazine, Haldol, Abilify, Lithium, etc.) say that though their symptoms are diminished, they are left feeling in a haze, they have lost interest in their life, other people, and pleasurable activities. Most of all, they have lost their mental acuity and the sharpness required to engage in intellectual activity. Now what are they supposed to do? How do they get on with their life, if it has lost all meaning to them?
At the beginning of the twentieth-century there weren’t many drugs available for diminishing the symptoms of schizophrenia or bipolar disorder. Psychoanalysis — “talking therapy” — seemed to fill the breach and mental hospitals devoted to treating psychotic disorders employed psychodynamic therapy as their principal treatment regimen. Whereas psychoanalysis gained renown for alleviating less disturbing, neurotic symptoms, its success with schizophrenia was relatively mixed. The reason for this is twofold: 1) psychotic symptoms are much more difficult to treat and far more resistant to therapy, so it often takes longer to see any results; 2) expectations for complete remission of symptoms was unrealistic. As with neuroses, gains from therapy are always relative. No one, neither neurotics nor psychotics, has ever been completely cured of their condition. Success is typically measured by palpable improvement in one’s condition, that one is better off than one was before treatment.
In the 1980s a biochemical revolution in psychotropic medication occurred and powerful drugs appeared on the market that succeeded in masking the more disturbing symptoms in question: paranoia and hearing voices. If our criteria for success were to be measured strictly in terms of diminished paranoia and hallucination then this biochemical revolution would have to be deemed an astounding success. As we have learned, however, mitigating these symptoms does not, in and of themselves, result in a viable life. It does not necessarily mean that one’s capacity for intimacy with other people has been enhanced, that the person being treated enjoys his or her life, that the loss of self-esteem and self-regard have been restored to a normal, healthy condition. And what of the medication itself? The side-effects are often toxic and the patient being treated with them often complains about them. This is why most people taking such drugs resist taking them, only to see their more alarming — and noticeable — symptoms reappear. The game that then ensues — to devote one’s efforts to medication compliance at all costs — fails to address the problems that such medication is unable to address: to restore the patient to a life that is worth living, a viable and engaged existence.
For the past decade, psychotherapy and medication have been engaged in a sort of competition, one claiming to be better than the other. This is a false competition, because neither is a panacea to our problems. Most psychiatrists and psychotherapists nowadays have concluded that people suffering from schizophrenia benefit from both medication and psychotherapy.
In the 1980s a former patient of Chestnut Lodge Sanitarium, a psychoanalytic mental hospital in Rockville, Maryland noted for treating schizophrenia and depression with a strict regimen of psychoanalysis without medicating drugs, sued the hospital. The former patient, who had been admitted for severe depression, saw no improvement in his stay and his condition actually deteriorated. After his family removed him he was treated with medication and his condition improved. This was not unusual. Some patients respond to psychotherapy and some do not. Chestnut Lodge was famous for its commitment to psychoanalysis and patients typically sought treatment there because medication had not helped them. The case was settled out of court, but the patient who brought the suit then initiated a decade-long public campaign to discredit Chestnut Lodge and other hospitals that promoted psychoanalysis exclusively. This succeeded in turning public opinion against the psychoanalytic treatment of schizophrenia (though the patient who brought the suit was not schizophrenic) and subsequently virtually every psychoanalytic hospital in America (e.g., Menninger Clinic; Austen Riggs; Sheppard and Enoch Pratt, etc.) added medication to their treatment regimen in order to avoid potential lawsuits.
As often happens, the pendulum swung violently toward the use of medication as the “standard of care” for schizophrenia, whereas previously it has swung in the direction of psychotherapy alone. Many today would argue that without psychotherapy, drug treatment alone does little to improve the quality of a person’s life who suffers from psychotic symptoms. Given the costs of psychotherapy, most hospitals nowadays devote themselves exclusively to drug treatment. Moreover, most psychiatrists today insist that medication for schizophrenia is a life-long affair and that such patients should not expect to ever live without such medications.
I have been treating patients who suffer from schizophrenia, bipolar disorder, and other psychotic symptoms for the past thirty-five years, in Great Britain as well as the San Francisco Bay Area. I have done so in the context of mental hospital, residential milieu therapy households, and in out-patient private practice. Most of these patients began with medication, but over time, with the benefit of ongoing psychotherapy, they were able to wean themselves off of medication entirely. Psychotherapy works exactly the same with people suffering from psychotic symptoms as it does with milder neuroses. The objectives are exactly the same: improvement in one’s relationship with others, enhanced capacity for intimacy, increased self-esteem, better quality of life.
This is no silver bullet. Psychotherapy is not a panacea. Some people benefit from it more than others, and we don’t know why this is the case. The core benefit of therapy is that it entails a viable relationship with another person who does not sit in judgment, but is capable of being honest and compassionate. Over time, this usually provides an incentive to risk other relationships too, with friends, sexual partners, family members. Though one may never be entirely free of the sense of vulnerability that we associate with schizophrenia, one’s quality of life is usually significantly improved, over time.
If you, or a family member, is suffering from schizophrenia or other psychotic symptoms I would be happy to meet with you to discuss treatment options.
The Myth of Mental Illness Redux
By Michael Guy Thompson
In the following remarks I want to say something about the problem I have with the conventional meaning of the word psychopathology, or as we typically encounter this term in the media, “mental illness.” The two most prominent psychiatrists who cast doubt on this concept were R. D. Laing and Thomas Szasz, each of whom achieved remarkable notoriety for their respective views on this topic in the 1960s and 1970s. Each remains an iconic figure in the field of psychiatry. In The Politics of Experience, for example, published in 1967, Laing questioned whether schizophrenia, the form of psychopathology he was most identified with, even exists. Yet many of the people Laing saw in psychotherapy suffered terribly, and sought his help to relieve them of the most incredible anguish. So what, exactly, was Laing relieving them of, if not a psychopathological condition? Surely, if there is such a bona fide activity as psychotherapy, then there must be some condition, or state of mind, however we come to label it, that the therapeutic process presumes to relieve. What else is the one person, the so-called patient, paying the other person, the so-called therapist, for?
Thomas Szasz, the author of The Myth of Mental Illness, published in 1960, built his career around the notion that mental illness is nothing more than a myth, that there is no such thing as an “illness” of the mind, and that psychiatrists have orchestrated a hoax by claiming they are treating patients for mental illnesses that don’t exist. Laing also rejected the concept of psychopathology, but took a more nuanced, less polemical approach to the problem than Szasz. Whereas Szasz argued that the entire structure of psychiatry, including its psychological derivative, psychotherapy, should be abolished, Laing argued that however flawed psychiatry is, we still need it, or something like it, to help those people who want someone to relieve them of their unremitting distress, but not necessarily in the way that psychiatry typically helps them. Though this distinction is not an easy one to appreciate, I hope to bring some clarity to the problem.
