(Adapted from a presentation given today at the “R.D. Laing in the 21st Century” symposium, at Wagner College in Staten Island, NY)
I would like to share with you some thoughts I have about R. D. Laing’s conception of psychopathology. This is not an easy topic to explore, in part because Laing was somewhat ambivalent about the concept and avoided even using this term. In The Politics of Experience, for example, Laing famously questioned whether schizophrenia, the form of psychopathology he is most identified with, even exists! Yet many of the people Laing saw in therapy suffered terribly and saw him in therapy in the hope that he could help them relieve their anguish. But what, precisely, was it that Laing was helping them be relieved of, if not a psychopathological condition? Surely, if there is a bona fide thing such as “therapy,” then there must be some condition or state, however we regard or label it, that the process of therapy presumes to relieve. What else is the one person, the patient, paying the other person, the therapist, for?
I will never forget when Thomas Szasz, the author of The Myth of Mental Illness, accused Laing in the 1970s of betraying the cause of anti-psychiatry by continuing to engage in treating the mentally ill, though Laing himself condemned the psychiatric community for the way they conducted this practice. Szasz built his career around the notion that mental illness is a myth, that there is no such thing as an “illness” of the mind, and that psychiatry had orchestrated a hoax by insisting that mental illness does exist and that psychiatrists are treating it. Szasz argued that Laing was merely advocating a more benign form of treatment than, say, drugs, lobotomy, or electric shock, but that it was treatment nonetheless Laing was advocating and, by it, perpetuating the same hoax as those psychiatrists whom Laing was so critical of. The gauntlet that Szasz threw down was undeniably direct: Do you believe in psychopathology or not; and if you don’t, then what is it exactly you claim you are “relieving,” if not mental illness?
Laing, in fact, did not believe in psychopathology, not in the way we have come to understand this concept, which derives from the medical term pathology, literally meaning suffering. The first psychotherapists were physicians and the term psychiatry, which was only coined in the nineteenth-century, became the medical specialty of doctors whose mandate was to treat the psyche or the soul, or as we prefer today, the mind. Laing’s first book, The Divided Self, was his most concerted effort to show why psychiatrists, and for the most part psychoanalysts, have misunderstood the kind of suffering that people labeled schizophrenic, say, are experiencing, and why psychiatric nomenclature does little to help us understand the phenomena so labeled. If what psychiatrists believe they are treating is, as Laing suggested, not schizophrenia, or any form of psychopathology, then what is it they are treating? And why are we calling the activity we are engaged in treatment, or its derivative, therapy?
In order to ponder these questions I want to focus on some of the arguments Laing put forward in The Divided Self, and then try as best I can to explain why Laing believed that what we do, while not a specifically medical activity, may nonetheless be termed “therapy.” Though some of my comments will be based on Laing’s writings, for the most part I will rely on my personal relationship with Laing, which includes being supervised by him while I was training as a psychotherapist at Laing’s school in 1970s London, and over the course of numerous informal conversations I enjoyed with him over the course of many years.
The subtitle that Laing assigned to The Divided Self was, “an existential study in sanity and madness.” It was not an existential study in “psychopathology.” Why this distinction? Are they not the same thing? To answer this, I want to take a look at what Laing set out to accomplish in this study, why he qualifies it as a study that is specifically existential in nature, and how this classic work laid the foundation for everything that Laing would write subsequently.
As Laing says in the preface to that work, this book is “a study of schizoid and schizophrenic persons,” and its basic goal “is to make madness, and the process of going mad, comprehensible.” At the outset, the diagnostic language Laing employs is readily familiar to every psychiatrist and psychoanalyst who works with this population. Terms such as psychotic, schizoid, schizophrenic, paranoid – all standard nosological entities with which therapists the world over are familiar –proliferate throughout this book. He is speaking their language, so to speak, but the meaning he is assigning to these terms is anything but ordinary. Laing explains that he has never been very skillful in recognizing the diagnostic categories that are standard in every psychiatric diagnostic manual in the world, including the DSM that is used in America. He had trouble recognizing the subtle nuances that are supposed to distinguish, for example, the various types of schizophrenia, of which there are many, or even what distinguishes them from other forms of psychotic process, such as paranoia, or bipolar disorder, previously known as manic-depression.
