Psychotherapy Paradigms in Schizophrenia: Understanding the Symbolisations of the Patients – III

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A psychotherapist seeks to understand the symbolisations of his patient, in both their aspects as suasive messages or communications to the psychotherapist and their aspects as representations of conceptions of the patient’s world and self. The psychotherapist seeks to respond to his patient’s symbolisations in ways that symbolise and communicate his understanding of them to the patient. Here’s the third part of the eight-part serialisation of Prof. Ashoka’s lecture, wherein he deals with the practical aspects of psychotherapy, in the weekly column, exclusively for Different Truths.

But perhaps you feel, as I sometimes do in moments of fatigue, that it is unfair to expect us physicians, who have spent most of our waking lives learning to manipulate things, to become as sensitive, precise, and scrupulous in the use of word and gesture as a poet must be, for whose enterprise the placement of a syllable is fateful. I would not blame you if in the face of such exacting requirements you forsake such work forever for the pill and the knife. Nevertheless, we are here today to consider that other tool with which you may confront your patient’s illness—psychotherapy. As a psychotherapist, your job, most simply, is to understand this person who sits silently facing you and to communicate in ways that are meaningful to him your attempts to understand. What do I mean by “understand”?

That would take us many hours to discuss. Provisionally, let us agree that if you understand your patient, minimally, you are able from moment to moment to see—by which I mean both think and feel—the world as he conceives it to be and himself as he conceives himself to be. That presupposes you are able to translate the language—not necessarily verbal—in which he wittingly or unwittingly, with various degrees of consciousness, represents these conceptions. More ambitiously, perhaps, eventually, you might even be able to formulate with him some ideas to explain how these representations of the world and self-come to have the shape and content they do have and change in the ways they do change.

More formally, I would define psychotherapy as treatment by symbolic means, directed to the personality system; the personality system is constituted by symbolic processes. Psychotherapy is applicable to the elimination of etiologic or pathogenic events, the mitigation of morbid processes, or the support of reparative efforts, when such events, processes, or efforts are constituted by symbolisation or its impairment. The nature, extent, and duration of the effects a psychotherapeutic endeavour may be expected to have probably depends in part upon the extent to which it involves control of the conditions in which vicissitudes of symbolisation are to occur and be observed. These conditions are especially those in which symbolisation processes emerge that either in form or in content under other conditions do not make themselves readily available. I am speaking now of the degree of sophistication or discipline evident in the use of a treatment modality; what I say has analogies in every medical discipline.

Psychotherapy should be distinguished from treatment methods making use of non-symbolic agents, for example, surgical interventions, drugs, and so on, to the extent that these are regarded as intrinsically rather than symbolically efficacious. Psychotherapy should also be distinguished from treatment methods directed to other than personality systems (even when these methods involve talking)—for example, those considered to have their principal impact upon the physiological organism (we might refer to physiological therapy) or upon such social or interactional systems as the family, other small groups, a hospital community, a neighborhood community, city, or some other portion of society (we might refer to sociotherapy, which encompasses then such enterprises as family therapy, therapy of the group, milieu therapy, and community therapy).

As I have already said, in other words, a psychotherapist seeks to understand the symbolisations of his patient, in both their aspects as suasive messages or communications to the psychotherapist and their aspects as representations of conceptions of the patient’s world and self. The psychotherapist seeks to respond to his patient’s symbolisations in ways that symbolise and communicate his understanding of them to the patient. The psychotherapist’s skill is also called upon to control conditions that will either enhance or support these processes, on the one hand, or limit, constrain, or interfere with them, on the other.

What is the therapeutic action of such activities by the psychotherapist? Whatever it is, I am not inclined for reasons that must be apparent to you to believe that it can be described in terms appropriate to the rewiring of tangled circuits or that it involves extinguishing the effects of previous automatic stimulus-response conditioning and substituting for such effects the linkage of new reactions to signals. Would you think it quixotic of me to regard psychotherapy as a process of becoming more fully awake? I realise that I may sacrifice what respect you have left for psychotherapy as an enterprise, if I seem to say that the psychotherapist is essentially, not merely metaphorically, enabling the patient to awaken. But I cannot help that. Psychotherapy is a process of becoming more fully awake. Psychotherapy is a process that increases the capacity of its participants—perhaps, we should say “both participants”—to attain voluntarily a state of becoming more fully awake. I like that way of putting it very much.

I am sure, however, that some of you regard such a formulation with puzzlement, if not skeptical mockery. I wonder as I think about your puzzlement and your skepticism if we do not underestimate the extent to which becoming able to speak the unspoken or unspeakable makes possible a higher level of functioning or organization to the personality system.

May I remind you of a passage from Helen Keller’s autobiography, quoted for similar reasons in that excellent work of Susanne Langer’s, Philosophy in a New Key? Miss Keller records the passage from a world of signs to a world of symbolic activity, made possible by the advent of language. “[My teacher] brought me my hat, and I knew I was going out into the warm sunshine.” That is an example of life in a world of signs. “This thought, if a wordless sensation may be called a thought, made me hop and skip with pleasure.” It is clear that Miss Keller doubts that symbolic activity, that thought, may occur without language, some sort of language that is more than sign, that is in fact symbolisation.

Contrast that view with Sullivan’s notion that language is but “grace notes” upon thought. The passage continues:

We walked down the path to the well-house, attracted by the fragrance of the honeysuckle with which it was covered. Someone was drawing water and my teacher placed my hand under the spout. As the cool stream gushed over my hand she spelled into the other the word water, first slowly, then rapidly. I stood still, my whole attention fixed upon the motion of her fingers. Suddenly I felt a misty consciousness as of something forgotten—a thrill of returning thought, and somehow the mystery of language was revealed to me. I knew then that w-a-t-e-r meant the wonderful cool something that was flowing over my hand. That living word awakened my soul, gave it light, hope, joy, set it free! There were barriers still, it is true, but barriers that in time could be swept away.

(To be continued)
©Prof. Ashoka Jahnavi Prasad

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Ashoka Jahnavi Prasad is a physician /psychiatrist holding doctorates in pharmacology, history and philosophy plus a higher doctorate. He is also a qualified barrister and geneticist. He is a regular columnist in several newspapers, has published over 100 books and has been described by the Cambridge News as the ‘most educationally qualified in the world’.