Let’s begin with the term itself. The word psychopathology derives from the medical term pathology, which comes from the Greek pathos, meaning suffering. The term was also used by the Greeks to connote passions, or feelings more generally. The first psychotherapists were physicians and the term psychiatry, which was only coined in the nineteenth-century, became the medical specialty of doctors whose mandate was to treat the psyche or the soul, or as we say nowadays, the mind. Both Laing and Szasz argued that psychiatrists, and for the most part psychoanalysts, have misunderstood the kind of suffering that people labeled schizophrenic are experiencing. They also believed that psychiatric nomenclature does little to help us understand the phenomena so labeled. If what psychiatrists believe they are treating is not, in fact, schizophrenia, or any medical or psychopathological condition, then what is it they are treating, if anything? And why do we, whether psychiatrists, psychologists, or lay psychotherapists still refer to the conversations we conduct with our patients as treatment, or its derivative, “psychotherapy?”
In order to ponder these questions I want to explore further whether the conversations we enjoy with our patients, though not specifically medical in nature, may nonetheless be termed a form of “therapy.” The subtitle Laing assigned to The Divided Self was “an existential study in sanity and madness.” It was not an existential study in psychopathology. Why this distinction? Are madness and psychopathology not the same thing? To answer this, I want to take a look at what Laing set out to accomplish in The Divided Self, why he calls it an existential study, specifically, and how this now-classic work laid the foundation for what would eventually evolve into anti-psychiatry.
As Laing says in the preface, the book is “a study of schizoid and schizophrenic persons,” and its basic goal “is to make madness, and the process of going mad, comprehensible.” At the outset, the diagnostic language Laing employs is readily familiar to every psychiatrist and psychoanalyst who works with this population. Terms such as psychotic, schizoid, schizophrenic, paranoid – all standard nosological entities with which therapists the world over are familiar – proliferate throughout this book. He is speaking their language, so to speak, but the meaning he is assigning to these terms is anything but ordinary. Laing explains he has never been especially skillful in recognizing the diagnostic categories that are standard in every psychiatric diagnostic manual in the world, including the Diagnostic and Statistical Manual (DSM) that is the bible to the mental health industry in America. Laing had trouble recognizing the subtle nuances that are supposed to distinguish, for example, the various types of schizophrenia, of which there are many, or even what distinguishes them from other forms of psychosis, including paranoia, or bipolar disorder (which used to be called manic-depressive disorder), or dementia.
None of these terms is laid in stone. In fact, they are constantly changing and undergo revision in every new edition of the DSM, currently in its fifth edition. So what is Laing saying here? Is he suggesting that he is too stupid to understand the complexity of these entities? I don’t think so. Rather, he is proposing that because there is no agreement in the psychiatric community as to how to recognize such symptoms and the mental illness they are purported to classify, it is impossible to take them literally, or even seriously. No two psychotherapists or psychiatrists agree on how to diagnose a person, and given the never ending revisions to these categories, currently numbering in the hundreds, practitioners often change their own minds as to how to recognize what it is they are supposed to be diagnosing and treating. This is hardly the science it is purported to be.
What did Laing conclude from this disarray in categorization? That there is no such thing as mental illness, or psychopathology, so no wonder there is no agreement as to what it is. When a doctor sets out to diagnose a typical medical illness, he customarily looks for physical symptoms in his patient. The color or tone of one’s skin, dilation of the pupils, body temperature, and so on may indicate an abnormality. Additional tests may be administered that examine the blood or urine, and if that fails to provide conclusive results, perhaps x-rays, CAT scans, EKG’s, heart stress tests, biopsies, mammograms or prostrate exams – all ways of examining the chemistry or interior of the body – may be utilized in order to hone in on what is malfunctioning. For so-called psychiatric symptoms, however, such tests will be of virtually no use, because no one has ever been able to locate any of the symptoms of psychopathology inside or on the surface of the body. Even an examination of the brain, now the darling of neuropsychiatry and neuropsychoanalysts, has yet to locate the presence of any form of mental or emotional disturbance that we can
Instead, what we are able to examine is the behavior of the person being diagnosed, whether, for example that person is suffering from delusions or hallucinations, confusion, disorganization, incoherent speech, withdrawal, flights of fancy, or depression, anxiety, dissociation or maladaptation, or perhaps a persistently elevated, expansive, or irritable mood, and so on. This list is hardly inclusive, but what all such symptoms have in common is that they signify experiences that everyone has, at one time or another, some more than others, some less. Even delusions and hallucinations, the gold standard for schizophrenia, are common in dreams, and not that uncommon when we are awake. Yet most people who exhibit or experience these so-called symptoms are never subjected to a formal diagnosis or treated for them. So why is it that some people are and some people are not? Why are some people deemed crazy and others sane, when they exhibit the same symptoms?
The principal mode of treating psychotic conditions today is not psychotherapy, but medication. Medication is typically prescribed for a medical illness or condition, so why is it prescribed for mental illnesses that do not really exist? How is it that drugs are used to treat people who do not suffer from a medical condition? There is nothing about drugs, inherently, that possess medicinal properties, though some do. Drugs were around a long time before they were adopted by medicine, and most of the drugs we use today are not the kind you need a prescription for. Alcohol, marijuana, opium and its derivatives, coffee, sugar, tea, tobacco are only some of the traditional mind-altering drugs that nearly all cultures throughout history have employed. For what? To reduce our anxieties, and perhaps the tedium of an unsatisfying life or a stressful occurrence. There is nothing wrong with this. Drugs are used to enhance our lives, though some in desperation err in believing they can obliterate our problems. We call them “addicts.” What distinguishes these drugs from the kind promoted by psychiatry is that street drugs are used episodically, when the need arises, usually prompted by anxiety. Prescription drugs, such as Prozac, Paxil, Zoloft,, Wellbutrin, Thorazine, Haldol, Abilify, Lithium, Adderall, or Xanax are employed variously for depression, psychosis, bipolar disorder, attention deficit disorder, or anxiety and are ingested daily in order to remain in the nervous system continuously. Whereas street drugs are ingested in response to anxiety or boredom, prescribed drugs are ingested to prevent such feelings from arising, or to keep them in check.
