Libertarian Psychiatry:
an introduction to
existential analysis
PETER FORD
s1
This article aims to draw attention to the work of a group of British psychiatrists of whom the best known are
R. D. Laing and
David Cooper. They have achieved some notoriety in this country because of the extent of their divergence, both in theory and practice, from current psychiatric orthodoxy—
and particularly as a consequence of their references to the prevalent “treatment” of the mentally ill as “violence”. As a teacher, I am not qualified to attempt more than an outline of their ideas as understood by me, after reading their books and articles and some related studies. But the implications of the work of the British existentialist group extend beyond the limits of psychiatry—
and the very generality of their assertions invites a response from the layman. Writing of the process which in their view results in the ultimate invalidation of persons through the labelling of them as “mad”, Laing asks: “… what function does this procedure serve for the civic order? These questions are only beginning to be asked, much less answered. … Socially, this work must now move to further understanding … of the meaning of all this within the larger context of the civic order of society—
that is, of the
political order, of the ways persons exercise control and power over one another.” (
New Left Review, No. 28.) Anarchism is about just this, and any theory, from whatever discipline, which leads to a questioning of the political order of society should have relevance for us—
and we should know something about it.
Dr. Laing has written that his main intellectual indebtedness is to “the existential tradition”—Kierkegaard, Jaspers, Heidegger, Binswanger, Tillich and Sartre—and of these there is no doubt that Sartre’s influence has been the greatest. The British analysts have clearly worked out their own theoretical basis and in many instances have developed Sartre’s ideas rather than merely adopted them as they stand. I am not certain, for example how completely Laing and Cooper share Sartre’s total rejection of the concept of “the unconscious”. However, their book Reason and Violence: A Decade of Sartre’s Philosophy 1950-1960 (Tavistock, 1964) opens with a complimentary prefatory note from the French philosopher—I believe this is an unusual honour for a book about his ideas—and this imprimatur suggests that whatever their divergencies, they cannot be basic.
In anarchy 44 J.-P. Sartre is referred to as “one of the foremost anarchist moralists” (Ian Vine: “The Morality of Anarchism”). This description compares intriguingly with another, made by the socialist Alasdair MacIntyre, reviewing Sartre’s book The Problem of Method in Peace News. He refers to Sartre as a newly found “spokesman of genius” for “ersatz bolsheviks” and “imitation anarchists”. Not knowing MacIntyre’s idea of the genuine article, this does not exactly rule the Frenchman out and I believe his work may well justify a place on an anarchist’s book list. Writing with particular reference to Sartre’s recent work, MacIntyre notes that Sartre can offer no bonds, other than reciprocally threatened violence and terror, of sufficient strength to maintain the cohesion of human groups in a world of “impossibly individualist individuals”. Perhaps a spokesman for Stirnerites? Nevertheless, the potentialities of Sartre’s philosophy as a basis for anarchism are incidental to my purpose here.
The first of four episodes of this essay are intended to create a setting against which existential analysis may be viewed.
s2
EXISTENTIAL FREEDOM
“Man cannot be sometimes slave and sometimes free; he is wholly and forever free, or he is not free at all.”
The concept of freedom at the core of existentialism is very different from what I take to be the common understanding of the term. In general usage, a man is free in as much as he can achieve his chosen ends with a minimum of effort. Similarly, a man’s freedom is reduced as the obstacles between his desires and chosen ends are increased. Freedom is regarded as a measurable quantity; one may have a lot or a little of it, and it can be taken away—
or even “given”. The anarchist’s hypothetical destination, the “free” society, may often be thought of in the sense of an harmonious environment in which all removable obstacles between man’s desires and their fulfilment have been eliminated. But for Sartre, man is totally free by reason of his very being as man, and obstacles between desires and chosen ends are of no relevance. To use a favoured existentialist phrase, man is free by ontological necessity. But his freedom rests, within this concept, in his total responsibility in the face of undetermined choice and in his recognition of the inescapable obligation to choose. An intuitive awareness of this responsibility—
perhaps provoked by some sort of “extreme situation”—
gives rise to what Sartre calls “the anguish of freedom”. It is our fate to be free. “… One must always decide for oneself and efforts to shift the burden of responsibility upon others are necessarily self-
defeating. Not to choose is also to choose, for even if we deliver our power of decision to others, we are still responsible for having done so. It is always the individual who decides that others will choose for him.”
[1] In so far as we are free in our choices, we “create” the obstacles that lie between our project and its fulfilment: “an insignificant public official in
Mont-de-Marsan without means may not have the opportunity to go to
New York if that be his ambition. But the obstacles which stand in his way would not exist as obstacles were it not for his free choice and values: in this case, his desire to go
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to New York.”
[2] Even though human freedom, in his view, is total, Sartre admits of a sense in which it may be spoken of in terms of degree. A man may be said to become “more free” as his consciousness of total freedom and responsibility increases; and certain situations in life can crystallize this awareness. In an apparently cryptic paragraph in
Being and Nothingness Sartre describes the
German Occupation of France during the last
war as such a situation. “… the choice that each of us made of his life and his being was an authentic choice because it was made face to face with death, because it could always have been expressed in these terms: ‘Rather death than …’.”
[3] But the issue is not just one of an increased sense of responsibility for our day-
to-
day options—
for instance in deciding upon a change in occupation, or merely which book to read next; most significantly
we choose ourselves, and our day-
to-
day decisions necessarily reflect this primary choice we have made. We are what we have chosen to be. All our subsequent modes of action are related to this original “project-
of-
being”, “Freely chosen at the moment one wrenches oneself away from the in-
itself to create one’s own world”
[4] (the in-
itself: the world of things). This event I take to be comparable with what R. D. Laing calls “existential birth” which, he suggests, is as essential for a fully human existence as the biological birth which it normally follows.
* It is only in relation to this fundamental choice, the individual’s original “project-
of-
being” that his later behaviour can be fully understood. The plausibility of this basic idea is not increased by Sartre’s denial of the division of the self into conscious and unconscious modes; the idea of a toothless infant consciously determining its future lifestyle and purpose is at first thought absurd. But whilst explicitly denying validity to the “unconscious” Sartre does separate consciousness into “reflective” and “non-
reflective” levels, and it is at the non-
reflective level that this fundamental choice is made. He stresses that this original choice is in no way deliberate: “This is not because it would be less conscious or less explicit than a deliberation but, on the contrary, because it is the foundation of all deliberation and because … a deliberation requires an interpretation in terms of an original choice.”
