We are all prone to make wrong judgments about others (and ourselves) based on inaccurate (or insufficient) information. I recently had this experience with a relative, who cited a number of behaviors as reasons for him to make a rather harsh judgment about my internal mental states. Before hearing his rationale - and despite my belief that he was wrong - I had to reserve some doubt that I might, unconsciously, have those disagreeable habits that my kind relative ascribed to me. But after I heard his explanation, the only possibility that seemed to fit was psychosis (in him, not me); since I was rather certain that he did not have a psychotic illness, I had to conclude that he had beliefs that served his own purposes in some way, though they were simply wrong.
We all do this, all the time (perhaps this is the source of the wisdom behind that peasant woman's admonition to Maxim Gorky: "Remember, above all, do not judge: that is the Devil's work").
But we do not all have delusions, at least in the sense that delusions are supposed to mark out psychiatric illnesses. Some think that delusions involve problems in logic and reasoning; others that delusions grow out of abnormal perceptions (which are then normally reasoned). But perhaps there is another explanation (proposed by philosophers recently based on the ideas of Ludwig Wittgenstein): Wittgenstein held that we have "bedrock certainties" that are founded on having served us in acting in the world (these beliefs do not require rational or empirical justification). Go mow the lawn, we say, presuming that scissors will not be used.
Perhaps delusions occur because these very basic certainties, which occur before thoughts and sensations, steer us wrong. They are messed up in some way. If delusions are due to some basic existential abnormality, an inability to experience the world as it really is, then this might explain why patients cannot be reasoned out of delusions; that's why they end up with psychiatrists.
We cannot reduce knowledge to rationality or logic, nor can we reduce our understanding of delusions to cognition or sensation, nor even emotion (the usual alternative). Which leaves us with - not thinking, not feeling - just being: existence, with the clear therapeutic implication of an existential approach to treatment.
What does that mean?
I find myself thinking back to stories I heard over and over again from my psychiatric teachers. Back in the 1960s, in Boston, the premier locus of psychiatric training and practice was Harvard's Massachusetts Mental Health Center, where the intellectual leader and residency director was Elvin Semrad. An aging, rotund Nebraskan, he apparently had a gruffness to him, mixed with a Midwestern sensibility that he seemed to cultivate ("I'm just a hayseed from Nebraska"); he used this persona to make an impression, on patients and trainees, so that, along with a knack for the short memorable phrase, those who knew him came away with many "Semrad stories". (He wrote little and his reputation was passed along primarily based on an oral tradition of these stories). Here is one:
(This is a fictionalized amalgamation of the kind of interviews my supervisors used to describe to me that they had observed with Semrad, augmented by specific comments by him documented by his students).
Semrad ran a weekly case conference, where he interviewed patients; each week, psychiatry residents tried to pick their most difficult patients to test Semrad's interviewing skills. On one occasion, an enterprising resident brought a chronic, mute, unresponsive patient with schizophrenia from the back wards of "Mass Mental." No one had succeeded in getting the patient to say more than a few words at a time, much less express any emotion. He was closed in the solitary cell of his insanity.
Semrad sat down on the podium, the residents below him in the audience. The patient was brought in, shuffling in from the side, guided on the elbow by the solicitous chief resident. The patient said nothing as he sat down, facing slightly away from Semrad. Semrad said nothing. They both sat awkwardly; Semrad finally broke the silence: "Thanks for coming, Jim." "Uh-huh" murmured the patient. Semrad sat silently some more, looking over the heads of the residents. Minutes passed. The patient shifted in his seat nervously; he glanced quickly at Semrad. Semrad peered at him, catching his eyes briefly: "Jim, it hurts." Jim shuffled some more; Semrad moved his weight from his left to his right. The audience was restless. "You loved her," he commented. "What?" said Jim. "You loved her - your mother - you loved her!" Semrad said, slapping his thigh lightly. Jim turned toward Semrad, then away, then back again and looked Semrad in the eyes: "You loved her" Semrad said more gently. Suddenly, Jim began to cry, the residents shocked at seeing any emotion in the patient. Semrad was unmoved: "You loved her." "I loved her," said Jim, sobbing. "But there was more," said Semrad ambiguously, hoping to bring out the ambivalence in all relationships. Jim pulled himself together a bit, sniffling some. "She was not easy," he said. "All mothers are like that," replied Semrad. And it went on, with the residents learning, for the first time, of a rather rich interpersonal life that had previously locked away, how the patient had blamed himself for his mother's lack of attention to him; how when she was hospitalized for a psychotic illness, he had seen himself as somehow at fault; how all his life he had been the cause of all his misery. Semrad let him go on, looked at him sympathetically, commented on how he could not have possibly been that bad. After more back and forth, Semrad finally tied up the interview, and patted the patient's arm, as he got up: "Well, you seem like a fine fellow to me."
The patient was escorted away, and Semrad turned to his stunned audience.
"Tears never lie in a male." He paused, then added: "I've always thought that some of the things people suffer most from are the things they tell themselves that are not true." Semrad proved, repeatedly, that there was something to psychosis that was intuitive and nonverbal. Admitting that the patient was psychotic, Semrad would insist on his humanity: "And so often, when you get to know a patient, they lose their diagnosis, you know." All this led up to the classic Semradism: "No one is psychotic in my presence." And his interviews proved it - except Semrad thought it was simple: there was nothing importantly biological to psychosis, otherwise delusions would not be as amenable to his interviewing skill as they invariably were. Semrad failed to realize that there could be two truths here: psychosis could be biologically (and cognitively) based, yet it could also be existentially reachable.
Semrad proved clinically what philosophers seek to explain logically: delusions are not just about faulty cognitions or biological abnormalities (though they usually involve both) - they also involve something more deeply human, a basic existential fault, perhaps, reminding us that even in the most severely ill psychiatric patients, our clinical work involves - first and foremost - contacting the person beneath the patient, and saying hello.
If only we could do the same in our non-psychotic lives.