What all these drugs share in common, whether prescribed or recreational, is not that they are treating a medical condition, but that they are capable of altering our states of consciousness, depending on the state of consciousness we wish to alter, and whether it is distressing. We like to say that alcoholics are self-medicating their depression or anxiety, but in fact they are not “medicating” anything. They are simply using a drug to mitigate their suffering whenever they feel they cannot handle it. Again, there is nothing wrong with this, nothing immoral or sick about it. We all draw the line somewhere. Some of us are able to handle a lot more anxiety than the next person, and some of us are pretty astute at solving our problems before they get out of hand. We don’t know why some people manage the stress and strain of everyday life more ably than others, but whatever the root cause or causes might be, we are nonetheless left with a choice when confronted with these feelings: we can either examine why life is making us so anxious and try to do something about it, or we can render ourselves senseless with drugs. What do we gain by calling these problems forms of mental illness? I don’t think you have to ponder that question for very long in order to arrive at the obvious answer. There is a drug industry that makes enormous amounts of money selling this product to an unwary public who don’t know any better.
These are only some of the questions that Laing raised in The Divided Self, but he never arrived at a conclusive answer as to how to solve to them. In matters of the mind, the act of diagnosis can just as often be a political as medical ceremonial. I don’t believe we will ever succeed in understanding such phenomena as long as we persist in looking at people from an alienating, and alienated, point of view. It is the way that we look at each other, the way that psychiatrists and psychoanalysts typically see a patient when they look at him or her, that is the crux of the problem. The reason Laing called The Divided Self an existential study instead of, say, a psychiatric, or psychoanalytic, or even psychological study is because the existential lens is a supremely personal way of looking at people, a person to person manner of regarding others and recognizing them, as Harry Stack Sullivan once said, as more human than otherwise. This is another way of saying that the person, or patient I am “treating,” is not literally a sick person, but a person like me. And it is the fact that my patient is just like me that allows me to understand and empathize with him in the first place.
Laing began writing The Divided Self while still working at a mental hospital in Glasgow, when he was just in his twenties. It doesn’t sound like he had an opportunity to do much psychotherapy there, but he did have lots of time to hang out with the patients under his charge, all of them diagnosed as schizophrenic. Instead of looking for symptoms of recognizable forms of psychopathology, Laing sought to simply talk to his patients, as he was fond of saying, “man to man,” and to listen to what they had to tell him. What he heard was nothing short of amazing. They told him stories about their life, their belief systems and experiences, the things that worried them and the things they thought about, day in and day out, just like any sane person would. The thing that I remember standing out for me when I first read this book was that I felt he was talking to me. This, from what I have subsequently gathered from others, was not an unusual reaction. It is this reaction that has made this book the classic that it is.
Instead of trying to determine what makes “us” – the sane ones – so different from “them” – the ones who are crazy – Laing sought to explore what we share in common. Laing used the term schizoid – quite common in Britain but only marginally employed in the U. S. – to depict a state of affairs that lies at the heart of every person labeled schizophrenic, as well as many who are not so schizophrenic, in fact all of us to varying degrees. The common thread is this: that the person so labeled, in his or her personal experience, suffers from a peculiar problem in his relationships with others: he cannot tolerate getting too close to other people, and at the same time cannot tolerate being alone.
This is a terrible dilemma to be burdened with. Most of us either hate to be alone and throw ourselves into the social milieu with others (Jung would have called them extroverts) or we cannot bear social situations and opt instead to spend most of our time by ourselves. These more introverted, private individuals may be gifted writers or artists or scientists or deep sea divers who are well suited to their relative isolation, whereas the extroverts among us make excellent politicians or salesmen or actors or any number of other callings that entail contact with other people. In other words, we tend to incline in one direction or the other, and either may be a perfectly viable way of existing and living a happy, contented life. The person who is schizoid, however, doesn’t excel at either. He cannot tolerate isolation, nor can he get genuinely close to others. He is caught in a vise, a kind of hell, that is rife with unrelenting anxiety, what Laing calls ontological insecurity, because simply existing is a serious and persistent problem for him. In speaking of a person this way we are not really diagnosing him, we are simply describing what it is like to be him.
When I first read this I couldn’t help but wonder how many of us are really all that comfortable being alone, and how many of us are truly that taken with our relationships with others, which is to say, free from anxiety. Isn’t this a problem, for example, that psychotherapists typically share in their work with their patients? Psychotherapy is a fabricated relationship whose purpose is to achieve uncommon intimacy with another person, while placing extraordinary constraints on it, conducted by two people who, relatively speaking, have problems with getting close to others. Isn’t this rather like the lame leading the blind? Laing didn’t think so, but he was acutely aware of the paradox, of how wounded a person must be to want to spend all of his professional time in the company of people who are obsessed with their problems!
Laing was not the first to recognize this paradox. Nor was he the first to accuse psychiatrists of employing means of helping others that are for the most part ineffectual. For that Sigmund Freud would have to be credited, arguably the first anti-psychiatrist. Freud was a neurologist, not a psychiatrist, and he was scathing in his commentary about the psychiatrists of his day who, Freud believed, knew nothing about why their patients suffered, nor how to help them. Freud believed that people develop symptoms of hysteria and other neuroses because they have been traumatized by unrequited love in their childhoods. He was the first to recognize the powerful effect that our parents, in fact all our social relationships, have on us, how our capacity to love is also the source of our greatest sorrows. Freud was also the first to recognize that our craving for love is both unremitting and insatiable, no matter how much we get, and that we are most vulnerable when at the mercy of the person we love.
Yet Freud was not interested in the kind of person Laing described in The Divided Self, because he didn’t believe a person who is schizoid or psychotic is capable of attaching himself to the psychotherapist who is treating him and, so, cannot be helped by him. Freud was correct in recognizing how vulnerable such people are, but mistaken in his conclusions about their capacity for attachment, and for therapy. It has been argued that Laing accomplished for the so-called schizophrenic what Freud accomplished for the neurotic: a way of establishing an intimate relationship with this person that, in fact, may serve as a vehicle for healing. In fact, the distinction between psychoses and neuroses is not a significant one; it is a matter of degrees. Freud was unhappy with the brutal manner in which the hysterics of his day, mostly women, were typically treated, and even less happy with the prevailing understanding of psychological suffering. Unlike psychiatrists, Freud did not believe in an us versus them mentality. He did not believe, for example, that some people are neurotic and that some people are not. He believed that everyone is neurotic to varying degrees and that neurosis is an aspect of our human condition. He also believed that neurotics may, on occasion, become psychotic if pushed far enough. So if everyone is neurotic but curing us of neurosis is not in the cards, what is psychotherapy good for?