[5] The concepts of “authenticity” and its approximate opposite “bad-
faith” are in a sense understandable as judgements (although Sartre claims only to use these terms descriptively) upon the degree of concordance between the choices of our reflective consciousness and our original project-
of-
being. In a passage which bears directly upon existential analysis he writes that a man “can make voluntary decisions which are opposed to the fundamental ends which he has chosen. These decisions can be only voluntary—
that is, reflective. … Thus, for example, I can decide to cure myself of
stuttering. I can even
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succeed in it. … In fact I can obtain a result by using merely technical methods. … But these results will only displace the infirmity from which I suffer; another will arise in its place and will in its own way express the total end which I pursue. … It is the same with these cures as it is with the cure of
hysteria by
electric shock treatment. We know that this therapy can effect the disappearance of an hysterical contraction of the leg, but as one will see some time later the contraction will appear in the arm. This is because the hysteria can be cured only as a totality, for it is a total project of the for-
itself”
[6] (the for-
itself: the world of consciousness and intention).
Sartre argues against the Freudian three-way split of the personality into id, ego and super-ego and the Psycho-analytic dictum of conscious behaviour as determined by drives, instincts and desires allegedly emanating from the id. As Sartre’s arguments hinge upon his stated belief in man’s ontological freedom, Freud’s project of “determination by the unconscious” is met with similar objections to those made against other determinist theories and I need not attempt to summarise them here.[7] The only valid form of therapy is one aimed at discovering an individual’s fundamental project-of-being—and this is the purpose of existential analysis (or psycho-analysis; the prefix seems to be optional). “The principle of this psycho-analysis is that man is a totality and not a collection; he therefore expresses himself in his totality in the most insignificant and the most superficial aspects of his conduct” (Being and Nothingness). Through the use of a technique or method based on such assumptions the initially “crazy” actions of the insane may be made comprehensible—and may even appear “reasonable” if a picture of the world in which the patient lives can be assembled.
R. D. Laing has written that “only by the most outrageous violation of ourselves have we achieved our capacity to live in relative adjustment to a civilisation apparently driven to its own destruction” and has described the “normal” person in the present age as “a half-crazed creature, more or less adjusted to a mad world”.[8] What is the norm that gives the generally accepted meaning to such relative descriptions as “mad”, “insane”, “maladjusted”? And what is the significance of what is done to the people that are disqualified when measured against this criterion; the people that the mad officials label as “officially mad”?
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THE INSANE IN A MAD WORLD
“In the context of our present madness that we call normality, sanity, freedom, all our frames of reference are ambiguous and equivocal.”
In 1965 there were 160,000 people in mental hospitals in Britain and an estimated 200,000 psychotics in the community. Nearly half of all hospital beds are occupied my the mentally ill. In a television programme on mental health
[9] the number of mentally ill in Britain was given as half a million. The televised psychiatrist suggested that there were four main categories of illness: people with mental deformity,
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old people with “mental equipment in decline” (… perhaps old people with nowhere else to go?
**), people with physiologically normal mental equipment but with acquired neurotic patterns, and lastly, victims of “bio-chemical illness”—
in his words, “Struck down out of the blue”. The fourth category perhaps reflects, more than anything else, the currently favoured styles of treatment!
By far the largest group is the third—the “neurotics and psychotics”. Among these “schizophrenia” is the most common diagnosis. “In most European countries about one per cent of the population go to hospital at least once in their lifetime with the diagnosis schizophrenia.”[10] But what meaning can be given to these statistics and assessments without a standard of sanity or madness? “Definitions of mental health propounded by the experts usually reduce to the notion of conformism, to a set of more or less arbitrarily posited social norms. …”[11] The labelling of people as mad can have the social function of defining the area of “sanity”—perhaps there is a parallel with Durkheim’s theory of crime and punishment as “necessary” to respectable society to mark off the limits of permissible and tolerated behaviour. “Society needs lunatics in order that it may regard itself as sane.”[12] It could also be argued that certain kinds of society “need” lunatics as their managers; a discussion in Peace News recently was concerned with the uncertifiable madness of the American President in relation to a “collective norm of insanity”. A Correspondent noted: “No significant member of a power establishment can ever be ‘certifiably insane’ since it is this same establishment which determines the definitions of ‘sanity’ and ‘insanity’ and which decides—checked only by the occasional conscience of an occasional professional medical man—when “insanity” becomes “certifiable”.”[13]
In official statistics there must, in any case, be a murky overlap area between what comes out as “crime” and what as “lunacy”—
and a lot of luck in who ends up in which institution. Perhaps it is the institutional bureaucracy that has most need of the labels: “According to the commonsense definition,” writes Dr. Theodore Szasz, “mental health is the ability to play whatever the game of social living might consist of and to play it well. Conversely, to refuse to play, or to play badly, means that the person is mentally ill. The question may now be raised as to what are the differences, if any between social nonconformity (or deviation) and mental illness. Leaving technical psychiatric considerations aside for the moment, I shall argue that the difference between these two no­tions—
as expressed for example by the statements ‘He is wrong’ and ‘He is mentally ill’—
does not lie in any observable
facts to which they may point, but may consist only of a difference in our
attitudes toward our subject.”
[14] What sort of behaviour is likely to lead those with the appropriate attitudes to see signs of mental illness and to set going the transfer process from
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“person to patient”? “Ordinarily the pathology which first draws attention to the patient’s condition is conduct that is ‘inappropriate in the situation’. … Further, since inappropriate behaviour is typically behaviour that someone does not like and finds extremely troublesome, decisions concerning it tend to be political, in the sense of expressing the special interests of some particular faction or person. …”
[15] As an example of “inappropriate behaviour”, consider the case of “The Naked Prisoner” (
freedom, 16.10.65). Mr. Paul Pawlowski was arrested during a demonstration at the
Spanish Embassy in
London. Eventually reaching
Brixton Prison, he refused to put on the standard prisoners’ uniform and was consequently locked up, naked, in his cell. Thus he remained for ten days. On the tenth day he was interviewed by a social worker: “… You know that two doctors have seen you while you have been in Brixton … they came to the conclusion that what you need is a little stay in a mental hospital.” In fact he did not have the benefit of this confinement. The hospital psychiatrist decided that Mr. Pawlowski’s opinions were not those of the majority but “people are not put into mental hospitals for their opinions. They do that sort of thing in
Russia.”
