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Dear Professor:
Your letters are so good and I want to thank you for them again. The last one, fifth in the series, showed your fallibility and vulnerability, and I appreciate that very much. It makes me feel that it is all right to struggle and even fail, along the pathway toward what I hope wiil become success.
In The Abyss of Madness and also in your letters, you have repeatedly spoken of a bright future for our field, even a new golden age of psychotherapy. I wonder if you can offer some further guidance to those of us who will be trying to contribute to this new era? What are the most important questions we will need to answer, and what are the directions of study we will need to pursue? What will be the themes of this new psychology in the 21st Century?
Adam
Dear Adam:
Your questions ask me to reach into the future. I will answer by trying to describe some of the currents that I see flowing in and beneath our lives, and I hope to be led to some worthwhile ideas about where our field might be going. This letter is going to be a long one.
Our time is one of immense loss. What I am speaking of is the progressive falling away of traditional answers to the question of the ultimate, as the solid foundations that once gave our lives meaning disappear in a whirlwind of available facts and diverse contexts and perspectives.
Our gods have died, long since, and we are bereft in the aloneness of our finitude.
Our time is also though one of great possibility. As the strictures of reassuring faith have dissolved, we have been cast into an open space, one that can only be filled in by our own creativity. Anxiety and uncertainty are inevitable companions in this journey, but so is the joy of anticipating what is to come. I want to imagine an emerging worldview that has been preparing itself for more than one hundred years, and that is already having important consequences for our field. Three features seem to me salient in this new way of interpreting the meaning of human existence: Interdependence, Self-reflection, and Responsibility.
1. A person is of his or her world, natural and social. The world that we experience is part of our very being, making us who and what we are. That constitutive world, at the same time, is what we make of it. A new mindset of radical interdependence is appearing, within which these statements do not stand in contradiction to each other.
2. Reflective awareness of the many contexts that shape our lives has in our time become pervasive, meaning that we are aware of the embeddedness in our personal existence of all our beliefs and values: philosophical, religious, political, scientific. One might say that the age of absolutes standing outside the circle of reflection is over. The yearning for ultimate answers and eternal foundations, however, seems likely to be a part of who we are forever.
3. Recognizing that all human beings are siblings in the same darkness, we are at last embracing the idea that we are our brothers’ and sisters’ keepers. We have also taken up the task of being guardians of the Earth and all its living creatures. I foresee a world in which these responsibilities are considered sacred. You may wonder how I can be so sanguine, in an age of terrorism and fanaticism. I regard these things as the death throes of religious ideologies that are giving way to a new humanism.
What are the implications of this new worldview for the fields of psychology and psychiatry? Here are a few thoughts on the matter.
The theme of interdependence leads to a reconceptualization of what it means to be an individual person. One might say: there is no such thing as a person. I am obviously not claiming that people don’t exist; it is rather that their existence is not one of being an isolated object, subsisting in a state of ontological separateness and solitude. The new worldview opens us to seeing our irreducible relatedness to our worlds and to others. This changes everything in how one understands so-called psychopathology. I will illustrate what I am saying with a clinical story.
A woman, 24 years old, was brought to a hospital by her father and mother after she had been arrested for trying to break into a well-known country musician’s home. I happened to be on the clinical staff and so met this young person. She was mute, and scarcely moving. The word “catatonia” was used by two of our psychiatrists, engaging in diagnostic deliberations at the time, but I have never thought much of such labels. I sat quietly by her side on a daily basis in the first weeks of my work with her, hoping she would eventually begin to speak to me. Finally she did, telling of a secret world in which she had lived for several years. This world was ruled by a famous country music star, and contained a large number of other figures who regularly talked to her in the mornings and in the nights. They were like the chorus in a Greek tragedy. A love affair had developed between her and the star, conducted via telepathy, and she had been able for a long time to function in her world (she had been a part-time student in college) while dwelling much of the time in the secret realm.
