Our minds can generate meanings and images of our deaths: we can picture the world surviving us, and we can identify with those that come later or otherwise immortalize ourselves through our works.   We can rage against the dying of the light, and we can look forward to reunions with lost loved ones.  We can think about the meaninglessness of human existence and its finitude.  We can be relieved that all our sorrows will soon be over.  We can even admire ourselves for being the only creatures in existence, as far as we know, who perceive their own wretched destiny to be extinguished.   The abyss of madness offers no such possibilities: it is the end of all possible responses and meanings, the erasure of a world in which there is anything coherent to respond to, the melting away of anyone to engage in a response.  It is much more scary than death, and this is proven by the fact that people in annihilation fear – the terror of madness – so often commit suicide rather than allow themselves to be engulfed by it.  Death is a piece of cake compared to the abyss.

The reason I say madness is a dragon has to do with the feelings a clinical observer may have when empathy is extended to such a subjective state.  One draws close to a realm in which there are no orienting landmarks, no coherent purposes and desires that point to a   future, no organized recollections establishing a continuous past that can be looked back upon.  The ordering structures of existence itself collapse, all sense of personal identity becomes erased, and one may fear being pulled out of one’s sanity and into the nothingness.  This is the terror of madness, and it affects all those who come into its vicinity.

So, what is one to do?  How can we, as explorers of the human soul, enter this dark territory?   I think we need a map of that chaos, a picture of the variations we will encounter, and some general guidelines as to how we might respond to the disastrous human situations that are encountered.  Also needed will be protections from how we are ourselves perceived.  A terrible toll may be taken on the clinician who may be viewed as a persecutor, as a god, or even as a persecuting god.  An even greater injury may be inflicted on the patient, someone already in terrible trouble who now faces being seen as insane. 

Psychotherapy is a world within the world, one in which patient and therapist gaze into each other’s eyes and see themselves mirrored in ways that may clash profoundly with what they feel is true or most deeply need.  The mismatching of such images leads to all manner of difficulties for both parties, often spiraling into chronic impasses and the loss of the possibility of a healing connection.   

How, you may ask, can we be shielded against the terror of going mad and against the potential violence to ourselves of the interplay with those who are lost in chaos?  What protections can there be that will not operate as well at the expense of the patient? The key lies in one thing only: the power of human understanding.   We must understand annihilation states and all the signs and symptoms expressing a person’s struggle with such experiences.   We must know the symbols typically used to represent these states of mind, images that are often concretized or reified, i.e., treated as tangible, substantial realities.  We must use our understanding then to discover responses to our patients’ crises that will help them refind a personal center and feel included again in the human community.  This is the work of clinical psychotherapy research, a field now on the threshold of a new golden age as the older ideas about objectified “mental illnesses” recede and a new emphasis on phenomenology arises.  Go forward, Adam, the future is very bright!

Let me offer a thought on objectifying systems of psychiatric diagnosis, which you will inevitably encounter along the path of your dreams.  Sometimes these systems turn into dragons themselves.  There is nothing wrong with careful studies of the symptoms and signs of psychological disturbances, and with efforts to classify the richly varied phenomena one sees in this field. Ordering principles need to be applied, so that we are not just left adrift in a sea of confusion.  A problem arises however when the classifications we impose on the variations that are observed become reified and objectified, turned into mental diseases imagined as existing somehow inside the people we seek to understand.  Our patients in extreme distress reify their fantasies, generally in order to substantiate personal realities that have come under assault and are threatened with dissolution.  We in parallel often reify our diagnostic concepts, ascribing the chaotic manifestations confronting us to a disease process inside the patient.  Such a locating of the problem in the internal, not grounded in any actual scientific knowledge, basically takes the clinician off the hook.  He or she is not implicated in what is seen; instead the clinician sits high and dry, observing and classifying from a position of serene detachment, wrapped in a cordon sanitaire.  This shields us from feeling responsible for how we are experienced and utterly neutralizes the power of the patient’s attributions to attack or displace our own ways of defining ourselves.  The problem is that the clinician is implicated: what people show us depends in part on how we are responding to them: human experience is always embedded in a relational context.  If that response organizes itself around an objectifying psychiatric diagnosis, one can expect to see reactions to the distancing and invalidation that is involved.  If those very reactions are then ascribed again to the supposed mental illness, the distancing is deepened and the disjunction rigidifies.   So learn whatever diagnostic system confronts you my friend, but do not let it become your commanding, reifying viewpoint.  Be guided instead by attention to your patients’ experiences and by reflections on your own.  We are still at the beginning of exploring this strange and complicated country, and perhaps there are important discoveries you will share in.

I hope these suggestions and ideas are giving something to you Adam.  I want you to write again if there are more questions that arise.

George Atwood