None of these terms are written in stone. In fact, they are constantly changing and undergo revision in every new edition of the DSM. So what is Laing saying here? He is not suggesting that he is too stupid to understand the complexity of these entities. Rather, he is suggesting that because there is no agreement in the psychiatric community as to how to recognize these symptoms and the mental illness they are purported to classify, it is impossible to take them seriously. No two practitioners agree on how to diagnose a person, and given the never ending revisions to these categories, practitioners often change their own minds as to how to recognize what it is they are proposing to diagnose and treat. This is hardly the science it is purported to be.
What did Laing conclude from this disarray in categorization? That there is no such thing as mental illness, or psychopathology, so no wonder there is no agreement as to what “it” is. When a doctor sets out to diagnose a typical medical illness, he customarily looks for physical symptoms in his patient. The color or tone of the skin, dilation of the pupils, body temperature, and so on may indicate an abnormality. Additional tests may be administered that examine the blood or urine, and if that fails to provide conclusive results, perhaps x-rays, CAT scans, EKG’s, heart stress tests, mammograms or prostrate exams – all ways of examining the chemistry or interior of the body – may be utilized in order to hone in on what is malfunctioning. For so-called psychiatric symptoms, however, such tests will be of virtually no use, because no one will locate any of the symptoms of psychopathology inside or on the surface of one’s body. Even an examination of the brain, which is now the darling of neuropsychiatrists and neuropsychoanalysts, will never locate the presence of any form of mental or emotional disturbance that we can label a mental illness.
Instead, what we can examine is the behavior of the person being diagnosed, whether, for example that person is suffering from delusions or hallucinations, confusion, disorganization, incoherent speech, withdrawal, flights of fancy; or depression, anxiety, dissociation or maladaptation, or perhaps a persistently elevated, expansive, or irritable mood! This list is hardly inclusive, but what all these symptoms have in common is that they refer to experiences that everyone has, at one time or another. Even delusions and hallucinations, the gold standard for schizophrenia, are common in dreams, and not all that uncommon when we are awake. Yet most people who exhibit or experience these so-called symptoms are never subjected to a formal diagnosis or treated for them. So why is it that some people are and some people are not? Why are some people deemed crazy and others sane, when they exhibit the same symptoms?
These are some of the questions that Laing pondered in The Divided Self, but he never arrived at a satisfactory answer. In matters of the mind, the act of diagnosis can just as often be a political as medical ceremonial. Laing believed that we will never succeed in understanding such phenomena as long as we persist in looking at people from an alienating, and alienated, point of view. It is the way that we look at each other, the way that psychiatrists and psychoanalysts typically look at a patient, that Laing believed is the crux of the problem. The reason Laing calls The Divided Self an existential study instead of, say, a psychiatric, or psychoanalytic, or even psychological study is because the existential lens is a supremely personal way of looking at people; a person to person manner of regarding others and recognizing them, as Harry Stack Sullivan said, as more human than otherwise. This is another way of saying that the person, or patient I am treating, is not a sick person, but a person like me. And it is the fact that he is just like me that makes it possible for me to understand and empathize with him in the first place.