Disaster came when she finally made an effort to have physical contact with her lover. The police had arrested her when she went to his actual home. The voices of the chorus, originally loving and sweet, had in the meantime turned increasingly critical and aggressive. Such idealized delusional companions often turn into persecutors, and the imaginary realm that has been found then becomes an unbearable hell. This patient was very similar to Joanne Greenberg, who wrote a classic work in the literature of madness: I Never Promised You a Rose Garden. Joanne also inhabited a secret world, initially a place of magic and love but then that turned dark and monstrous. Read this book, Adam, if you have not already done so.
Traditional psychiatric thinking would understand this story as involving a dreadful mental illness that erupted in this woman’s young life, an illness it calls schizophrenia.
This was the diagnosis she was given during the period of her hospitalization. When looked upon within the new worldview, however, the symptoms of this so-called illness are no longer seen as emanating solely from a pathological condition somehow existing inside of her; instead, they are understood as having meaning within complex relational and historical contexts, as significantly relative to what had happened and was still happening in her social world.
Her emotional history, as I came to understand it in the long course of our contacts, centered around a theme of abiding loneliness. This context, unseen as such by members of her family of origin, was one in which she had accommodated herself to parental expectations and needs, becoming a child fulfilling their dreams through stellar academic achievements. The parents’ marriage had at the same time been a bloody chaos of tension and hostility: repeatedly, the mother and the father had fought physically and threatened to abandon each other. She had tried, with all her might, to be a shining manifestation of hope for familial cohesion, always sensitive to her mother and father, moving back and forth between them, forever striving to make them proud and happy.
The extremity of this young girl’s commitment to pleasing her parents and forestalling the disintegration of her family began at some point to lead to a division in her subjective life: on the one side were her harmonizing accommodations; on the other was an unarticulated and yet intensifying sense of hurt and of her own abandonment. There was no real recognition or validation of her pain by anyone, and therefore nowhere to go with her emerging suffering. This was the setting, following a series of separations and other changes in her living situation, in which she found her true love during her late teen years. Listening to his songs of loss and alienation, of broken hearts and searing loneliness, she saw her own experiences set to music: she had found a twin, a soul mate whose feelings precisely mirrored her own. Appearing recurrently in her dreams and reveries, his presence suddenly one day became utterly real and she immersed herself in their shared affection, magically expressed through mental telepathy. Catastrophe occurred when she finally tried to establish physical contact with him.
Perhaps Adam you would be interested in what happened in this young woman’s life. I worked closely with her for many years, helping her to find words for her deep feelings of isolation and loneliness, and helping her as well to resist the siren-call of her lover and the chorus of voices associated with him. That is what is needed in such cases: patience, devotion, and understanding. I don’t want to make it sound easy; it wasn’t. There were a great many back and forth movements with respect to the secret world, and there were dangerous suicide attempts in the first years of our contacts. I suffered greatly with how close she came to ending her life. But it eventually worked out well enough. She brought herself together finally and found new ways to connect with others, expressing in her life a wonderful creative spirit.
I have told this little story to illustrate what I think will become commonplace in our field within the worldview I have been talking about. This young woman’s psychological disturbance, her “schizophrenia” if you will, is here seen as a set of reactions embedded in her life in her family, and related to her trauma history and to the absence in her background of validating recognition. Her illness was not, from this standpoint, a pathology afflicting her from within; it was a personal disaster brought on by complex transactional patterns inhering in her relationships over time to all those who were important to her, both real and imagined.
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A great task facing us in the years ahead will be the thorough phenomenological redescription and reconceptualization of severe psychological disorders, and then a corresponding development of psychotherapeutic approaches embodying the new understandings that are attained. Great strides in this project have already occurred, and so we will not be starting from scratch. Among the many geniuses on whose phenomenological and clinical contributions one can build, I would list: Jung, Tausk, Federn, Winnicott, Sullivan, Fromm-Reichman, Binswanger, Searles, Laing, DesLauriers, Kohut, Stolorow, and Brandchaft, among others. Read these gifted thinkers and clinicians, Adam, and apply what you learn in the life you pursue.