Freud was never able to definitively answer this question, though he was confidant that it can help. If you read between the lines, you can’t help concluding that Freud viewed anxiety, and the more psychotic forms of alienation that Laing was so good at describing, as essential aspects of our human condition. So what we call “ill” versus “healthy,” or crazy versus sane is not all that black or white, but shades of grey. If all of us are neurotic, and on some occasions even psychotic, some more, some less than others, then all of us are healthy and sane, to varying gradations.
Freud’s invention of psychoanalysis was a huge step forward in treating people we think of as nuts or crazy as human beings like ourselves. But once it was embraced by psychiatrists, psychoanalysis became another weapon in their war on mental illness. Whereas psychiatrists had depersonalized the relationship between doctor and patient by pretending that it wasn’t the person, but rather his illness, that was being treated, psychoanalysts depersonalized the treatment relationship by insisting that it wasn’t the person or his body that was responsible, but his unconscious. Though psychoanalysis made extraordinary gains in humanizing the treatment relationship over prevailing psychiatric practices, both seem strangely incapable of formulating a genuinely symmetrical therapy relationship between equals. There have been notable exceptions to this, such as Laing, who stood proudly on the shoulders of other remarkable, humanistic practitioners such as Sullivan, Fromm-Reichmann, Winnicott, and other psychiatrists and psychoanalysts who advocated more personal way of “treating” their patients, not treating them for illnesses, but treating them like
This isn’t to say that Laing was advocating simply being nicer, or kinder to his patients, as though that alone was sufficient. Instead, his concern was with being more real, or authentic with them, more honest. That’s a lot harder than just being nice. This, he believed, could only happen if we stop objectifying our patients into diagnostic categories that only serve to alienate them from us. Perhaps the model that best exemplifies what Laing advocated is not a relationship between therapist and patient, or parent and child, but one between friends. After all, friends confide in each other, and confiding is an essential aspect of what therapy entails. In one of his more mischievous moments Laing even suggested that therapists might as well call themselves prostitutes, because what patients are buying is not treatment, per se, but a relationship with another person. Whether he thought of himself as a friend, or prostitute, to his patients, Laing didn’t have a problem with calling the people who paid to see him his “patients,” any more than he had problems with calling what they were doing “therapy,” both undeniably medical terms. But isn’t this contrary to what I have been saying about the myth of psychopathology?
Whatever problem Laing had with the institution of psychiatry, he never had a problem with being a doctor. He was proud of his medical training, and while such training is not necessary to practice psychotherapy, he thought is was as good a way as any to enter the field. After all, what all doctors share in common is that they want to help people. This is basically what therapists are trying to do. Laing was fond of pointing out that the word therapy is etymologically cognate with the term attention or attendant. In ancient Egypt a religious cult called the Therapeutae were literally attendants to the divine, so the term predates the subsequent medical appropriation of it by the Greeks. If we take the term literally, a therapist is simply a person who is attentive, or pays attention to the matter at hand, the suffering of his patient. Similarly, a patient is literally a person who patiently bears his suffering without complaint. The term doesn’t necessarily refer to someone in medical treatment because the kind of suffering is not specific to the term itself. Laing concluded that if you put these two terms together you get one person, the therapist, who attends and is attentive to the other person’s, the patient’s, suffering. To what end? Hopefully, such attention, with enough patience, good will, and most importantly, time, will lead to something: an end point where the patient no longer requires such attention and can get along perfectly well without it.
According to Michel Foucault, the philosopher, it was purely by accident that medical doctors became responsible for treating crazy people in the first place, in eighteen-century Europe. If fact, it was a very recent moment in history when mad people were deemed mentally ill. Historically, people who acted crazy were thought to be possessed, either by evil spirits or the gods. In the seventeenth century Europeans began to feel unsafe with the crazy people in their midst, who wandered the streets – not unlike the homeless people who wander about our cities – and began to confine them as a means of protection. Not surprisingly, such confinement made them even crazier and their jailors began chaining them to the walls of the Lunatic Asylums they had put them in. They soon developed diseases, which only escalated their problems further until the French physician, Philippe Pinel, was brought in to attend to their specifically medical maladies and observed that the way they were being treated was inhuman. Pinel argued they should instead be treated as sick people, in order to treat them more compassionately. It was then, according to Foucault, that mad people were for the first time in history deemed mentally ill.
This was a remarkable step forward in treating such people with sympathy who deserved to be helped, but it also initiated the slippery slope that occasioned the birth of psychiatry and, with it, the diagnostic universe we now live in. Laing was proud of being a physician but recognized that we now find ourselves in an historical quandary. Like the Europe that invented the Lunatic Asylum, our society feels the need to protect itself from crazy people, some of whom are undeniably dangerous and capable of savage violence, even murder, but most of them are harmless, even more vulnerable than you or me. If and when violence does erupt, someone has to make the call: Is the person in question crazy enough to lose, even temporarily, his constitutional rights and be confined to treatment– which is to say, “medication,” intended to render him senseless or worse, against his will? Whether we like it or not, that task has been assigned to psychiatrists, and it has given them enormous power over those members of society they deem dangerous, whether to themselves or others. Laing had no ready or easy solution to this problem, but believed that all of us is implicated in it.
In fact, Laing never formulated an overarching theory of psychopathology to replace the edifice that psychiatry and psychoanalysis have built. For the most part, his focus was on schizoid phenomena and schizophrenia, not as specific diagnostic entities but, like Freud’s conception of neurosis, as a metaphor for varieties of mental anguish that compromise our ability to develop a satisfying relationship with others, and with ourselves. As the subtitle of The Divided Self suggests, Laing was more comfortable thinking in terms of sanity and madness than psychopathology. But what does it mean to be crazy? And what does it mean to be sane?
These terms lack precise definition when compared, say, with the plethora of diagnostic categories in the DSM, because they are used colloquially, as a manner of speaking, so it is up to each of us, individually, to determine how to employ them. It seems to me that the essence of what it means to be crazy, in the way that term is ordinarily used, can be broken down into three components, the combination of which will tell us just how crazy a person is. The first concerns how a given person exercises his or her judgment; the second concerns how agitated that person may be; and the third concerns the lengths a given person will go to mitigate his anxiety.
Our use of judgment is probably the most critical of the three, because it determines how we make sense of things, including the situation we are facing at a given moment. The judgment of a person suffering a manic episode, for example, is said to be seriously compromised, but so is that of a person who suffers from acute paranoia or hallucinations. Our judgment is where we live, and there’s no escaping it, though we can improve it if – and only if – we have the presence of mind to realize that we cannot entirely trust it. Yet, who gets to decide whether a given person’s judgment is impaired or sound? If I judge that I need help in improving my judgment and take my plight to a therapist, can I trust the judgment of that therapist over my own judgment? I’m not going to get much out of therapy if I can’t trust his judgment, but who is to say that my therapist’s judgment is more sound than mine is? How can I make such a judgment if, say, I don’t trust my judgment? This is a problem, and one that makes therapy almost, but not quite, impossible.