*** Mr. Pawlowski was fortunate in his psychiatrist, but it is interesting to see how the pre-existing attitudes of officials brought him to the brink of admission. The overt political implications may make this example exceptional—
but it would not seem to be to the advantage of a person suspected of mental illness to have been “mixed up in politics” or “the dregs of society in
CND”—
which it seems, may well be taken as a confirmatory symptom.
† The mental health service—
like the education “service”—
is a functional part of the present social system and, as such, acts to preserve that system and its values. “The psychiatric profession is a bureaucracy,” writes James Green, a contributor to
Views, No. 8, “making an essential contribution to the running of government and administration. … Most psychiatrists would probably take for granted the structure and values of their own society, in such a way that the therapeutic process becomes a question of returning the sick person to his social context or roles, e.g. his family, whether the context and roles are themselves satisfactory.” Although no doubt unrepresentative and redolent of “what they do in Russia” I cannot resist quoting the words of a psychiatrist participant in a recently televised discussion: “Our function is to get people well enough to be indoctrinated.” It would be misleading to suggest that anything but a tiny minority become inmates of asylums simply or only because they hold disapproved
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opinions, but possibly such cases may lead to a consideration of the far more subtle “political” and social meaning of the labelling and confinement of the unvocal majority.
s4
CURATIVE—OR PUNITIVE?
“Many of us, for quite some time have considered that problems of punishment and repression are most acute in the context of imprisonment. But this is not so; the really intractable problem in this sphere is that of the mental hospital.”
Roger Moody: “Driving The Mad Insane”,
Peace News (
3.6.66).
In his account of “de-institutionalisation” (anarchy 4) Colin Ward referred to the prison as “the most sinister of institutions” and no doubt it is. But as anarchists are aware, the state can make skilful use of the “approved” concepts of crime and criminality to divert attention from its own more grandiose but identical activities: so we should be alert to the possibility that the institutions openly labelled as prisons are not the only ones serving that function. Suppose, as Roger Moody says in his article that mental hospital and prison are “different terms for the same thing”? If there is some truth in this there is consequently an additional danger in that anything called a “hospital” has automatically a protective cocoon around it as a result of its claim to provide therapy. But surely the “voluntary” presence of many of the patients in mental hospitals ensures that they cannot have a punitive character or effect? A different approach is suggested by the American sociologist Erving Goffman: “… We must see the mental hospital, in the recent historical context in which it developed, as one among a network of institutions designed to provide a residence for various categories of socially troublesome people.”[16]
Goffman states that only a small number of patients enter mental hospital willingly, in the sense that they believe it will be good for them, having come to see themselves as “mentally unbalanced”—
and as Laing and Cooper argue, even in these cases this self-perception as being “ill” or “mad” can be induced by the behaviour or strategy of the person’s immediate relatives and contacts. The sequence from “person to patient” can follow a series of associated stages set in motion by a “complainant” who sees an action on the part of the pre-patient as perhaps a “last-straw” and refers him to a succession of “mediators”—
probably drawn from among teachers, social workers, clergy, psychiatrists, lawyers, police—
one of whom, with co-operation from the “sick” man’s relatives, will commit the individual to hospital with legal sanction. “The society’s official view,” writes Goffman, “is that inmates are there because they are suffering from mental illness. However, in the degree that the ‘mentally ill’ outside hospitals numerically approach or surpass those inside hospitals, one could say that mental patients distinctively suffer not from mental illness, but from contingencies.”
[17] In other words, good or bad luck—
depending on your point of view. One might debate the degree to which this whole process is “voluntary”—
bearing in mind that the individual is unprepared for the nature of his future life in the hospital, is probably living
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in socially distressing circumstances which would have the effect of making most alternatives seem favourable, and is subject to collusive pressure from both relatives and “mediators”.
As Malatesta noted in his essay “Anarchy”, “Organs and functions are inseparable terms. Take from an organ its function, and either the organ will die, or the function will reinstate itself.” The existence of the mental hospital is justified by its function of curing the mentally ill. “The patient’s presence in the hospital is taken as prima facie evidence that he is mentally ill, since the hospitalization of these persons is what the institution is for.” A very common answer to a patient who claims he is sane is the statement: “If you aren’t sick you wouldn’t be in the hospital.”[18] One consequence of this for the person initiated into a “career” as a mental patient is that his past life will be restructured in terms of a “case history”—and he may be denied rights of privacy over what he previously regarded as “his own business”—any facet of which may now provide evidence of “symptoms”.[19] Once inside, the patient may find the internal organisation of they asylum dominated by a “ward system” separating patients off into “disease” categories, the various levels providing different standards of accommodation, food and grounds-and-town “privileges”, among other factors of importance in the life of the patient. The material and social provisions on each ward level are officially those that are most appropriate to the mental condition of the patient. But whilst the system may be justified by its partisans on these grounds, it has an unacknowleged function as an inmate-controlling device. There is a direct parallel here with the alleged purpose of the streaming system in schools; invariably defended on the basis of its educational value yet actually operating in schools as an important component of the disciplinary system. And in asylums, as in schools, these “divide and rule” disciplinary strategies have developed as the best method of “management by a small staff of a large number of involuntary inmates”.
Because society needs lunatics to provide it with reassurance of its own sanity, so it has need of institutions to contain them. But as with prisons, the real enemy is not the material structure—“It is our own anxiety which forces us to lock people up”[20]—and it is through anxiety about our own sanity that we build walls around the “mentally ill”. “Mental hospitals are not found in our society because supervisors, psychiatrists and attendants want jobs; mental hospitals are found because there is a market for them. If all the mental hospitals in a given region were emptied and closed down today, tomorrow relatives, police, and judges would raise a clamour for new ones; and these true clients of the mental hospital would demand an institution to satisfy their needs.”[21]
s5
SCHIZOPHRENIA—A PSEUDO-DISEASE?
“In the popular mind the schizophrenic is the proto-typical madman—author of the totally gratuitous crazy act that always has overtones of violence to others”
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The various titles given to mental diseases, says Goffman, serve to meet the needs of hospital census regulations. “When pressed … staff will allow that these syndrome titles are vague and doubtful.” A lot of people at the present time, appear to have schizophrenia—
this diagnosis is applied to two out of three patients in British mental hospitals and it has been estimated that for every “schizophrenic” receiving some form of treatment there are ten “undetected” in the community.