Laing began writing The Divided Self while still working at a mental hospital in Glasgow, when he was just in his twenties. It doesn’t sound like he had an opportunity to do much psychotherapy there, but he did have lots of time to hang out with the patients under his charge, all of them diagnosed as schizophrenic. Instead of looking for symptoms of recognizable forms of psychopathology, Laing sought instead to simply talk to his patients, as he was fond of saying, “man to man,” and to listen to what they had to tell him. What he heard, which he recounts in The Divided Self, is nothing short of amazing. They told him stories about their life, their belief systems and experiences, the things that worried them and the things they thought about, day in and day out. The thing that I remember standing out for me when I first read this book – and I have probably read it a dozen times in the past forty odd years – was that I felt he was talking about me. This, from what I have subsequently gathered from others, is not an unusual experience. It is this reaction that has made this book the classic that it is.
Instead of trying to determine what makes “us” – the sane ones – so different from “them” – the ones that are crazy – Laing sought instead to explore what we share in common. Laing used the term schizoid – quite common in Britain but only marginally employed in the U. S. – to depict a state of affairs that lies at the heart of every person labeled schizophrenic, as well as many who are not so schizophrenic. The common thread is this: that the person so labeled, in his or her personal experience, suffers from a peculiar problem in his relationships with others: he cannot tolerate getting too intimate with other people, but at the same time cannot tolerate being alone.
This is a terrible dilemma to be faced with. Most of us, says Laing, either hate to be alone and throw ourselves into the social milieu with others – Jung would have called them extroverts – or we can’t bear social situations and opt instead to spend most of our time alone. These more introverted, private individuals may be gifted writers or scientists or deep sea divers who are well suited to their relative isolation, whereas the extroverts among us make excellent politicians or actors or any number of other callings. In other words, we tend to incline in one direction or the other, and either may be a perfectly viable way of existing and living a happy life. The person who is schizoid, however, doesn’t excel at either. He cannot tolerate isolation, nor can he get genuinely close to others. He is caught in a vise, a kind of hell, that is rife with unrelenting anxiety, what Laing calls ontological insecurity, because simply existing is a serious and unrelenting problem for him.
When I first read this I couldn’t help but wonder how many of us are really all that comfortable being alone, and how many of us are truly all that comfortable in our relationships with others, which is to say, free from anxiety. Isn’t this a problem, for example, that psychotherapists typically share with their patients? Psychotherapy is a fabricated relationship whose purpose is to achieve uncommon intimacy with another person, while placing extraordinary constraints on it, conducted by two people who, to a considerable degree, have problems in their relationships with others. Isn’t this rather like the lame leading the blind? Laing didn’t think so, but he was acutely aware of the paradox, of how wounded a person must be to even want to spend all of his professional time in the company of people who are obsessed with their problems.
Laing, however, was not the first to recognize this paradox. Nor was he the first to accuse psychiatrists of employing means of helping others that are for the most part ineffectual. For that Sigmund Freud would have to be credited, arguably the first anti-psychiatrist. Freud was a neurologist, not a psychiatrist, and he was scathing in his technical papers about the psychiatrists of his day who, Freud believed, knew nothing about why their patients suffered and how to help them. Freud believed that people develop symptoms of hysteria and neuroses because they have been traumatized by unrequited love. He was the first to recognize the powerful effect that our parents, in fact all our social relationships, have over us and how our capacity to love is also the source of our greatest sorrows. Freud was also the first to recognize that our thirst for love is unquenchable, no matter how much we get, and that we are most vulnerable when intimate with another person. Laing loved this about Freud and was writing a book on love when he died. He had also hoped to write a book about Freud.
Yet Freud was not interested in the kind of person Laing described in The Divided Self, because he didn’t believe a person who was psychotic was capable of attaching himself to the psychotherapist who was treating him. Freud was right in recognizing how vulnerable such people are, but was mistaken in his views about their treatment. It has been argued that Laing accomplished for the so-called schizophrenic what Freud accomplished for the neurotic: a way of establishing an intimate relationship with them that may, in itself, serve as a vehicle for healing. Freud was unhappy with the brutal way that the hysterics of his day – mostly women – were typically treated, and even less happy with the prevailing understanding of psychopathology. Unlike psychiatrists, Freud did not believe in an us versus them mentality. He did not believe, for example, that some people are neurotic and that some people are not. He believed that everyone is neurotic and that this is an essential aspect of our human condition. So if everyone is neurotic and curing us of neurosis is not feasible, then what is psychotherapy good for?
