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.
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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]
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.”
* 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).
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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