[22]
One psycho-analytic view is that schizophrenia is the outcome of a split between a person’s “conscious” and “subconscious” forces which in the normal state are believed to work simultaneously. Another idea—in schizophrenia “there is a subtle change in brain chemistry which interferes in some way with nerve impulses.”[23] The popularity of this view and others similar to it has led to an emphasis on surgical or physical treatment such as electro-convulsive therapy (a low voltage shock passed between the temples) and, in some cases, operations on the brain (leucotomy and lobotomy). In at least one London hospital schizophrenics have been placed in a deep freeze. Drugs are much used. And it seems that what are taken to be the symptoms of the disease can be eliminated by the use of such means at least for a time. As Sartre observed, one “can obtain a result by using merely technical methods.” But, as the writer of a survey in The Observer (5.6.66) commented: “No one knows, except in the fuzziest outline, what the treatments do. And none of them is a cure.” John Linsie in his article in anarchy 24 pointed out that the effectiveness of drugs and E.C.T. in temporarily removing “symptoms” has perhaps prevented more widespread research into the basic aetiology of the “disease”. Schizophrenia often occurs within the same family and some researchers believe that it is transmitted genetically. John Linsie quoted Mayer-Gross: “It may now be regarded as established that hereditary factors play a predominant role in the causation of schizophrenic psychosis”—and then trumped this with the opinion of another expert, Roth: “No simple genetic hypothesis accords with all the facts.”
This I hope is enough to provide some basis for R. D. Laing’s and A. Esterson’s statement in the introduction to Sanity, Madness and the Family that there is no more disputed condition in the whole field of medicine. “The one thing certain about schizophrenia is that it is a diagnosis, that is a clinical label, applied by some people to others.”[24] The essentially social process which results ultimately in the fixing of this label to one person is the underlying theme of three books and a good many articles by Dr. Laing and his colleagues. I shall try to outline their account of this process subsequently, but an idea of their truly radical conclusions can be given here:
“We do not use the term ‘schizophrenia’ to denote any identifiable condition which we believe exists ‘in’ one person.”[25]
“I do not myself believe that there is any such ‘condition’ as schizophrenia. …”[26]
“Schizophrenia is not a disease in one person but rather a crazy
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way in which whole families function. …”
[27]
“Schizophrenia, if it means anything, is a more or less characteristic mode of disturbed group behaviour. There are no schizophrenics.”[28]
s6
THE FAMILY—“FROM GOOD TO BAD TO MAD”
“Over the last two decades there has been a growing dissatisfaction with any theory or study of the individual which artificially isolates him from the context of his life, interpersonal and social.”
Sartre holds that all groups are structured against an awareness of a “spectator”. This “spectator” may be an individual—as in the case of children seeing themselves as “pupils” in relation to a teacher—or another group, as in the case of workers constituting themselves against managers. This spactator he calls the “Third” for whom the group exists as an object. Laing and Cooper seem to have developed their views on groups{{dash|and in particular, the family system of the future “schizophrenic”from Sartre’s interpretation of group structure and cohesion. In elaborating their theories the British existential analysts have made use of a number of terms, some of their own creation, whilst others are also used by Sartre. This rather technical and esoteric language creates a density in some of their writing which obscures the importance of what is being said; in my view, the value of Laing and Cooper’s book Reason and Violence is much reduced by their over-reliance on such terms and it is a pity that what one senses to be important ideas are couched in language which requires a good deal of deciphering before it becomes intelligible. If this particular book had been in existence at the time Orwell was preparing his essay “Politics and the English Language” it would have provided him with some remarkable cautionary extracts.
The British existentialists make use of two words, series and nexus, in differentiating between kinds of group—and two words, praxis and process, which describe group dynamics or the relationships between group members. A series is typically, a human association on negative grounds—for example a bus queue in which the sole link between persons is a common desire to travel on the bus; each person in the queue being “one too many” for the others. Also regarded as series are persons united solely on the basis of opposition to some shared concept: anti-semites sharing only their hatred of Jews, or one could perhaps say anarchists, united by shared opposition to the state (the only belief common to all anarchist views). A series may move towards being a group through “an act of group-synthesis” (Laing’s term). “If I think of certain others as together with me, and certain others as not together with me, I have already undertaken two acts of synthesis, resulting in we and them. However, in order that we have a group identity, it is not enough that I regard, let us say, you and him as constituting a we with myself. You and he have to perform similar acts of synthesis, each on his own behalf. In this we (me, and you, and him), each of us recognises not only our own private syntheses, but also the syntheses that each of the others makes.”[29]
The distinctive qualities of the nexus are that each person acknow
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ledges: the need of each for the others; the existence of strong bonds between members (not maintained principally by institutional or organisation structures, or a shared external “common object”. “The relationships of persons in a nexus are characterised by enduring and intensive face-to-face reciprocal influence on each other’s experience and behaviour.”
[30] The family, or at least the family as we are accustomed to think of it, is representative of a nexus.
Praxis and process are both terms used by Sartre. Basically, praxis is what is done by someone: “deeds done by doers”, “the acts of an individual or group”; whilst process refers to “what just happens”, activity not intended by anyone and of which no one person in a group may be aware.
The position of the person within the group will affect his idea of himself—of who he is. In the same way his view of others in the group affects their definitions of themselves. And again, his behaviour will be affected by his idea of what other people make of him. As a person moves during even one day, from group to group, from one mode of association to another, he must adapt himself to each context: “Each group requires more or less radical internal transformation of the persons who comprise it. Consider the metamorphoses that the one man may go through in one day … family man, speck of crowd dust, functionary in the organisation, friend. These are not simply different roles: each is a whole past and present and future, offering differing options and constraints, different degrees of change or inertia, different kinds of closeness and distance, different sets of rights and obligations, different pledges and promises.”[31]
Dr. Laing’s second book The Self and Others deals with the way in which a person is affected by his situation in a “nexus” of others, in particular within the family. “The others either can contribute to the person’s self-fulfilment, or they can be a potent factor in his losing himself (alienation) even to the point of madness.” He asserts his belief that “fantasy is a mode of experience” and that relationships on a fantasy level are “as basic to all human relatedness as the interactions that most people most of the time are more aware of.”