Let me suggest some ideas that are more specific in regards to the most meaningful directions of our field in the coming decades. If I had another thirty years to live and to work, something which is not likely, I might throw myself into the following sorts of things. Maybe some interesting variations on what I will describe will inspire you, Adam.
1. So-called schizophrenia
An influential book appeared in 1911: Eugen Bleuler’s Dementia Praecox or the Group of Schizophrenias. In addition to introducing the term “schizophrenia” to our world, this work attempted to describe and provide examples of widely differing forms of the most extreme psychological disturbances that exist. It is worth reading even today for its rich accounts of madness in its many variations, although the work does suffer from some serious limitations from our present vantagepoint. The clinical descriptions are framed within a broadly Cartesian, intrapsychic frame of reference, locating the disturbances being considered inside the patients who are then pictured in isolation from their worlds. The presentations, in addition, tend to be restricted to the patients’ symptomatology in the present moment, leaving out of account the complex histories in which their symptoms are embedded and have meaning. Finally, the book is written almost entirely from the perspective of the medical model, viewing psychological disturbances as disease processes occurring in the mind.
I think Adam that a very wonderful project, one that would require a great many years of devotion, would be the modern counterpart to Bleuler’s classic study. This would involve even more detailed descriptions and examples of madness in its many forms and variations, with the focus however always being on the subjective states that are involved. Such a phenomenological emphasis would then be accompanied by a life-historical perspective, from which the overt symptom-pictures are cast in relation to the personal backgrounds of the people concerned. There would only be one way to accomplish the immense task I am suggesting: the collaboration of a number of dedicated clinicians and thinkers. It would be required that there be long-term commitments to the patients being studied, so that the inquiry into their worlds have a grounding in deep explorations of history and also include the nature of the healing processes that can be achieved.
Bleuler proposed that the heart of what was known in his time as dementia praecox consisted in various splitting processes occurring in the mind: hence the term, schizo-phrenia. These included the disintegration of the logical associations of thought, the splitting of cognition from its associated affects, the dividing of positive and negative emotions, and the separating off of a private reality from contact with the externally real. My own view is that future phenomenological studies of patients in this range will show how these various features can be significantly understood as secondary to a sense of personal annihilation. This means that the primary disturbance would be seen in the shattering or even erasure of the experience of personal selfhood. Also central would be the dissolution of the sense of the realness of the world and the disintegration of all that we ordinarily experience as substantial and enduring. The most prominent visible symptoms of these disturbances, such as one sees in hallucinations and delusions, in this context appear as restitutive or reparative reactions, efforts to reunify all that has fallen apart and resolidify all that has melted away.
Another clinical story comes to mind that relates to the sort of understanding I am thinking of. Consider this brief account, Adam, as standing for a thousand that I could provide. One of my patients from many years ago came to me after a long period in a psychiatric hospital. Twenty one years old at the time, she described herself as having always been in “pieces,” having separate and distinct “selves” that floated about in a strange space, without there being a common center. There was a sexual self, a religious self, a political self, a comical self, a professional self, and a social self. Each of these entities embodied an area of her interests and capabilities, but they were like islands suspended in the sea with no land bridges between them. It was interesting to me that a delusion haunting her during the many months of her hospitalization was a belief she was part of a world-revolution aiming to dissolve traditional nation-states and establish a universal government based on the power of all-embracing love. Out of her own personal fragmentation, it seemed, was arising a dream of world unity. She had been told by her doctors her diagnosis was that of schizophrenia, and, confused about what this meant, studied Bleuler’s derivation of the term from the Greek words for “split” and “mind.” She told me a better translation, still respecting the etymology but connecting more closely to her own familiar self-experience, would be: “torn soul.” I found her statement, obviously rooted in her feeling of being in pieces, to be one of the most astute things I have ever heard on this subject, and I told her so. We worked together for several decades and got along very well.