A person’s judgment is for the most part a private affair. The person who is crazed is often in a state of agitation, which others can’t help but notice. It is this state than usually makes my judgments public, when, for example, I am about to leap off a tall building, or assault someone for no discernable reason. This is the prototypical image that we all have of the crazy person, who is acting crazy, and often in a manner that not only gets our attention, but scares us, because we don’t know what he is going to do next. Each of us has been crazed at some time or other, but the moment usually passes before any real harm has been committed. If it persists, that is a different matter, and things can quickly spiral out of our self-control. This is when I am most likely to be taken to a mental hospital, whether I want to go there or not.
The third way I may feel or appear crazed concerns what psychoanalysts call defenses, the mind-games I employ to mitigate my anxiety. This was the issue that Laing was most concerned with in The Divided Self, the so-called schizoid person. We see his defenses in the way he engages in social space. As we noted earlier, this is a person who cannot tolerate being isolated from or being intimate with others because either position makes him intolerably anxious, so he walks a tightrope between the two where he feels the least amount of anxiety, but still too much fear to navigate his relationships effectively. Much of what we do to cope with our anxieties does not appear crazy and does not feel crazy, and works for us, more or less. It is the most severe states of anxiety, the more psychotic variety epitomized by ontological insecurity, that are the most problematic and result in extreme measures to mitigate, such as catatonic withdrawal.
If these criteria offer a rough and ready means of discerning what it means for me, or you, to be in a crazy state, then what does it mean to be sane? It would more or less approximate the exact opposite of feeling crazy. Our judgment would be sound, relatively speaking; our use of defensive maneuvers would be minimal because we would bear our anxieties with relative indifference; and we would not be in a state of panic or agitation, but one of serenity, of feeling at peace with ourselves and the world. When we weigh the two, there are no crazy people, or sane people. Every single one of us goes from one state to the other in the course of our lives and sometimes in the course of a single day. By this definition, all of us have been crazy, no matter how sane we are most of the time, and will be tomorrow. If this were not so there would be no way for a psychotherapist to connect or empathize with a person who has been diagnosed, say, schizophrenic. We can only help people with problems we ourselves can relate to, and have experienced ourselves.
No one has ever developed an air tight etiological theory of what “causes” us to become neurotic, or psychotic, or just plain crazy, though most therapists favor the environmental thesis over the biological. Neither model is entirely satisfactory, so our mental states and what accounts for them are for the most part a mystery, and may always be. We may never know why this person is crazier than the next person, or why, in fact, all of us are crazy in some contexts and not so crazy in others. It seems that some people are capable of driving others crazy, but there are those who appear to be perfectly capable of becoming crazy by their own device. It appears that common deception is a problem, but difficult to recognize in the situation as it is lived. The bottom line, given the inherent ambiguity of the situation we find ourselves in, is to proceed cautiously, with a degree of humility in how we treat such people when we meet them.
Whenever Laing addressed this topic, whether in writing or in public, he often invoked the Golden Rule. How would you, if you lost your wits, fell apart with grief or consternation, want to be treated by those who have you at their mercy? When the shoe is on the other foot, shouldn’t you treat them the way you would like to be treated yourself? It is impossible to separate our thoughts about psychopathology from the work of psychotherapy. If I met a mad person on the street who was threatening me, I would defend myself without hesitation and, if need be, ask the police to confine him. But if he wandered into my consulting room, no matter how crazy he might be, and wanted my help, and was not trying to assault me, that is another matter. And that is the matter that concerns us all. How we come to meet another person in dire straights, whether we happen to be that person’s therapist, family, or friends, and how to treat that person in such a way that, in the name of the Hippocratic oath, we do no harm.
And what of today? One century after the birth of psychotherapy, are we more humane and compassionate in our treatment of those at our mercy? It is difficult to say. But one thing we cannot deny, our culture has become even more “medicalized” than at any time in history. The medical metaphor that Laing found more or less acceptable when explaining what he thought therapy is, has become increasingly literal. In California, we even have medical marijuana. Pot is not just a pleasing way of altering our consciousness, it has become medicine. When you smoke pot you are no longer getting high, you are medicating yourself for whatever ailment you are “treating.” You are no longer deemed a pot smoker, you are a “patient.” More and more, anything that pains us is a condition that can be treated. If you are caught having extra-marital affairs with a dozen women, you are no longer a philanderer. You have a sex addiction, which is a condition for which you can be treated, so you are not responsible. This seems to be the thing our culture is most concerned about, to escape responsibility for who we are and the mischief we get up to.
I think this trend in our culture creepy, because it implies that just about anything we do that might get us into trouble is simply a condition for which we bear no responsibility. Is this a sane way of proceeding? Is this what our capacity for judgment has come to? I will let you be the judge of that.
Living in One of R.D. Laing’s Post-Kingsley Hall Households
By Michael Guy Thompson
Kingsley Hall was the first of Laing’s household communities that served as a place where you could live through your madness until you could get it together and live independently. It was conceived as an “asylum” from forms of treatment — psychiatric or otherwise — that many were convinced were not helpful, and even contributed to their difficulties. Laing and his colleagues, including David Cooper and Aaron Esterson, leased the building from a London charity and occupied it from 1965 to 1970. The house was of historic significance, having been the residence of Mahatma Gandhi when he was negotiating India’s independence from British rule. Muriel Lester, the principal trustee of Kingsley Hall, agreed that Laing’s vision for its use was faithful to its long-established humanitarian purpose. Kingsley Hall was leased to his organization — the Philadelphia Association — for the sum of one British Pound per annum.
In 1970 the lease expired and Laing moved his, by now famous, operations to a group of buildings that were acquired by various means. Esterson and Cooper departed and a new cadre of colleagues and students who shared Laing’s unorthodox views about the “non-treatment” of schizophrenia joined him. They included Leon Redler, an American, Hugh Crawford, a fellow Scotsman and psychoanalyst, John Heaton, a physician and phenomenologist, and Francis Huxley, the nephew of Aldous Huxley and an anthropologist. Numerous post-Kingsley Hall houses gradually emerged, each adhering to the basic “hands-off” philosophy that had been initiated at Kingsley Hall. Each place, however, was different, reflecting the personalities of the people who lived there as well as the therapist or therapists who were responsible for each house.
