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Why Doctors Must Learn to Tolerate Uncertainty

A famous patient teaches us the importance of not knowing, by Dr Tom Stockmann

...Negative Capability, that is, when a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason... —John Keats, Letter to George and Tom Keats (1817) 

Schreber’s story 

Daniel Paul Schreber (1842–1911) was a successful German judge who developed a recurrent psychotic illness. He was diagnosed with dementia praecox (the original term for schizophrenia), and eventually died in the Leipzig state mental asylum. His Memoirs of My Nervous Illness was famously interpreted by Freud in Notes on a Case of Paranoia.

Schreber first became unwell in 1884, after suffering an election defeat. He recovered from this moderate depression but later endured two episodes of severe depression with psychotic symptoms (that is, delusions and hallucinations). As with the initial bout, the latter two spells came after traumatic events. In 1893 his wife suffered a stillbirth, and in 1907 his mother died and his wife had a stroke.

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Schreber was treated by Professor Paul Flechsig at the Psychiatric Hospital of Leipzig University. Flechsig was an esteemed neurologist and anatomist, and lends his name to Flechsig's fasciculus, a nerve tract in the spine. As was normal practice for the time, Flechsig also dealt with so-called ‘nervous’ illnesses, or insanity.

In 1893, Schreber consulted Flechsig for help with symptoms including low mood and insomnia. Then as now, it was typical to prescribe medication, which is just what Flechsig did; but Schreber’s mood deteriorated and he gradually developed the distressing paranoid delusions and auditory hallucinations characteristic of psychotic depression

Insights from insanity

The content of Schreber’s delusions is fascinating, and reveals his insights about his treatment by Flechsig.

In his thoughts, Schreber distinguished between an infinite, omnipotent God and human beings of ‘limited nerves’. He complained that this God did not look into the hearts of men, and also spoke of 'soul murder'.

One wonders whether Schreber's God corresponds to Flechsig, who was then the Hospital Director. Flechsig was also an expert in anatomy, especially the nervous system. Perhaps Schreber was suggesting that Flechsig's only interest lay in diagnosing and treating neurological, that is, physical, problems. But what Schreber really wished for, and needed, was for Flechsig to guide him through his difficult thoughts and feelings. Flechsig had ignored, done away with, or, indeed, 'murdered' Schreber’s soul.

Divine doctors 

A French copy of Daniel Paul Schreber’s book
A psychoanalyst might point out Schreber’s insight into Flechsig’s omnipotent phantasy (a phantasy is an unconscious fantasy) of being able to cure psychological problems. Flechsig had been so troubled by Schreber’s difficulties as to pretend to himself that he could cure them, something which would have required a God-like power.

To attain to this God-like power, Flechsig had convinced himself that the problem was in fact a biological illness of the brain that could be treated with pills. Of course, this was the predominant view at the time, and so Flechsig cannot bear full responsibility for this belief.

And, by and large, it remains the predominant view. Despite the scant evidence, psychiatry is still in thrall to reductionist and simplistic biological theories of mental illness involving genes and chemical imbalances. One important reason for clinging on to these beliefs is that they are less painful than not knowing what to think or do.

Enduring unsuredness

Physicians tend to see the world through a materialistic lens and to search for relations of cause and effect. And they see themselves as problem-solver, leader, healer. These roles form a significant part of their identity and may supply them with much of their self esteem. For them, being unable to help is never the easy option.

Thus, the mounting evidence that antidepressants are no more effective than sugar pills for most cases of depression has not curbed prescription rates. You can imagine the scene in the consulting room, with the patient in tears and the doctor feeling helpless and not a little ruffled. Few would blame the doctor for handing out a prescription and calling for the next patient.

It is not just the doctor who feels relieved, but, often, the patient as well. But how long will this relief last? Like Schreber, the patient may well deteriorate. She may, as Schreber suggested, need more than 'a pill for the nerves'. She may need an actual understanding and acceptance of her fuller self, her soul.

Sharing suffering 

People in mental distress are experiencing deep disturbances in their thoughts and feelings. And their distress may spill out onto the observer. It can be extremely difficult to sit with a depressed or psychotic patient and bear the pain that is being transferred to you. Think of a time when you encountered a person behaving unusually in public: how did you feel, and how did you, and others, react?

Psychoanalyst Donald Winnicott emphasized the importance of being able to sit with a patient’s suffering without reacting, of containing the suffering without 'acting out'.

Psychoanalyst Wilfred Bion explored the origins of containment in the role of the caregiver, who receives raw stimuli from the infant, processes them, and returns them in a more digested and digestible form. A similar relationship exists between the patient and therapist—or indeed any clinician. To receive, translate, and adapt the patient’s thoughts and feelings, the clinician must be able and willing to hold them in his mind and process them.

The complications of containment 

Containment forms the basis of the therapeutic relationship but presents obvious challenges. The immediate urge for the clinician may be to distance himself from the patient. This separation may be achieved physically by walking away, by referring the patient to another speciality, or mentally through psychological defenses such as reducing the problem to genes and chemicals.

There is also the more concrete containment of admitting the patient to hospital. Psychoanalyst Patrick Casement argues that such containment may help the clinician while doing nothing for the patient. Unwell people, he says, always want personal containment: a person to help them.

Personal containment can be difficult, because taking on the distress of the other (transference) is difficult. Bion, in explaining the concept of the ‘container contained’, highlights the importance of the clinician reflecting on his own, often unacknowledged, thoughts and feelings towards the patient (countertransfererence).

Containing the containers

The difficult thoughts and feelings experienced by doctors, not just from transference but also from more obvious traumas such as the death of a patient, themselves need containment. However, as it stands, there is no space within medicine for this to happen.

Painful thoughts and feelings are instead kept at bay by keeping busy, keeping distracted with other things—the manic defense.

In psychiatry, this has translated into a preoccupation with risk reduction. Rather than concentrating on the patient's suffering, we make use of bureaucratic procedures to reassure everybody and ourselves that 'risks' are minimized. But maybe people and their illnesses are much more unpredictable than we pretend, and, like Flechsig, we are merely phantasizing about being omnipotent.

To quote Schreber,

I cannot of course count upon being fully understood because these things are dealt with which cannot be expressed in human language; they exceed human understanding. Nor can I maintain that everything is irrefutably certain even for me: much remains only presumption and probability. After all I too am only a human being and therefore limited by the confines of human understanding; but one thing I am certain of, namely that I have come infinitely closer to the truth than human beings who have not received divine revelation.

This is a guest blog by British psychiatrist Dr Tom Stockmann.

Neel Burton, M.D., is a psychiatrist, philosopher, and writer who lives and teaches in Oxford, England.

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