The Idea of a Mental Illness: Is it a Response Located in Psychic Reality? – II

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The more radical formulation holds that the etiologic event of mental illness, the event to which the illness is a response, is always located in psychic reality, is always ultimately an internalised, relatively stable or structuralised symbolic form or forms representing a conception or conceptions of reality—and never events in the situation in and of themselves, opines Prof. Ashoka, a renowned psychiatrist, in the second part of his erudite research, in the weekly column, exclusively in Different Truths.

Let us agree, then, that mental illness, like any disease, is, first of all, a concept or idea — and that, therefore, any particular mental illness such as schizophrenia is also a concept or idea. Do you agree also that it may prove useful to distinguish mental illness from other diseases as involving primarily an impairment of symbolic functioning? My guess is that you prefer that formulation to the more radical one —that the concept mental illness necessarily includes the idea of an illness that is the effect of symbolic events or virtual intrusions, of internalised representations of self or the object world. This more radical formulation holds that the etiologic event of mental illness, the event to which the illness is a response, is always located in psychic reality, is always ultimately an internalised, relatively stable or structuralised symbolic form or forms representing a conception or conceptions of reality—and never events in the situation (whether physiological organism or external reality) in and of themselves.

If you draw back from this formulation, I don’t wonder at that. You are quick to sense that a possible implication of such a formulation might be that no amount of alteration of the situation (whether physiological organism or social system) will radically cure a mental illness so defined, once it has come into being — that is, once an internalised symbolic structure effects and maintains it. Such an implication cannot be easily accepted in these times when so much human misery, so obviously a response to the physical and social conditions of human life, commands our attention and demands of us alleviation. Perhaps we can avoid such an unhappy conclusion. We shall see.

It is, of course, possible to study a mental illness in terms of neurophysiological structures and processes, which, strictly speaking, must be considered the conditions for, and the determinants of the availability of resources limiting, symbolic functioning. It is possible to study a mental illness as a manifestation of systems of internalised symbolisations, regulated according to different principles and with different aims or tendencies, constituting the personality system. It is possible to study a mental illness as a manifestation of the characteristics of a system of interaction such as a family, community, or society, which is constituted by the symbol systems its members share. It is also possible to study a mental illness from the point of view of a cultural system of beliefs and values, which, when institutionalized in social systems or internalized in personality systems, govern beliefs about and attitudes toward mental illness.

It should be clear that I do not believe that any one of these approaches to the study of any mental illness has the right, conceptually speaking, to first claim upon scientific interest or to scientific validity. It is, however, useful for consistency of focus and conceptual clarity to distinguish between them. But, following now our own interest in these lectures, we may ask: how, in fact, do psychiatrists study the personality system — and a mental illness such as schizophrenia from the point of view of the personality system? Not that there is a one-to-one relation between an investigator’s method of study and his conception of a particular mental illness. Not at all. A conception may lead to a preference for a method of study and a method of study may influence the formation of a conception. Method and idea influence each other in a complicated way in the history of science, the invention of methods leading to new ideas, and ideas, no matter how vague, determining how and at what we look.

Suppose you wanted to discover something about a mental illness— again, let us stick to our example, schizophrenia—or you had some ideas about it you wanted to test. How might you begin? Most simply perhaps you might, as Bleuler did, examine a large number of patients, asking questions, studying their verbal, affective, and motoric products, observing their performances as each attempts to solve some standard problem you set. You end up with a list of cardinal or primary features, which, you hope, distinguish this class of patients from any other, and another list of secondary features, which may or may not be present in such patients. But these secondary features, even when present, do not distinguish these patients from those belonging to some other class. You decide that the illness in some patients has an insidious onset, because there is no apparent triggering event, and that in others the onset has a more discernible cause. Your conjecture that the former patients suffer from an organic defect of some sort, since you can discover nothing else to account for their malady.

Ladies and gentlemen, I am sorry to be disagreeable, but I must argue with your results. You have already forgotten that it is the animal symbolicum that we study. If the symbolization function operates, then behaviour is not our datum, but rather the meanings of behaviour. If I ask you, what is the meaning of the behaviour of a man falling from the third floor to the first floor, you quite rightly respond that that question is meaningless. This man’s fall follows the laws of Newton; so would any other man’s fall. He is a physical thing. You have no objection to my assigning him to the class of physical things. But if I ask you, what is the meaning of the behaviour of a man who jumps out of the third-floor window, you immediately understand that here is a different situation.

The behaviour of the man who jumps—assuming he is not coerced to do so; if he is pushed he behaves as any other physical thing—depends on the intention, whether conscious or not, with which he jumps, on the nature of his symbolisations of past and present experience and his anticipations of the future—yes, at that moment he imagines the future. You cannot answer the question concerning the meaning of his behaviour merely by observing the behaviour, no matter how meticulously or with what refinements of quantification you do so. You would certainly caution me about putting the man who jumps in the same class as all other men who jump and labelling this class the jumping disease. Quite rightly, you see that the behaviour may be a final common pathway for a number of quite different processes. You would, I think, not advise me to attempt to discover the nature of these processes by taking motion pictures of men jumping, and separating those who jump rapidly from those who are hesitant, those who leap from those who crouch, those who cry from those who are silent.