By the time I arrived in London in 1973 to study with Laing there were four or five such places, primarily under the stewardship of Leon Redler and Hugh Crawford. I opted to join Crawford’s house at Portland Road. Though it was essentially like the others, I was drawn to Crawford’s personality and the unusual degree of involvement he effected with the people living there. While some of the houses went to extraordinary lengths to adopt a hands-off approach to the members of their household, Crawford employed a more engaged, in-your-face intimacy that I found inviting and comforting. Most of the people living there were also in therapy with him, an arrangement that was unorthodox, though had its advantages. Getting in wasn’t easy. Since there was no one officially “in charge,” not even the therapist who visited regularly, there was no one from whom to seek admittance. No one was paid to work there, not even the therapist who was responsible, but not in charge. And because I didn’t happen to be psychotic, I lacked the most compelling rationale for wanting to join. Some of the students I had met told me how they had visited Portland Road and, while sipping tea, offered to “help out.” “What’s in it for you?,” they were asked. When they replied that, being students, they wanted to learn more about psychosis and what it meant to be mad, they were summarily rejected. Having failed the test, they were never invited to return.
It occurred to me it would take some time, as with any relationship, to gain sufficient trust to be welcome. I attended Crawford’s seminars on Heidegger and Merleau-Ponty, went to the occasional Open House that welcomed strangers, and slowly made my presence felt. Eventually I was invited to participate in a “vigil,” a group of around-the-clock, relay of two-person teams commissioned to accompany a person who had succumbed to a psychotic episode. These affairs usually lasted a couple of weeks, sometimes longer, before they abated.
In my first such experience, a man in his twenties was in the throes of a manic episode, in Laingian terms, a psychotic “voyage” of self-discovery. Having managed to stay cool and not panic in such situations, I suppose I proved I could be counted on and sensitive to the extreme vulnerability of the people living there. After six months or so, I was finally invited to live at Portland Road. Crazier people fared better. Like Laing, I had struggled with depression since childhood. My mother committed suicide when I was fourteen, and I was still struggling with the guilt I felt at not being able to prevent that. But depression was not usually a rationale for living at Portland Road. In Britain, just about everyone was depressed due to the weather, so that was hardly out of the ordinary. Typically, a person who was interested would call, say he or she was going through a crisis or had simply reached the end of their tether, and they would be invited to come around to visit. On arrival, everyone who lived there, a dozen people or so, would meet with the visitor. He, in turn, would have the evening to himself in order to make his case heard. What were people at Portland Road looking for? By the same token, what criteria do psychotherapists use in evaluating a prospective patient’s suitability for undergoing therapy? At Portland Road this was especially problematical because many of the applicants were not interested in therapy and, if they were, had a hard time finding a therapist who was willing to work with them off of medication. Still, there were similarities between the two frames of reference.
Freud, for example, had looked for patients who, irrespective of how neurotic they happened to be, were nevertheless prepared to be honest with him. The fundamental rule of analysis assumes a capacity for candor. Similarly, at Portland Road people were expected to be candid with the people to whom they offered their case, no matter how crazy they might be. The residents who conducted the interview were looking for a sincerity of purpose and a hint of good will beneath all the symptoms the interviewee was saddled with, seeking, no matter how crazed or crazy, to contact that part of their personality that was still sane.
To complicate matters further, every applicant had to be admitted unanimously. One negative vote and you were rejected. Yet, once in, the new member could count on the unadulterated support of everyone living there, because of the fact that everyone supported his moving in. The sense of community and fellow-feeling was extraordinary. So was the frankness with which everyone exercised their “candid” opinions about everyone else. The effect could be startling, as one was slowly stripped of the ego that was so carefully created for society’s approval. I soon realized why candor is something most of us prefer to avoid, however much we complain about its absence. Again, the similarity to the psychotherapy experience was unmistakable. But now, instead of having to contend with merely one therapist for one hour a day, at Portland Road you were confronted with an entire cadre of relationships, all of whom engendered transference reactions, all of which you had to manage and work through.
I would now like to introduce Jerome, a twenty year-old man who had been referred to Laing by a psychiatrist at a local mental hospital. Jerome was a rather slight, dark-haired and extremely shy person who, in a quiet and tentative manner, told us the following. Over the past two or three years Jerome had developed a history of withdrawing from his family — mother, father, and a younger sister — by retiring to his bedroom and locking himself in. His parents would try to cajole him to come out of his room, and when that didn’t work they became angry and threatened to punish him if he did not open his door. Jerome refused to budge. Eventually, his parents contacted the local mental hospital for help. Jerome was then forcibly taken from his room and removed to hospital via ambulance and restraints. Once there, he persisted in his behavior and refused to speak to anyone. All the while, he couldn’t say why he was behaving this way or what he hoped to gain by it. He simply believed that he must.
He was soon diagnosed as suffering from catatonic schizophrenia with depressive features. A series of electro-convulsive therapy sessions were administered and before long Jerome was returned to his ordinary, cooperative self. Six months or so later he repeated the same scenario: withdrawal, removal to hospital, ECT, recovery. Never any idea as to why Jerome persisted in this behavior was ever determined. But each time he repeated it, a lengthier course of treatment was required to bring him back “to his senses.” He and his family endured this routine on three different occasions over a period of two years.
The psychiatrist who contacted Laing confessed that his colleagues at the hospital had thrown in the towel with Jerome and vowed that if he were admitted to the hospital again he wouldn’t leave. This, now, was the fourth such episode. On this occasion, when his parents implored Jerome to come out of his room he replied that he would on one condition: that Laing would see him. Jerome had read The Divided Self and concluded that Laing was the only psychiatrist he could trust not to “treat” him for a mental illness.
When Jerome visited Portland Road, he recounted what he wanted. He wanted a room of his own, to stay until he was ready to come out. We were asked to honor his request and, with some trepidation, we agreed to his terms. I single Jerome out, of all the other people I came to know at Portland Road, because he presented us with the most serious challenge we had ever had to face. Due to the nature of his terms, Jerome effectively deprived Portland Road of its most effective source of healing: the communion shared by the people living there. Jerome’s plan undermined the philosophy that Laing and Hugh Crawford had formulated, a sense of fellow-feeling that honored a fidelity to interpersonal experience, no matter how crazy or alarming a person’s participation in that process was. We felt that Jerome was entitled to pursue the experience he felt called upon to give way to, even if the outward behavior his experience effected was problematic. Though a person’s experience is a private affair, the behavior with which one engages others is not. Because the two are invariably related, the philosophy at Portland Road was to tolerate unconventional behavior to an amazing degree in order to facilitate the underlying struggle that person was engaged in.
