Existential Psychiatry: Can Doctors Really Understand Psychotic Patients?

A 'psychotic' reaction to being routinely misunderstood by psychiatrists

We have all had the experience of at least crossing paths with a psychotic person. The common response to being in the presence of such people is to shy away and basically do anything possible to avoid interacting with them; we like to pretend they don’t exist. Responding in this way is not necessarily something to be ashamed of though; it is an understandable reaction to encountering others who in many ways seem alien and thus somewhat frightening to us. If we have any compassion for these suffering people, however, we may like to take solace in the notion that there are many qualified psychiatrists that are trained to deal with this otherwise neglected segment of humanity. Unfortunately, the training that psychiatrists receive today is largely insufficient in preparing them to truly ‘understand’ their psychotic patients.

The current practice of psychiatry is almost completely dominated by what William James referred to as the “medical materialist” model. This model essentially consists of reducing the understanding of mental illness to observable symptoms, which are seen as indicative of some biological (mostly brain) pathology. In other words, deviant human experience, like that of the psychotic, is largely seen as indicative of an underlying pathology in the brain. Although this view has done a lot to advance our treatment of mental illness, relying on it exclusively has also done much to diminish the scope of clinical psychiatry. This focus on the “disease model” of mental illness effectively absolves psychiatrists from the responsibility of appreciating or really ‘understanding’ the subjective experience of their patients. Instead, the behavior and communication of the patient is reduced to being seen solely as a vehicle by which symptoms can be identified and then diagnosed according to orthodox methods. Not too long ago, however, psychiatrists often received training that was complementary to this model and that helped them to appreciate the humanness of the patient rather than seeing them as 'simply mad' expressions of some 'disease.'

Existential psychiatry, which came into prominence in the early 1960’s (of course), was in part a response to the problems inherent with biological psychiatry. Arguably one of the most influential figures involved with this movement was R.D. Laing, a Scottish psychiatrist who incidentally had some personal experience with bouts of psychosis. Laing’s basic premise was that the odd behavior and communication of psychotic individuals can often be understood as rational expressions of their peculiar subjective experience. Rather than operating from the orthodox method of observing patients in terms of identifying pathological symptoms of disease, Laing strove to understand the meaning behind his patients’ communications. In doing so, he helped open the doors to a more thorough understanding of madness, one where the madman’s perspective was actually taken into account.

Laing (1967) conceived the psychotic’s dilemma in social interactions to be representative of what he called “primary ontological insecurity,” a state characterized by a fear of engulfment and/or petrification by others, and the parallel fear of authentic self-disclosure. The psychotic person in this state is typically tormented by a conflict between the desire to reveal and the desire to conceal one’s self (Burston, 2000). Seen in this way, the bizarre communication of psychotic individuals is made more intelligible.

In his classic book, “The Divided Self,” (1960) Laing describes the existential psychiatric approach to observing patients, which offers an alternative perspective to interpreting the communications of psychotic individuals. My favorite example from this book is Laing’s critique of the observations made by Emil Kraeplin (the father of modern biological psychiatry) of a schizophrenic patient who was being put on display in front of a lecture hall full of psychiatrists in training. I will now quote at length from this text (pp. 29-31) in order to provide a vivid depiction of the differences between the two approaches to understanding psychotic behavior.

“Here is Kraeplin’s (1905) account to a lecture-room of his students of a patient showing the signs of catatonic excitement:


‘The patient I will show you today has almost to be carried into the room, as he walks in a straddling fashion on the outside of his feet. On coming in, he throws off his slippers, sings a hymn loudly, and then cries twice (in English), “My father, my real father!” He is eighteen years old, and a pupil of the Ober-realschule (higher-grade modern-side school), tall, and rather strongly built, but with a pale complexion, on which there is very often a transient flush. The patient sits with his eyes shut, and pays no attention to his surroundings. He does not look up even when he is spoken to, but he answers beginning in a low voice, and gradually screaming louder and louder. When asked where he is, he says, “You want to know that too? I tell you who is being measured and is measured and shall be measured. I know all, and could tell you, but I don’t want to.” When asked his name, he screams, “What is your name? What does he shut? He shuts his eyes. What does he hear? He does not understand; he understands not. How? Who? Where? When? What does he mean? When I tell him to look, he does not look properly. You there, just look! What is it? What is the matter? Attend; he attends not. I say, what is it, then? Why do you give me no answer? Are you getting impudent again? How can you be so impudent? I’m coming! I’ll show you! You don’t whore for me. You mustn’t be smart either; you’re an impudent, lousy fellow, such an impudent, lousy fellow I’ve never met with. Is he beginning again? You understand nothing at all, nothing at all; nothing at all does he understand. If you follow now, he won’t follow, will not follow. Are you getting still more impudent? Are you getting impudent still more? How they attend; they do attend”, and so on. At the end, he scolds in quite inarticulate sounds.’


Kraeplin notes here among other things the patient’s ‘inaccessibility’:


‘Although he undoubtedly understood all the questions, he has not given us a single piece of useful information. His talk is…only a series of disconnected sentences having no relation whatever to the general situation’ (Kraeplin, 1905)."


Laing now offers his interpretation of the patient’s behavior:


“Now there is no question that this patient is showing the ‘signs’ of catatonic excitement. The construction we put on his behavior will, however, depend on the relationship we establish with the patient…What does the patient seem to be doing? Surely he is carrying on a dialogue between his parodied version of Kraeplin, and his own defiant rebelling self. ‘You want to know that too? I tell you who is being measured and is measured and shall be measured. I know all that, and I could tell you, but I do not want to.’ This seems to be plain enough talk. Presumably he deeply resents this form of interrogation which is being carried out before a lecture-room full of students. He probably does not see what it has to do with the things that must be deeply distressing him. But these things would not be ‘useful information’ to Kraeplin except as further ‘signs’ of a ‘disease’.

Kraeplin asks him his name. The patient replies by an exasperated outburst in which he is now saying what he feels is the attitude implicit in Kraeplin’s approach to him: What is your name? What does he shut? He shuts his eyes…Why do you give me no answer? Are you getting impudent again? You don’t whore for me? (i.e., he feels that Kraeplin is objecting because he is not prepared to prostitute himself before the whole classroom of students) and so on…such an impudent, shameless, miserable, lousy fellow I’ve never met with…etc."

In this example, Laing is simply pointing out the different ways that this patient’s behavior can be interpreted, which is analogous to the visual illusion where either a vase or a face can be seen depending on one’s perspective. In this case, the patient’s behavior can be regarded as ‘signs’ of a ‘disease’ (i.e., Kraeplin’s and modern psychiatry’s approach) or as an expression of his existence (i.e., Laing’s existential approach). “The existential-phenomenological construction is an inference about the way the other is feeling and acting. What is the boy’s experience of Kraeplin? He seems to be tormented and desperate. What is he ‘about’ in speaking and acting in this way? He is objecting to being measured and tested. He wants to be heard” (Laing, 31).

The existential-phenomenological approach to psychiatric observation that Laing is promoting here should be used in psychiatry to complement orthodox methods. Neither approach should be used exclusively; important information is lost whenever doing so. It is vitally important, however, that Laing’s methods be more appreciated by mainstream psychiatry. The psychotic experience cannot be adequately conceived outside of the relationship between the psychotic individual and those around him/her. The current psychiatric approach to dealing with psychotics combined with the effects of institutionalization only serve to exacerbate the patient’s feelings of being viewed as an unintelligible, almost “alien” being by those with the authority to “treat” them. The exclusive reliance on this method of “treatment” is thoroughly reprehensible. It is high time for the profession of psychiatry to broaden its narrow perspective.

References

Burston, D. (2000). The Crucible of Experience: R.D. Laing and the Crisis of Psychotherapy. Massachusetts: Harvard University Press.

Laing, R.D. (1960). The Divided Self. London: Tavistock Publications. Harmondsworth: Penguin, 1990.

http://laingsociety.org/colloquia/psychotherapy/laing.heaton.htm

http://hugesponge.blogspot.com/

~Wolf