Freud was never able to definitively answer this question. But if one reads between the lines, one can’t help concluding that Freud viewed anxiety and the other forms of alienation, that Laing was so good at describing, as an essential aspect of our human condition, so that what we call “ill” versus “healthy,” or crazy versus sane is not black or white, but a matter of degrees. If all of us are neurotic, some more or less than others, then all of us are also healthy or sane, to varying degrees. Though he was loathe to admit it, Freud rejected the concept of psychopathology as it is commonly understood, and replaced it with an existential perspective that emphasized the management of anxiety, as an inescapable aspect of living.
After The Divided Self Laing published its companion volume, Self and Others, where he continued his critique of psychoanalysis and the problems he had raised in The Divided Self. Whereas psychiatry had depersonalized the relationship between doctor and patient by pretending that it wasn’t a person, but rather his illness, that was being treated, psychoanalysts depersonalized the treatment relationship by insisting that it wasn’t the person or his body that was to blame, but his unconscious. Though psychoanalysis made extraordinary gains in humanizing the treatment relationship over prevailing psychiatric practices, Laing believed that both seem strangely incapable of formulating a genuinely symmetrical therapy relationship between equals. There have been notable exceptions to this, and Laing stood proudly on the shoulders of Sullivan, Fromm-Reichmann, Winnicott, and many other psychiatrists and psychoanalysts who advocated an interpersonal way of regarding their patients.
But Laing’s agenda was far more radical than simply being nicer, or kinder to his patients. Instead, his concern was with being more real, or authentic, or honest. This, he believed, could only happen of we stop objectifying our patients into diagnostic categories that only serve to separate them from us. Perhaps the model that best exemplifies what Laing advocated is not a relationship between therapist and patient, or parent and child, but one between friends. After all, friends confide in each other, and confiding is an essential aspect of how Laing conceived therapy. Laing suggested that therapists might even be called prostitutes, because what patients were buying from him was not treatment, per se, but a relationship. Whether we think of ourselves as friends or prostitutes to our patients, Laing didn’t have a problem with calling the people who paid to see him his “patients” any more than he had problems with calling what they were doing “therapy,” both undeniably medical terms. But isn’t this inconsistent with what he has been saying about the myth of psychopathology?
Whatever problem Laing had with the institution of psychiatry, he never had a problem with being a doctor. He was proud of his medical training, and while such training is not essential to the practice of therapy, he thought it was as good a way as any to enter the field. Laing was fond of pointing out that the word therapy is etymologically cognate with the term attention or attendant. In ancient Egypt a religious cult called the Therapeutae were literally attendants to the divine. So the term predates the subsequent medical appropriation of it by the Greeks. If we take the term literally, a therapist is simply a person who is attentive, or pays attention to the matter that concerns him. Similarly, a patient is literally a person who patiently bears his suffering without complaint. The term doesn’t necessarily refer to someone in medical treatment because the kind of suffering is not specific. Laing concluded that if you put these two terms together you get one person, the therapist, who attends and is attentive to the other person’s, or patient’s suffering. To what end? Hopefully, such attention, with enough patience, good will, and most importantly, time will lead to something, to a point where the patient no longer requires such attention and can get on without it. This is something that Thomas Szasz never understood. He seemed more interested in the legalities of the issue than he was with helping people.