The conventional psychoanalytic setting, for example, places enormous constraints on a person’s behavior, including the use of a couch to facilitate candor. At Portland Road, you were obliged to live with the behavior that everyone else exhibited, so the course of a given person’s behavior was unpredictable, and sometimes violent. In other words, there was an element of risk at living in such conditions because no one knew what anyone else was capable of and what lengths some might go to in order to be “true” to what they were experiencing, authentically.
True to his word, Jerome took to his room and stayed there. He had his own room, which no one saw him come in or out of. Though it wasn’t uncommon to forgo the occasional meal, the way Jerome removed himself from the household was extreme. No one even saw him sneak downstairs for food in the middle of the night, or to use the bathroom. Our sense of worry soon turned into alarm. Jerome apparently wasn’t eating anything and it became increasingly clear that he was also incontinent. We tried talking to him. Out of frustration we said, “This wasn’t part of our agreement”, to turn us into a hospital where we would have to take care of him. “Oh yes it is!” Jerome insisted. Still, Jerome wasn’t in any ostensible pain. He didn’t seem especially depressed, or anxious, or catatonic. He was just being stubborn! He insisted on doing this his way, even if he could not or would not explain why.
We reminded Jerome that we had put ourselves out on a limb for him, keeping his parents in the dark while he was jeopardizing his health. Where was the gratitude, a gesture of good will, in return? Jerome refused to discuss his behavior or explore his underlying motives. Nor would he acknowledge his withdrawal as a symptom that was generating a crisis. He simply submitted to, and was inordinately protective of, his private experience, the details of which he refused to share. Jerome eventually agreed to eat some food in order to ward off starvation, as long as we brought it to him. The stench of his incontinence became onerous, though Jerome was apparently oblivious to it. Not surprisingly, he soon became the topic of conversation each evening around the dinner table.
“What are we going to do about him?,” we wondered. Ironically, he had transformed Portland Road into a mental hospital. We were constantly concerned about his physical health, his diet, and the increasing potential for bed sores, which he eventually developed. He continued to lose weight due to the meager amount of food he was eating. We could either tell him he had to leave or we had to capitulate to the extraordinary conditions he presented us with. As news of our dilemma leaked out, Laing became increasingly nervous. Once Jerome developed bed sores he was in danger of being taken to a hospital for medical treatment. Compounding everything else, Jerome couldn’t keep down the meager amounts of food he was eating and vomited it up frequently. Whether this was self-generated or involuntary we didn’t know.
None of us possessed the expertise or inclination to serve as a hospital staff. Who was going to clean him, bathe him, and all the other things that were essential to his survival? Some of us eventually consented to be his nursemaid in order keep his condition stable. At least he was alive and more or less coping. But how much longer would we have to wait before Jerome finally came out of it and abandon his isolation?
Four more months went by. By now Jerome’s family insisted they visit and threatened legal action if we wouldn’t permit them to. We weren’t, however, about to let that happen. Crawford implored us to remain patient and let things take their course. Laing, however, was especially worried, but given our determination to see this through, he agreed to support us and keep Jerome’s family, who had by now complained to him, at bay. Meanwhile, Jerome continued to lose weight and was becoming ill. Now, six months into this, we faced a real crisis. Jerome developed bed sores, but he continued to resist talking to us or to relent in his behavior. On the contrary, he bitterly protested our efforts to bathe him and even to prevent his starvation.
We finally decided that a change of some kind was essential if we hoped to see this through to a satisfactory conclusion. We decided that Jerome needed to be in closer proximity to the people he lived with, whether or not he wanted to. The threat to his physical health and the lack of contact, in the most basic human terms, was alarming. If he couldn’t, or would not, join us, perhaps we could join him. So we decided to move him into my bedroom to share. In deference to the sacrifice of my previously private room, others agreed to bathe Jerome and feed him on a regular schedule, change his bed sheets, spend time with him, and endeavor to talk to him, even if he refused to reciprocate. We gave him therapeutic massages to relieve the loss of muscle tone and for some physical contact. We resigned ourselves to the fact that we had, whether we liked it or not, become a “hospital,” however reluctant we were to. We felt confident, however, that his condition was bound to improve.
In fact, his condition stabilized, but that was about all. I got used to the stench, the silence, the close quarters. But it didn’t help my depression, sharing a room with a ghost who haunted the space but couldn’t occupy it. I needed something to relieve the deadness that now permeated our shared space, so I invited the most floridly “schizophrenic” person in Portland Road, another young man who believed he was Mick Jagger, to move into our room with us, making it three who were sharing the room. This new person, who I will call Mick, serenaded Jerome morning and night with his guitar – which he had no idea how to play! – and probably made Jerome feel even crazier than before. But hey, at least it was a livelier, if more insane, arrangement, and with all the commotion and Jerome’s complaining I soon recovered from my depression. Whether Jerome liked it or not, our “rock star” guest was here to stay, and I admit to the guilty pleasure I felt in the comfort that Jerome was not in complete control of our lives.
Before long a who year had transpired, but still no discernible change in Jerome. In the meantime, a number of crises had occurred between Jerome’s family and Laing, Laing’s growing impatience with us, our impatience with Jerome, and finally, between ourselves and Hugh Crawford for not supporting our numerous efforts to have Jerome removed from the house. We were ready, eager!, to admit defeat and resign ourselves to an unmitigated failure. Jerome’s condition was apparently interminable. His “asylum” with us had become for him simply a way of life. It seemed obvious to us now that this was all he had really wanted from us, to live in the squalor he had generated around himself.
The time, in the immortal words of Raymond Chandler, staggered by and the urgency of Jerome’s situation gradually became a commonplace, and somehow less urgent to resolve. Life continued at Portland Road independent of Jerome’s situation. Others had their problems too, which were addressed in the communal way that was our custom. Another month slipped by, and then another, until I finally lost track of the time and stopped counting. Jerome had long ceased to be the nightly topic of conversation and his presence had become a fixture, like the furniture in the house. Nobody even noticed when the year and a half anniversary arrived since Jerome had arrived at Portland Road. We had become so accustomed to his odd definition of cohabitation: the baths, the linen changes, the serenades, that we hardly noticed that evening by the fire when Jerome nonchalantly sauntered downstairs to use the bathroom. When he was finished he flushed the toilet, peeked his head into the den to say hello, and quietly returned upstairs. To put it mildly, we were in a state of shock, and pinching ourselves to make sure we weren’t dreaming.
An hour later, Jerome came back, summarily announced that he was famished, and effectively terminated the fast that had reduced him to 90 pounds of weight. This was a Jerome we had never even met: talkative, though shy, but suddenly social nonetheless. We couldn’t believe our eyes and ears. How long, we immediately worried, would this last, before he returned to our room and his isolation?