Insofar, then, as we view phenomena from the point of view of the personality system, that is, from the point of view of internalized systems of symbolization with different characteristics and aims, no observable behaviour always has the same meaning, whether one man repeats it or it is observed of many men, any more than a word always has the same meaning when spoken by many different men or on different occasions by the same man. Furthermore, the probability is great that any behaviour on any occasion has at the same time more than one meaning, just as any word is a nidus of intersecting meanings, is surrounded by a nimbus of meanings belonging to different levels of organisation of symbolisation.

Language is intrinsically ambiguous, and so is human behaviour. Using positivistic terms, we speak in psychoanalysis of the multiple determination of any phenomenon in psychology, but you will recognize that causation is not at issue here but rather a characteristic of phenomena involving symbolisation.

If I guess rightly, you now seem ready to complain that if no behaviour always has the same meaning and every behaviour has many meanings, it is impossible to study man scientifically. I agree even before you say so that the study of man is marvellously difficult.

Nevertheless, I cannot disregard, even to make things easier, the possibility that your conclusion that an insidious onset is apparently without adequate cause, your description that affect is inappropriate or associations loose or disorganized, tell me more about you than about the patient. Your conclusions and descriptions tell me that you cannot make sense of the patient, but do not convince me that the patient does not make sense. The confidence of your assertions is based on your assumption that what is meaningless to you has no meaning to the patient. We have here a defect in our investigating instrument, which we should not confuse with the defect we hope to investigate. In other words, “insidious onset” means you did not understand the etiology of the illness; “inappropriate affect” means you did not know what symbolisation of events motivated the affect or lack of it or its connection with certain contents; “disorganised associations” means associations you could not follow.

For these dubious results, I blame your method, which involves wresting samples of behaviour from their context, which you ignore, and treating such behaviours as primary data in and of themselves. You ignore the nature of the clinical setting in which you examine the patient; you ignore what that setting means to him, what being tested in that setting means to him, and what you mean to him. Therefore, if the patient should be attempting to create and communicate a symbolic representation of his experience—with whatever resources he has at his command, including his inappropriate affect and his loose associations, and with an organization in part determined by the nature of those resources—the likelihood is great that such an effort will communicate, nothing to you.

Incidentally, in science allusion to residual factors as causative (such as, in this case, “organic” or “constitutional”)—that is, factors outside the conceptual frame of reference chosen—is always a confession of ignorance. Perhaps, too often, it is also a flight from more cogent inquiry within that frame of reference. I warn you that I will probably make similar objections if you want to do statistical studies of the appearance of this or that behavioural datum in groups of patients. I cannot, for example, make myself believe that one can assume the same behaviour in any patient or in the same patient on different occasions checked off on a rating list always means aggression, dependency, regression, or what have you, because it looks aggressive, dependent, or regressive to an observer. Such studies may purport to test psychoanalytic hypotheses, for example, involving such notions as aggression, dependency, or regression; I cannot accept their claims to do so adequately.

Perhaps I have convinced some of you that the methods of clinical observation of sample performances and of statistical correlations of behavioural items may either bias us in the direction of attributing meaninglessness to phenomena or coarsely blunt and blur the meanings and the differences in meaning of what we observe. Feeling discouraged, you are now inclined to abandon classification and hypotheses altogether. If I insist on introducing the symbolisation function, you will insist that scientific explanation is impossible, even that the idealistic conception of a unique and irreducibly individual man steadily grows more to your liking in dealing with psychological matters. You prefer to abandon the attempt to understand a particular mental illness and attempt instead by talking to an individual person, by listening carefully to his own accounts of his illness, by grasping intuitively what it has meant to him in his own terms, only to understand that person, with no pretence at generalisation, theory, or explanation. You may even begin using words like existential psychology, phenomenology, encounter, and I will then become somewhat frightened and withdraw in haste because neither as physician or scientist do I know how to respond to these ideas. On the whole, though, I commend your intention to begin by listening carefully to what a patient has to say about his experience. I am afraid, nevertheless, that being an animal symbolicum yourself you will not be able to avoid having certain preconceptions or developing certain conceptions of what ails your patient. I do not advise you to try to maintain a kind of conceptual innocence or nudity, in the vain hope that such an effort will enable you to grasp experience immediately in and of itself. If you are determined not to theorise, you will simply end up theorizing poorly or naively without being aware that you have done so, or you may uncritically adopt the patient’s theories about what is going on inside him.

These theories, which like all scientific theory are full of metaphor, even when they involve reference to demons or a demoniacal reality, to quantities of some stuff or other that flows here and there, to inner boilers about to burst, have a great deal of interest for us, so much so and so much may we find ourselves in agreement with them, that we may forget to inquire how it is that the patient forms these particular theories about himself, entertains these particular phantasies, symbolises in just this way and not in some other. Since the patient tends to take his symbolisations for granted, he is not usually of immediate help in answering this kind of question.

(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’.