What happens in the families of “schizophrenics”? It is important to emphasise that it is not the thesis of these workers that the family rather than the individual is “ill”. A group is not an organism—
even though it may appear to be one to its members or to observers outside it. A human group of whatever size, does not possess either a body or a mind that can be either well or ill. In the family, a person’s self can be either confirmed or disconfirmed by the actions and influence—
including influence in “fantasy”—
of others in the family nexus. Mystification of a person can be carried so far that all genuine expressions of independent development are denied validity. “in the families of schizophrenic patients intentions, which link up with the ‘psychotic acts’ of the patient are denied, or even, their antithesis asserted so that the patient’s actions have the appearance of pure process unrelated to praxis and may even be experienced by him as such.”
[32] In the moving final section of
The Divided Self (called “The Ghost of the Weed
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Garden”) R. D. Laing describes the clinical biography of a schizophrenic. This was based on a series of interviews with the patient, members of the patient’s family, both individually and jointly with other members. These interviews were designed to secure the information necessary for an existential analysis and were not a form of group psychotherapy. It is here that Laing first outlines the sequence which would appear to be typical of this kind of family interaction: whilst each family member had his or her own view of the patient-to-be’s life, they all agreed on three basic phases:
- “The patient was a good, normal, healthy child; until she gradually began
- “to be bad, to do or say things that caused great distress, and which were on the whole ‘put down’ to naughtiness or badness, until
- “this went beyond all tolerable limits so that she could only be regarded as completely mad.”
What was seen by the mother as her daughter’s “good” period, in infancy and early childhood, she described with such remarks as “she gave no trouble”, “she always did what she was told”. Laing comments that what to the mother were signs of goodness, were signs that the child had never been permitted to become “existentially alive”—in fact “being existentially dead receives the highest commendation”. The “bad” period was the time of adolescence, during which the patient made her greatest struggle towards a realisation of her own self through autonomous action but found that her efforts were continually defeated by “the complete absence of anyone in her world who could or would see some sense in her point of view”. The transfer from “bad” to “mad” came as something of a relief to the rest of the family, who “blamed themselves for not realising sooner”. As the mother said: “I knew she really could not have meant the awful things she said to me. In a way, I blame myself but, in a way, I’m glad that it was an illness after all, but if only I had not waited so long before I took her to a doctor.”
In Sanity, Madness and the Family (the first volume of an uncompleted study) Drs. Laing and Esterson present extracts from interviews with members of 11 families, all of which contained daughters diagnosed as “schizophrenic”. In the Introduction to this book the authors write “… we believe that we show that the experience and behaviour of schizophrenics is much more socially intelligible than has come to be supposed by most psychiatrists … we believe that the shift of point of view that these descriptions both embody and demand has an historical significance no less radical than the shift from a demonological to a clinical viewpoint 300 years ago.” Behaviour which is eventually interpreted by the family as a sign of madness is, they argue, the outward expression of a desperate attempt on the part of the “mad one” to “make sense of a senseless situation”—to preserve some authentic elements of personality—a struggle for autonomy, spontaneity, responsibility and “freedom”. Here is an excerpt from Laing and Esterson’s transcript of Mr. and Mrs. Gold’s account of their daughter: “When she is her ‘real’ self, that is, when she is ‘well’, she is not to be seriously interested in writers or art, not to wear coloured stockings, not to listen to jazz in a jazz club, not to bring friends home, not to stay out late. It is only from time to time that Ruth tries to assert herself over against this parental eternal essence, and when she does she wears clothes to her liking, and insists vehemently on going where and with whom she wishes. Then her mother ‘knows’ and ‘attack’ is coming on. She is told she is being difficult, inconsiderate, disrespectful, thoughtless, because she is causing her parents such anxiety—but they do not blame or hold her responsible for all this, because they know she is odd and ill. Thus mystified and put in an intolerable position she becomes excited and desperate, makes ‘wild’ accusations that her parents do not want her to live, and runs out of the house. …”[33]
These writers claim, and I think demonstrate, that armed with a knowledge of the patient’s existential situation, it is possible to make sense of what “psychiatrists still by and large regard as nonsense”. For example, Julie, the patient in “The Ghost of the Weed Garden” referred to herself whilst in her “psychotic” state as “Mrs. Taylor” and as a “tolled bell”. Dr. Laing interprets her chosen title “Mrs. Taylor” as expressing the feelings: “I’m tailor made; I’m a tailored maid; I was made, fed, clothed and tailored” and a “tolled bell” is also “the told belle” “the girl who always did what she was told”. The schizophrenic’s “delusions” of persecution are real expressions of reaction in response to real persecution and are existentially true; that is to say they are “literally true statements within the terms of reference of the individual who makes them.”††
The person is now launched on a “career” as a mental patient. He is confirmed in this role by society’s agents the psychiatrists, in collusion with the patient’s family, and by process of betrayal and degradation[34] becomes an inmate of a mental hospital, which institution embodies “a social structure which in many respects reduplicates the maddening peculiarities of the patient’s family … he finds psychiatrists, administrators, nurses who are his veritable parents, brothers, sisters, who play an interpersonal game which only too often resembles in the intricacies of its rules the game he failed in at home.”[35]
The existential analysts have asserted that a great deal of what passes for treatment in mental institutions is violence. Perhaps we can now begin to see what is meant by this. David Cooper in his article in
Views, No. 8 quotes Sartre’s definition of violence: “The corrosive
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action of the freedom of a person on the freedom of another.” And he explains this: “The action of a person … can destroy the freedom of another or at least paralyse it by mystification.” In an article printed in
Peace News (22.1.65) called “Massacre of the Innocents” R. D. Laing makes his understanding of the word clear: “Love and violence, properly speaking, are polar opposites. Love lets the other be, but with affection and concern. Violence attempts to constrain the other’s freedom, to force him to act in the way we desire, but with ultimate lack of concern, with indifference to the other’s own existence or destiny.” The basic theme of his article is that a most brutal and destructive form of violence is “violence masquerading as love”. In relation to the family and its “schizophrenic” member, action to secure care and attention in hospital for someone who is “ill” could well be interpreted as an expression of concern and love. Whether or not one believes that this process and the patient’s subsequent treatment is a form of violence will depend in part, on whether one believes that there is any illness “in” the person to be “cured”. It is not violence to amputate a
gangrenous leg. We would all agree that it would be a violent project to persuade a person that his leg was diseased (“because you do not keep in step with us …”), to find a surgeon who believes that there is a social need for one-legged people—
and for him to cut off the leg. In the actual case of the hospitalised schizophrenic each person in the chain sees himself as acting in the best interests of the others … “but we have also to remember that good intentions and all the wrappings of respectability very often cover a truly cruel human reality.”