According to Michel Foucault, a close friend of Laing’s, it was purely by accident that medical doctors became responsible for treating crazy people in the first place, in eighteen-century Europe. If fact, it is very recent in history that mad people were deemed mentally ill. Historically, people who acted crazy were thought to be possessed, either by evil spirits or by the gods. In the seventeenth century Europeans began to feel unsafe with the crazy people in their midst, who wandered the streets – not unlike the homeless people who wander around our cities – and began to confine them as a means of protection. Not surprisingly, such confinement made them even crazier and their jailors began chaining them to the walls of the Lunatic Asylums they put them in. They soon developed diseases, which only escalated their problems further until the French physician, Philippe Pinel, attended to their specifically medical conditions and observed that the way they were being treated was inhuman. Pinel argued they should instead be treated as sick people, in order to humanize their treatment. It was then, according to Foucault, that mad people were first deemed mentally ill.
This was a remarkable step forward in treating such people as human beings who deserved society’s help, but it also initiated the slippery slope that occasioned the birth of psychiatry and, with it, the diagnostic universe we now live in. Laing was proud of being a physician but recognized that we now find ourselves in an historical quandary. Like the Europe that invented the Lunatic Asylum, our society feels it needs to protect itself from crazy people, some of whom are undeniably dangerous and capable of savage violence, even murder. When the violence erupts, someone needs to make the call: are you crazy enough to lose, even temporarily, your constitutional rights and be confined to treatment – which is to say, medication – against your will? For better or worse, that task has been assigned to psychiatrists, and it has given them enormous power over those it deems dangerous, whether to themselves or others. Laing had no ready or easy solution to this problem, but believed that all of us are implicated in it.
In fact, Laing never formulated an overarching theory of psychopathology to replace the edifice that psychiatry and psychoanalysis have built. For the most part, his focus was on schizoid phenomena and schizophrenia, not as specific diagnostic categories but, like Freud’s conception of neurosis, as a metaphor for varieties of mental anguish that compromise our ability to develop satisfying relationships with others. As the subtitle of The Divided Self suggests, Laing was more comfortable thinking in terms of sanity and madness than psychopathology. But what does it mean to be crazy? And what does it mean to be sane?
These terms lack precise definition when compared, say, with the plethora of diagnostic categories in the DSM, because they are used colloquially, as a manner of speaking, so it’s up to each of us, individually, to determine how to employ them. Laing thought that the essence of what it means to be crazy, in the way that term is ordinarily used, can be broken down into three components, the combination of which will tell us how crazy a person is. The first concerns how a given person exercises his or her judgment; the second concerns how agitated that person may be; and the third concerns the lengths a given person will go to mitigate his anxiety.
Our use of judgment is probably the most critical of the three, because it determines how we make sense of things, including the situation we are facing at a given moment. The judgment of a person suffering a manic episode, for example, is said to be seriously compromised, but so is that of a person who suffers from acute paranoia or hallucinations. Our judgment is where we live, and there’s no escaping it, though we can improve it if – and only if – we have the presence of mind to realize that we can’t trust it. Yet, who gets to decide whether a given person’s judgment is impaired or sound? If I judge that I need help in improving my judgment and take my plight to a therapist, can I trust the judgment of that therapist over my own judgment, or not? I’m not going to get much out of therapy if I can’t trust his judgment, but who is to say that my therapist’s judgment is more sound than mine is? How can I make such a judgment if, say, I don’t trust my judgment? This is a problem, and one that Laing thought makes therapy almost, but not quite, impossible.
A person’s judgment is for the most part a private affair. The person who is crazed is often in a state of agitation, which others can’t help but notice. This state more than usually makes my judgments public, when, for example, I am about to leap off a tall building, or assault someone for no discernable reason. This is the prototypical image that we all have of the crazy person, who is acting crazy, and often in a manner that not only gets our attention, but scares us, because we don’t know what he is going to do next. Each of us has been crazed at some time or other, but the moment usually passes before any real harm has been committed. If it persists, that is a different matter, and things can quickly spiral out of our self-control. This is when I am most likely to be taken to a hospital, whether I want to go there or not.