So-called bipolar disorder
In The Abyss of Madness, I made the claim that the most important frontier for present-day clinical psychoanalytic research is that of the psychotherapy of bipolar disorder, also known as manic-depressive illness. Of course these terms are medical-diagnostic designations, embedded in a Cartesian, objectifying worldview. How the patients so diagnosed will appear under a phenomenological lens remains to be seen, and what innovations in our approach to them will come forth are still to be defined.
A fabulous insight into the experiential core of a great many of the patients showing an oscillating pattern of mania and depression was given to us by Bernard Brandchaft, in his book Toward an Emancipatory Psychoanalysis. He saw a problem again involving a sense of personal annihilation, wherein the manic episode expresses a transitory liberation from annihilating ties to caregivers, whereas the depression that ensues represents the reinstatement of those ties. A division has occurred between accommodative and individualizing trends in these patients’ personalities: on one side of this division, there is a compliant surrender to authority and the installation within the patient’s selfhood of others’ purposes and expectations; on the other side is a glorious overthrow of such captivity and the embrace of shining freedom. The magical emancipation, of course, cannot last, because there is nothing and no one to support it, and so it collapses into a dark despair. Here would be my questions for those who seek pathways of psychotherapy with such patients in the future. Can an experience be facilitated that establishes a new center, one in which compliance and rebellion are somehow integrated? Can the empathy of the clinician become a medium in which previously aborted developmental processes can be reinstated? Can a deep understanding of what is at stake for the patient finally make a constructive difference to his or her destiny in the continuing nightmare of bipolarity?
The great psychoanalyst, Frieda Fromm-Reichman, in 1954 published a now-classic clinical study: Its title was: “An intensive study of twelve cases of manic-depressive psychosis.” A generalization arising from this study was the notion that such patients were, in their families growing up, treated as extensions of their caregivers rather than as independent beings in their own rights. I would like to see a modern counterpart to this work, tracing carefully the subjective worlds and histories of bipolar patients and exploring the outer limits of our efficacy as therapists in arresting their destructive patterns and stabilizing their lives. The key to success in such a project will be in the new understanding flowing from Brandchaft’s insight, one highlighting the patients’ needs to find pathways of emancipation from enslaving accommodation that do not lead into the structureless chaos of the manic episode.
An amazing example of the twin-sides of bipolarity is given in another classic of the literature of madness: Kay Jamison’s An Unquiet Mind. This author tells the story of her extended resistance as a young woman against her doctor on the issue of her taking mood-stabilizing drugs. Back and forth their arguments went, with her trying to defend her right to a life free of medical intrusions, and with her psychiatrist telling her she had a biologically-based mental illness that absolutely required medications in order for her to be able to function. Finally, with the greatest reluctance, Kay agreed to begin on a course of taking regular doses of lithium. However, when she went to the pharmacy to pick up her prescription, she suddenly was seized by a terrifying vision. She saw, in her mind’s eye, vast numbers of poisonous snakes approaching her vicinity and foresaw how these dangerous creatures would strike at her and all those she cared about, filling their bodies with lethal toxins. So she purchased, along with her lithium, all the snake-bite kits the pharmacy had available, hoping to use the kits to save herself and as many people as she could.
Let me tell you, Adam, my theory of what this delusion about snakes symbolized. The poison carried by these imagined creatures, about to be injected into Kay herself and the unsuspecting public, represented the diagnostic authority of her doctor, to which she was in the process of capitulating. The theme of at first fighting back willfully but then caving in and surrendering appears also in her early family life, which she describes as having been a battle against oppressive control. The side of this woman tending toward compliant surrender was accepting into her self-definition the medical attributions she had earlier resisted; the side of her wanting to protect her self-integrity from invasion and usurpation armed itself with antidotes to snake venom. There is a parallel between Kay’s desperate purchase of the life-saving snakebite kits and Patty Duke’s attempt to drive imagined foreign agents out of the White House, which is briefly described in Letter # 4. Remarkably, neither of these women appears to have had any awareness of such symbolic connections. It has been my sense that so-called bipolar patients often seem to live in a world of utter concreteness, rendering subjective life strangely opaque.