[36]
THEORIES IN PRACTICE: “THE ANTI-HOSPITAL”
In his pamphlet Youth for Freedom (1951) Tony Gibson wrote to the effect that the chief value of Summerhill to the community lay in its having taken the general concept of what a school should be and turned it on its head. Dr. David Cooper’s unit in a large mental hospital “just north-west of London” has done very much the same thing to the general concept of the asylum. To maintain the educational parallel, Dr. Cooper’s experiment (judging from his account of it in New Society[37] also has great relevance for those who would wish to attack the violence implicit in the customary methods of social organisation in schools.
The theoretical basis of the experiment rested on the findings of Laing and Esterson, published in
Sanity, Madness and the Family. I hope already to have given some idea of what these findings were: the family preserves its inauthentic system by using one of its members as a kind of “scapegoat”, ending by attributing madness to him. In general, society confirms the attributions made by the “sane” relatives and invalidates the patient’s version of events by translating them into “symptoms of a disease”. The bearing of this theory on the psychiatric ward, writes Dr. Cooper, is that “staff must begin to refuse to enter into the traditional covert collusion with the patient’s family. In the past this collusion has often meant that staff become implicated in a progressive violence that is perpetuated, in the name of treatment,
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against the labelled patient.” The workers on the “anti-hospital” project maintained one central conviction: that it was necessary to understand, in some measure, the processes going on in themselves before they could hope to have real insight into the “inner” world of their patients.
The unit—one ward in a hospital of some 2,300 patients—opened in January, 1962, with 19 young male patients, two-thirds of whom had been diagnosed as “having” schizophrenia. They had all been previously in the insulin-coma ward. In the second year, the number of patients was increased to 30.
The programme during the first year was highly structured, with daily meetings of the whole staff-patient group, separate and regular staff meetings, occupational therapy and organised recreational activity. No “physical” treatments were used except for the occasional dose of mild tranquilliser, and there was no individual psycho-therapy; there were however regular “interviews” between therapist and patient and therapist and patient with various members of his family. After about a year, the staff became dissatisfied with the rigidities of the system and changes in the direction of greater fluidity were felt to be appropriate.
Dr. Cooper writes of two areas in which the consequent “destructuring” had remarkable effects—the traditional business of getting patients out of bed in the morning and the attitude to the provision of work and activities. “One of the commonest staff fantasies in mental hospitals is that if patients are not coerced verbally or physically into getting out of bed at a certain hour in the morning they will stay in bed until they rot away.” This fantasy, like all anxiety over punctuality, is a form of projection. For the staff, the patient represents “that frightening aspect of themselves that sometimes does not want to get out of bed in the morning and come to work.” After considerable discussion and the trial of various approaches by different staff groups it was found that if the usual “rousing procedures” were abandoned the patient did get up himself—even if he “rebelled” to the extent of remaining in bed most of the day for a week or more. “No one rotted away after all and the gain in personal autonomy seemed worth while.” Dr. Cooper relates one episode when “all the occupants of a six-bed dormitory rebelled against the community meeting by staying in bed until after 11 o’clock. One of the charge nurses went upstairs to see what was going on. One of the patients left to go to the toilet and the nurse seized the opportunity to take off his white coat (worn not as uniform but as protective clothing for certain messy jobs like washing up) and climb into the vacant bed. The patient, on his return, appreciating the irony of the situation, had little option but to take the vacated ‘staff role’, put on the white coat and get the others out of bed.”
The motivating fantasy or belief behind the provision of work and “occupational therapy” activities is frequently that this in some way protects the patients from the eroding effects of institutionalisation. But Dr. Cooper observes: “The bitter truth is that if they submissively
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carry out all these required tasks they become what is implied by these labels anyhow.” If one wishes to encounter the ultimate in withdrawn chronic institutionalisation one has only to visit one of the more “active” and productive “factories in a hospital” or “industrial occupational therapy departments”. In the unit, discussion centred on this theme; the patients were in any case showing resistance to conventional projects. Jobs of a vigorous, destructive kind (“knocking down an
air-raid shelter”) which within a certain mythology, would have been supposed to provide a proper outlet for aggression, were not tackled with enthusiasm. “People had real reasons to be angry with real other people at home and in hospital.” Hammering away at brick walls was of no relevance. Partly as a result of failure to hold the patient’s interest in tasks such as these—
despite an attempt to influence them by reduction of their money allowance—
a situation was reached in which “no organised work project was presented to the community”. The occupational therapist decided that she would be better employed in the unit as an assistant nurse. It was at this stage of developments that the staff became conscious of the breakdown of role boundaries: There was a progressive blurring of role between nurses, doctor, occupational therapist and patients which brought into focus a number of disturbing and apparently paradoxical questions: for example, can patients ‘treat’ other patients and can they even treat staff? Can staff realise quite frankly and acknowledge in the community their own areas of incapacity and ‘illness’ and their need for ‘treatment’? If they did what would happen next and who would control it?”