The third way I may feel or appear crazed concerns what psychoanalysts call defenses, the maneuvers I employ to mitigate my anxiety. This was the issue that Laing was most concerned with in The Divided Self, the so-called schizoid person. We see his defenses in the way he engages in social space. As we noted earlier, this is a person who cannot tolerate being isolated from or being intimate with others because either position makes him intolerably anxious, so he walks a tightrope in the middle where he feels the least amount of anxiety, but still too much anxiety to effectively navigate his relationships. Much of what we do to cope with our anxieties does not appear crazy and does not feel crazy, and works for us, more or less. It is the most severe states of anxiety, such as ontological insecurity, that are the most problematic and may result in the most extreme measures to mitigate, such as catatonic withdrawal.
So if these criteria offer a rough and ready means of discerning what it means for me, or you, to be in a crazy state, what does it mean to be sane? It would more or less approximate the exact opposite of feeling crazy. Our judgment would be sound, relatively speaking; our use of defensive maneuvers would be minimal because we would bear our anxieties with relative indifference; and we would not be in a state of panic or agitation, but one of serenity, of feeling at peace with ourselves and the world. From this perspective, there are no crazy people, or sane people. Every single one of us goes from one state to the other in the course of our lives and oftentimes in the course of a single day. By this definition, all of us have been crazy, no matter how sane we are most of the time. If this were not so there would be no way for a psychotherapist to connect with or empathize with a person who has been diagnosed, say, schizophrenic. We can only help people with problems we ourselves have experienced.
Laing never developed an etiological theory of what “causes” us to become neurotic, or psychotic, or just plain crazy, though he clearly favored the environmental thesis over the biological. Neither model, Laing concluded, is satisfactory and, like the good sceptic he was, Laing believed that our mental states and what accounts for them are for the most part a mystery, and may always be. We may never know why this person is crazier than the next person, or why, in fact, all of us are crazy in some contexts and not so crazy in others. It seems that some people are capable of driving others crazy, but there are those who appear to be perfectly capable of becoming crazy on their own. He thought that common deception is a problem, but difficult to recognize. The bottom line, given the inherent ambiguity of the situation we are in, is to proceed cautiously, with a degree of humility, in how we treat such people when we meet them.
Whenever Laing addressed this topic, whether in writing or in public, he often invoked the Golden Rule. How would you, if you lost your wits, fell apart with grief or consternation, want to be treated by those who have you at their mercy? When the shoe is on the other foot, shouldn’t you treat them the way you would like to be treated? It is impossible to separate Laing’s thinking about psychopathology from the work of psychotherapy. If he met a mad person on the street who was threatening him, Laing would defend himself without hesitation and, if need be, ask the police to confine him. But if you wandered into his office, no matter how crazy you might be, and wanted his help, that was another matter. And that was the matter that concerned him, for the most part, over the course of his life. How to meet another person in dire straights, and how to treat that person in such a way that, in the name of the Hippocratic oath, you commit no harm.
And what of today? Twenty-five years after Laing’s death, are we more humane and compassionate in our treatment of those at our mercy? It is difficult to say. But one thing that we cannot deny, our culture has become even more “medicalized” than at any time in history. The medical metaphor that Laing found more or less acceptable when explaining what he thought therapy is, has become increasingly literal. In California, we even have medical marijuana. Pot is not just a pleasing way of altering our consciousness, it is also “medicine.” When you smoke pot you aren’t getting high, you are medicating yourself for whatever ailment you have convinced yourself you are suffering. You are no longer a pot smoker, you are a “patient.” More and more, anything that pains us is a condition that can be treated. If you are caught having extra-marital affairs with a dozen women, you are no longer a philanderer. You have a sex addiction, which is a condition for which you can be treated, so you are not responsible.
This development in our culture is creepy, because it implies that just about anything we do that might get us into trouble is simply a condition for which we bear no responsibility. Is this a sane way of proceeding? Is this what our capacity for judgment has come to? I think we can guess what Laing would have had to say about that.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.