Possibly this opacity arises out of the absence in the patients’ families of origin of validating responsiveness to the child’s unique world of experience.
Madness and Creative Genius
Another favorite subject of mine, one that I hope will be taken up in our field in coming years, pertains to creativity and its complex relationships to madness and trauma. It is my view that the events and circumstances of our lives that hurt us most deeply, sometimes that even take us into an experience of personal annihilation, are implicated as also being among the factors leading to great achievements of creative imagination.
I taught an advanced seminar at my college for a long time, a class in which each year we would select a person for study showing great creativity but also signs of madness. A generalization unexpectedly emerged from the long series of analyses that took place: in almost every case there was evidence of a profound, irreconcilable conflict in the personality of the creator, one that threatened to lead to fragmentation and madness but that seemed to be integrated by the acts of creation. The specific content of the division varied from instance to instance, but the presence of such a duality seemed not to. As you know, Adam, four such divided geniuses are described and discussed in the final chapter of The Abyss of Madness: Soren Kierkegaard, Friedrich Nietzsche, Martin Heidegger, and Ludwig Wittgenstein.
I would be very interested in a much more inclusive exploring of major figures in art, philosophy, and science in order to see just how truly general this apparent pattern is. It would also be important to study carefully how it is that the creative activity brings the warring trends in the creator’s soul into a unity. I am thinking that a thorough understanding of such matters could lead to innovative psychotherapeutic approaches with people otherwise fated to lives of paralysis and despair. Would it not be a beautiful development in our field, Adam, if ways could be found to transform delusions and hallucinations into works of art?
I shall offer a single instance of the analyses conducted in my college seminar, that of the great German poet Rainer Maria Rilke. If you have not read this gentleman’s works, Adam, I recommend studying two of them: Duino Elegies and Sonnets to Orpheus. Rilke’s writings abound with a concern with spirits and ghosts. He was himself inhabited by the soul of a sister who died, a short period before he was born. His mother, broken-hearted by her loss, raised her son to be the dead child’s reincarnation. Consider his name, as it was given to him by his mother: Rene Karl Wilhelm Josef Maria Rilke. The name “Rainer,” which one normally associates with him, does not appear in this sequence. It is a masculinization of “Rene,” originally given as his first name. He changed it under the influence of his muse and lover, Lou Andreas Salome.
Rilke’s given names form a sequence of male designations bounded at the beginning and the end by female ones. His mother, having lost her daughter, enclosed his name, and his soul, in a vision of a resurrected female. She dressed him in girl’s clothes, encouraged his playing with dolls, and interpreted his early interests in drawing and watercolors as essentially feminine preoccupations. Born a boy, he was raised from birth to be a girl.
The soul of the dead sister took up residence inside the young boy. Although the female spirit never became the whole of him, she did alternate in his experience with the male child he also became. Sometimes her presence was felt as a mystical mask he would put on; the problem arose when this mask began to melt into his face and displace his identity as a boy. Or was it the girl he was raised to be whose identity was displaced by the mask of a boy? At other times, the alien spirit erupted from within, draining away all vitality and pursuing its own independent agendas. This spirit might have been, again, the girl emerging from within the boy, or the boy erupting from the depths of the girl his mother saw him as being. With Rilke, it is always both/and, and never either/or. The key to the genius of his poetry lies in his ability to embrace both sides of his androgenous nature, and this ability also shielded him from madness.
In the journey of the creator, there is almost always a division within the soul, one that – left unaddressed – carries the possibility of madness within its depths. The act of creation provides a pathway in which the division can be transcended and unified, and is a protection against psychological destruction. There are countless examples one can find in the life histories of artists, philosophers, and scientists. The need to bring together that which has been torn asunder establishes an everlasting tension, one that leads to a spiraling of creativity. This is a theme one could spend a lifetime studying.
These are my thoughts for now, Adam, and I hope you will find something of interest in them. Write again, my friend – your questions open the doorway to thoughts I might never have otherwise come to.
George Atwood