“It was at this point that the most radical departure from conventional psychiatric work was initiated. If the staff rejected prescribed ideas about their function and if they did not quite know what to do next, why do anything? Why not withdraw from the whole field of hospital staff and patient expectation in terms of organising patients into activity, supervising the ward domestic work and generally ‘treating patients’.” After this, the staff retained control of the issuing of drugs and continued their administrative work. Other sections of the hospital were made aware of the policy change in the unit and the details of the new approach were clarified at the community meetings. The immediate effect of the change was reflected in piles of washing-up left undone and a marked increase in dirt. The normal level of staff anxiety increased as the patients gave no sign of organising among themselves. The patients were divided between those who wanted a return to the previous system and others who “appreciated the more authentic elements in the policy change”. The crisis point came during Dr. Cooper’s absence on holiday. Up to that time, many of the staff had found assurance in the belief that the evident disorder was a consequence of enacting the Doctor’s {{qq|ultra-permissive policy—
they had done his bidding and what happened was ultimately his responsibility. But during the period of his absence, they acted together to put a limit to their intense anxiety and reintroduced some controls within the ward. This, Dr. Cooper suggests, was an advance on their part in that they achieved a joint decision and all members of the unit began to
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experience the real demands made by the “group reality”. Dr. Cooper’s observations at this point are interesting and recall the distinctions made by other writers between forms of authority—
“functional or arbitrary” (
Martin Buber) “overt or anonymous” (
Erich Fromm). Dr. Cooper writes: “This leads us on to the central problem of the psychiatric hospital of distinguishing between authentic and inauthentic authority. … The authority of the authority person is granted him by arbitrary social definition rather than on the basis of any real expertise he may possess. If staff have the courage to shift themselves from this false position they may discover real sources of authority in themselves. They may also discover such sources of authority in ‘the others’ who are defined as their patients. … Perhaps the most central characteristic of authentic leadership is the relinquishing of the impulse to dominate others. Domination here means controlling the behaviour of others where their behaviour represents for the leader projected aspects of his own experience. By domination of the other the leader produces for himself the illusion that his own internal organisation is more and more perfectly ordered. The
Nazi extermination camps were one product of this Dream of Perfection. The mental hospital, along with other institutions in our society, is another.” Substitute “school” for “psychiatric hospital” and “pupil” for “patient” and one sees the wider relevance of this passage.
The workers in the unit were faced with conflicting pressures—pressures to conform with the customary approaches facing them in social systems and relationships outside the unit (professional advancement and willingness to conform to some extent going together)—and contrary pressure from within the unit itself. This again resulted in tension which obliged them to face the need for “commitment one way or the other”.
The position of the experimental ward inside the framework of the large hospital prompted the growth of fantastic and distorted attitudes towards the unit in the minds of senior staff members working outside it; this indicated the deep challenge which the new approach made to their more traditional concepts. For example an incident one night, in which an hysterical girl patient was helped back to her ward by a male friend was “processed” by the communications system until in its final form, it had become a case of attempted sexual assault.
An Assessment of the success of the “anti-hospital” in terms of “results” (usually measured in such cases by the incidence of re-admission) would not be any more meaningful than a judgement on Summerhill based simply on the pupil’s success rate in public examinations. The criterion of re-admission rates is also inadequate in that staff encouraged patients to return after discharge if they felt that a return to the unit would be of value to them. Nevertheless, even by this standard the “anti-hospital” results compare favourably with those achieved by more widely accepted methods—
17 per cent of patients being re-admitted during a one-year period following discharge. In the issue of the
British Medical Journal which included these results Dr. Cooper stated his belief that the experiment has established “at least
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a
prima facie case for radical revision of the therapeutic strategy employed in most units for schizophrenia”.
[38]
As a postscript to the foregoing, I can deal only sketchily with an intriguing aspect of the work of the British existentialists—their ideas on the nature of “madness” itself. A recurrent theme in R. D. Laing’s writing is his emphasis on the disastrously narrow field of experience which is credited in contemporary life, as “reality”. “We are far more out of touch with even the nearest approaches of the infinite reaches of inner space, than we now are with the reaches of outer space. … We are so out of touch with this realm that many people can now argue seriously that it does not exist.”[39] It is no surprise that Dr. Laing has spoken on the power of the drug LSD to extend the boundaries of reality for those who make use of it responsibly. In The Divided Self he cites the value of the Prophetic Books of William Blake and (in The Self and Others) relates Blake to his previous description of a “psychotic”: “Blake’s position seems to me to have been this. Single ‘vision’ (one modality of experience) is death. This is what most people regard as sanity.” He also charts in this book and in other articles, the dualism implicit in the idea of fantasy to be found in most psycho-analytic works and in the minds of a good many psychiatrists: “A very confused dualistic philosophy of psychical and physical, inner and outer, mental and physical.” It is the opinion of Laing and Cooper that what is clinically described as “a schizophrenic breakdown” may be the onset in the individual of a voyage into the world of inner space and time. The word “inner” is misleading, suggesting a place located “inside” the person; as they use the word it refers to “our own personal idiom of experiencing our bodies, other people, the animate and inanimate world: imagination, dreams, fantasy …”. And far from being a “disease” this process, or “voyage”, may well be the path to greater awareness, the crisis of the individual’s struggle to realise himself as a person, even—the onset of sanity! (Dr. Cooper has suggested that it may be “when people start to become sane that they enter the mental hospital”). A person undergoing this experience may well be “difficult for others” and is in need of special care—but not “treatment” in “the quite bizarrely incongruous context of the mental hospital”. Those who care for him should assume the role of guides—and people capable of providing this help will very probably be those who have themselves been through similar experiences: “We need a place where people who have travelled further and, consequently, may be more lost than psychiatrists and other sane people, can find their way further into inner space and time, and back again … the person will be guided with full social encouragement and sanction into inner space and time, by people who have been there and back again. Psychiatrically, this would appear as ex-patients helping future patients go mad.”[40]
No fully autonomous unit in which this process can take place exists at the present moment,
††† but we can deduce from the “anti-
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hospital” experiment, a good deal about what is required for its successful realisation.
CRITICISM AND CONCLUSIONS
The only extended criticism known to me of the work and ideas of these British psychiatrists is an article by B. A. Farrell called “The Logic of Existential Analysis” which appeared in New Society (1.10.65). This writer argues that the existentialists have dismissed orthodox views on the causes and treatment of schizophrenia on inadequate grounds and also make logically unwarrantable deductions from their research into families of schizophrenics. Referring to the claim of Laing and Esterson that they have made the “symptoms” of schizophrenia intelligible, he makes the point that even if they are successful in doing this, making the symptoms intelligible is not the same thing as establishing truth for their hypothesis. Farrell comments that “this would be a trivial point to make” if we had other grounds for believing that the narratives were true. In relation to their suggestions for treatment he asks for evidence that units of the {{qq|anti-hospital type produce results “as good as, or better than, the traditional methods”. In conclusion he advises them that some of the opposition to their work might not have been so vehement had they avoided “abusive” and “intemperate” language in their references to the Establishment; and also that “they would help themselves if they could avoid giving the impression that they had fallen in love with their schizophrenic patients. …”
Correspondents in subsequent issues suggested some answers to these criticisms. Commenting on Mr. Farrell’s remark on the lack of supportive evidence, Dr. John Bowlby wrote: “Although Dr. Laing’s is the only psychiatric group in this country publishing material of its sort, in the United States there are several. The two best known are the group at the National Institute of Mental Health … and the one at Palo Alto. … Each of these research groups has used methods and reported findings essentially similar to those of Dr. Laing. Some of their most recent reports … are of projects that at critical points in the procedure are ‘blind’ in just the way that Mr. Farrell rightly requests. In addition to a number of findings derived from quite other methods are supportive. … There is thus substantial evidence derived from more than one method in support of the Laing type of hypothesis. … When compared with evidence advanced to support other types of hypothesis, it is not unimpressive. On the one hand it is far more substantial than any yet offered in support of psycho-analytic theories, whether traditional or Kleinian, and, on the other, more consistent than that supporting a genetic-biochemical type of theory” (my italics).[41]
I have already made some reference to the “results”, in terms of re-admissions, of the “anti-hospital” which were published in the
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BMA Journal and reprinted in
New Society three months after the appearance of Mr. Farrell’s article. They are indeed as good as, or better than, results achieved by traditional methods.