By the next day, Jerome had obviously taken a new turn. He was finally, if inexplicably, finished with whatever he had been doing, engaged in God-knows what manner of bizarre silent meditation. Naturally, we wanted to know. “What on earth were you up to, Jerome, all that time by yourself?” I asked him. “What was it you were getting out of your system?”
I don’t think any of us expected an answer. We didn’t think that Jerome had one, but it turned out that he did. He told us that the reason he had isolated himself all that time, for a year and a half, was because he had had to count to a million, and then back to zero, uninterrupted, in order to finally achieve his freedom. That was all he had ever wanted to do, over the past four years, since his first compulsion to withdraw into his bedroom at home. No one had ever let him do it.
But why, we asked, did it have to take so long? A year and a half! Did it have to take that much time? We had given him his way, hadn’t we? According to Jerome, yes and no. After all, we didn’t just let him be. We intruded and interfered, talked to him, played music, gave him massages and generally distracted him from the task at hand, his counting. He said that every time he got to a few thousand, even a few hundred thousand, someone broke his concentration with a song, a massage, or whatever, and he was obliged to start counting all over again, from the beginning. The worst, he said, was when we added the guitar player! “But why didn’t you just tell us,” we asked, “what you were doing?” “We would have eagerly obliged, if only we knew what you were doing.” “That wouldn’t have counted,” Jerome shot back. “It was essential that you let me have my way, but without having to explain why.”
Apparently, it was only when our collective anxiety over Jerome’s behavior subsided, after the anniversary when we finally gave up and backed off, that he was able to complete the task that he had set himself to accomplish. We had eventually, without entirely appreciating its significance, submitted to his conditions, permitting him to get on with, and submit to, his own self-imposed mission of whatever mad inspiration had compelled him to count to a million and back again, uninterrupted, without excuse or explanation.
The unorthodox nature of the “treatment” that Jerome received at Portland Road is impossible to compare with conventional treatment modalities. Nevertheless, the question is invariably asked: did it really “work?” And if so, how? Nearly forty years later, Jerome has never experienced another psychotic episode again. He soon left Portland Road, resumed his life, and proved to be an unremarkable person, really, ordinary in the extreme. Naturally, we wondered why Jerome had felt the need to withdraw in the first place. What were the dynamics, the unconscious motivation that prompted such a radical solution to his problems? These were questions that Jerome couldn’t answer. It is telling, and doubly ironic, that Jerome didn’t need those questions to be answered in order to repair what he, in his shattered condition, couldn’t himself comprehend.
This story won’t make much sense to anybody who attempts to glean from it an identifiable treatment philosophy, unless they take into account the central importance that Laing gave to the inherent problem of freedom in every therapy experience. This was a concern that had also preoccupied Freud in the development of his clinical technique, just as it did the existentialist philosophers, such as Kierkegaard, Nietzsche, Heidegger, Sartre, with whom Laing was principally identified. How does one “help” those who are in some measure of personal jeopardy without impinging on that person’s inherently private, though socially intelligible, right of freedom?
Freud’s solution to this problem was analytic neutrality, the cornerstone of his clinical technique. It followed the ancient dictum: “do no harm,” what Laing recognized was a form of benign neglect. In many ways, Jerome’s experience at Portland Road was a perfect example of benign neglect put into practice. The respect we tried to pay this young man was all that any of us felt qualified to offer. We didn’t understand what was the matter with him, nor did we pretend to. We weren’t sure what would help nor what might make matters worse, so we did as little as possible. Following the principle of neutrality, we employed benign neglect as as unobtrusively as we could. Neither Laing nor Crawford directed the treatment, because there was no “treatment” to direct.
The way that we struggled with and responded to Jerome’s impasse as if unfolded will no doubt be regarded as reckless, indulgent, dangerous, even bizarre by the psychiatric staff of virtually every mental hospital in the world. His behavior — intransigent, stubborn, resistant — would no doubt be met with an even greater force of will, determination, and power than his own. Who do you suppose, given the forces at play, would ultimately “win” such a contest? Naturally, the use of medicating drugs would be brought to bear, and electric shock, as well as whatever form of incarceration is deemed necessary.
Few, if any, psychoanalysts believe it is possible to treat such an impasse with analysis. Yet, our treatment of Jerome was arguably a form of analysis, stretched perhaps beyond its limit. Because Jerome refused to talk, we were obliged to let his behavior do the “talking.” D. W. Winnicott, Harry Stack Sullivan, Frieda Fromm-Reichmann, Clara Thompson, and Otto Allen Will, Jr., are only some of the prominent psychoanalysts who helped people in this kind of crisis. Some have recounted the many hours they spent with patients who were silent, letting time run its course until something broke through the impasse they were struggling with. Who would deny that Jerome resisted treatment? But what manner of treatment can a person wholeheartedly submit to when it coerces its way in, without invitation or compassion? And let’s be frank about this, without love. It seems to me, on reflection, that it was our love for Jerome that finally had its way when we backed off from all of our efforts to “help” him, when we were able to just let him be, as he had asked us to, and allow him to join our community, but on his terms, not ours.
Love is a hard thing to pin down, because there are many types of it, and not all of them are applicable to the therapeutic process. Jerome for searching for the truth, his truth, and was determined to find it, whatever the cost. In a manner of speaking, his journey was a search for authenticity, to be capable of being the person he was, however unpleasant or demanding that might appear to others. He had spent his life cowing ot others, and the time came when he had had enough. What he wanted from his family, and the psychiatrists who treated him, was the freedom to be real, or genuine, without airs or pretense. Jerome couldn’t spell this out; few of us are able to. But he knew, somewhere in his soul, what he had to do, and what the freedom to be himself would feel like. When you think about that, his journey was not just an act of desperation, it was an act of courage, where everything was on the line, come what may.
Laing saw his role as one of helping the people who came to see him “untie” the knots they had inadvertently tied themselves in. He believed this entailed extraordinary care to not repeat the same types of subterfuge and coercion that had got them into those knots in the first place. Jerome had tied himself in a knot, and had come up with his own solution as to what he needed to do in order to untie it, including his insistence on doing it silently. That we were able to get out of his way and facilitate his task was nothing short of a miracle.
This degree of non-intrusion in the context of psychotherapy is a rarity. Those therapists who believe it is incumbent on them to run a “tight ship,” who maintain their authority over their patients at all costs, and who reduce the therapy experience to a set of techniques that can be learned by rote aren’t likely to embrace a method of “treatment” that is as modest in its claims as it is cautious with its interventions. Jerome taught me that techniques are of no use when all a person is asking is to be accepted for who he is, unconditionally.