Mr. Farrell’s final charge is valuable in that it draws attention to the basis of the method of existential analysis as described and practised by Dr. Laing and his colleagues. I do not think that Dr. Laing would wish to deny that “love” is involved in his attitude towards his patients and their predicament. In The Divided Self he writes of the act of empathy—this is not a strong enough word—that is required if the therapist is to understand the patient’s existential position. “I think it is clear that by ‘understanding’ I do not mean a purely intellectual process. For understanding one might say love.”[42] In making this attempt the therapist “draws on his own psychotic possibilities”. Although not a direct parallel, one is reminded of Homer Lane’s attitude towards emotionally disturbed “delinquent” adolescents and his dictum of “being on their side” even when their actions were most anti-social. A concept that recurs in a similar way in Dr. Laing’s writing is to “let the other be”: “The main agent in uniting the patient, in allowing the pieces to come together and cohere is the physician’s love, a love that recognises the patient’s total being, and accepts it, with no strings attached.”[43]
As I hope I have succeeded in indicating in this article, the work of Drs. Laing, Cooper and Esterson constitutes far more than just another theory of what causes “schizophrenia”; a correspondent in New Society characterised it as “an exploration of the necessary conditions for a fully human relationship”.[44]
Dr. Laing has suggested that the reason why exploration of the “inner” world of the self is invalidated by society as “madness” is that such experience is subversive. “And it is subversive because it is real.”[45] Deified destructive illusions—“the health of sterling”, “the Red menace”, “the interests of the State”—are the stage-props of normal social life and these phantoms are confirmed as “reality” by all the resources available. Because the vast majority of people act in terms of these negations “we find ourselves threatened by extermination that will be reciprocal, that no one wishes, that everyone fears, that may just happen to us ‘because’ no one knows how to stop it. … Everyone will by carrying out orders. Where do they come from? Always from elsewhere. …”[46] Dr. Cooper has also described this tragic condition: “The myth of Thanatos is a self-actualizing phantasy. The bomb really did drop on Hiroshima. … The basic paradox that we live is that mankind needs illusions but the illusions it needs destroy it. Even through relatively innocuous or ‘good’ illusions we imprison ourselves metaphysically and then find we have built real prison walls (perhaps around someone else).”[47]
I hope that, as Dr. Laing has hinted, their future work will involve and imply further criticism in depth, or our society; if this is the case it will have direct relevance for contemporary anarchism (notwithstanding the association of these writers with a form of Marxism). In conclusion, I would risk the statement that the body of work they have so far produced—derived as it is from social psychology and observational research in the best Alex Comfort manner—already “upholds” a form of anarchism—a form which could be typified by a phrase of Dr. Cooper’s: “The way of autonomy”.
* See
The Divided Self, pp. 41-42. For an account of the consequences of the obstruction of this occurrence: “an existentially dead child” see p. 183. In
Views, No. 8,
David Cooper writes: “… the beginning of personal development is never pure passivity. … From the first moment of mother-
child interaction, where each is another to the other, the child is in the position of having to initiate the project to become whoever he is to be, and this is in principle a free choice, his free creation of his essential nature.”
** An article in The Observer (4.9.66) announced the formation of “Project 70”—“a plan to rescue mentally normal old people from the wards of mental hospitals.”
*** This may be an allusion to a case which was receiving some publicity at that time. Zenya Belov, a student, was confined in a Russian mental institution around September, 1965—and he is presumably still there. It was alleged that he had shown “schizophrenic symptoms” (“drawing diagrams, trying to reorganise the world graphically”) but the only “symptoms” evident to the British students who were with him shortly before the onset of “illness” were his “unorthodox and reformist political views”.
† References to a letter from Brenda Jordan in Peace News (17.6.66).
†† See also Laing’s interpretation of the statements of a schizophrenic from the original account in Kraepelin’s Lectures on Clinical Psychiatry, 1905 (pp. 29-31 The Divided Self). Laing writes: “What does this patient seem to be doing? Surely he is carrying on a dialogue between his own parodied version of Kraepelin, and his own defiant rebelling self. ‘You want to know that too? I tell you who is being measured and is measured and shall be measured. I know all that, and I could tell you, but I do not want to’.” Laing comments: “This seems to be plain enough talk.”
††† Since this was written an article has appeared. “Schizophrenia as a way of life”, by Ruth Abel (Guardian, 4.10.66), describing a “fully autonomous unit” for “schizophrenics” established by Drs. Laing, Esterson and Cooper at Kingsley Hall in London. This project is financed by The Philadelphia Association and it seems that two new centres have been opened during the last few months in North London, and it is hoped that these are only the first of “a chain of communities”.
Relevant Books and Articles not mentioned in References:
R. D. Laing, “Series and Nexus in the Family”,
New Left Review, No. 15.
David Cooper, “Sartre on Genet”, New Left Review, No. 25.
R. D. Laing, The Politics of Experience and the Bird of Paradise, Penguin Books, Autumn, 1966.
R. D. Laing, H. Phillipson, A. R. Lee, Interpersonal Perception: A Theory and a Method, London, Tavistock, 1966.
T. S. Szasz, The Myth of Mental Illness, London, Seeker and Warburg, 1962.
Carl R. Rogers,
On Becoming a Person, London, Constable & Co., 1961.
NOTES
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