II
Freud is often dismissed nowadays as
unscientific or outdated, or out of touch in some fundamental way with
modernity. But all that such unthinking attitudes reflect is that as a culture
we are not able to get into perspective the scale of our debt to him.
We assume that by now we must know Freud
& have assessed what is of value in him. But in fact, he is very difficult
to know properly.
Freud’s thought is intricate, complex &
subtle, it evolved & changed with the years, & it was developed against
the background of an intellectual culture with which only a handful of
specialists now have real familiarity. Over 45 years working as a psychoanalyst
he wrote a great deal. The Standard
Edition of his writings in English consists of 24 volumes, the German Gesammelte Werke contains 18 volumes.
Some of the most familiar terms associated with him, like the Id, the Ego, & the Superego,
he never used & are mistranslations of the terms he did use. As a result
most people, including most psychotherapists & also a surprisingly
significant number of people who call themselves psychoanalysts, have no more
than a glancing or second-hand acquaintance with him.
In the past psychiatrists evidently believed
that after the demanding years of medical school they could pick up Freud’s
essential ideas in a couple of years of practice almost as an afterthought. But
to master Freud’s thought is as difficult as acquiring a proper training in
medicine, perhaps more so. It certainly takes many more years of experience
& maturation. And much of the training available for psychodynamic
therapists, undermined as it is by rivalry & often petty-minded competition
between different therapeutic factions, is poor. In reality the fashion for
Freud’s ideas in the middle decades of the 20th century was as
superficial & was based on as many misconceptions as is his unpopularity
now. As a culture Freud has always been largely unknown to us, & all the
more so because we assume we do know him.
Freud’s achievement was to show us how to
translate the language of madness into the language of everyday experience.
This was his great legacy. Nothing in human history has had such a humanising
influence on the treatment of mental distress as this. Before Freud everyone
was frightened of insanity because they could not understand it. It was as
incomprehensible to them as is Ophelia’s state of mind to us after her
breakdown in Hamlet. The result was
shame, incarceration & cruelty. Freud showed how to understand mental
alienation & pointed out how its expressions can be found everywhere else
in our lives. To learn the language of mental illness is to learn how to
interpret our own everyday neurotic symptoms & how they express in an
indirect way our personal divisions & anxieties. Even the world of outright
psychosis is not alien to us; we are all familiar with it & enter it every
night in our sleeping dreams.
By showing how to translate the language of
insanity Freud took a lot of the fear of mental illness away. But at the same
time he made plain that the price of overcoming this fear is acknowledging how
indistinct in all of us is the line between illness & health. In the sphere
of the human mind – as opposed to the human body – there is not a clear
distinction between the healthy & the sick. It turns out that to understand
madness is to understand ourselves.
We are all sick to the extent that we are
all divorced from ourselves & misunderstand ourselves. We are all
struggling to make sense of a self that we only very imperfectly understand
& which is all the time developing & evolving beyond the little
understanding we do have of it. And we are all healthy, to the extent that we
all continue to evolve & develop throughout life & are always
discovering new things about ourselves & about our relation with the world.
This does not mean we can make no
distinction at all between mental illness & mental health. But it does mean
we need to be aware of the underlying human context within which mental illness
occurs. This context is different from that of physical disease.
The strange co-existence of sickness &
health within us draws attention to just how unusual an animal we are. The
physical structure & function of the human body are similar to the body
structure & function of many other animals. One can learn a great deal
about human physical health from the study of other animals. But the emotional
life of the human animal is unlike that of any other. In this regard, between
man & that of even our closest relatives there is a gulf.
Most of the important mistakes that are made
in psychology & in psychiatry are rooted in an unwillingness to accept how
large this gulf is, how strange is human life when viewed from the perspective
of the other animals, & how difficult it is to be honest & accurate about
this strangeness. It is intriguing when we find other creatures behaving in
ways that seem reminiscent of ourselves. But all this does is remind us of our
fundamental animal heritage. As far as the serious study of human emotional
life is concerned, from the other animals we have learnt nothing.
Down through the centuries of course this
was taken as grounds for exempting man from total immersion in nature on the
basis of his powers of reason. Now we have gone to the other extreme of
pretending there is nothing unusual about us at all. Both positions show how
difficult it is to keep a clear view of how we fit into nature.
One thing that clearly sets us apart is the
scale of our savagery & our strange addiction to cruelty. The deep &
intense gratification we achieve in inflicting pain as an end in itself, on
others & on ourselves, has, apparently, no parallels among other species.
All our knowledge of ourselves has come from
the study not of other animals but of the artefacts of human culture. And all
of these are made possible by the more, or less, regulated & sublimated
exercise of this cruelty, this strange human passion for sacrifice, of
ourselves, of others, & of parts of ourselves. What we know of the mind
comes from the study of what the conflicts within our nature have made
possible: our religion & philosophy, our science & technology, our
poetry, literature & music, our visual art, our perverse sexual lives, our
family life, our political & economic structures, our laws & our prison
camps. There are no animal analogues of any of these. The divisions within us
have made us the most creative thing that nature has given birth to, & the
most destructive. Nothing, as Sophocles
says, is more terrible than man.[i]
What distinguishes the animal man is his
suspension between the past & the future. He is the perpetually unfinished
animal. Possibly this is the root of our terrible cruelty, because to live
suspended in this way is constantly to have to sacrifice things that we value.
A creature cannot make a future that is significantly different from its past
unless it is prepared not just to accept loss but is actively excited by loss.
Let us bear in mind that depression too is a kind of excitement at loss because
it is a refusal to let the experience of loss go.
The emotional life of man is the struggle of
the future to be born out of the past. No other animal lives even vaguely like
this. No other animal is constantly losing its way & constantly having to
correct its errors in this perpetual condition of war with itself.
In this suspended state between past &
future, & between health & sickness, we all experience throughout our
lives times of distress & trauma & despair, as well, hopefully, as
times of fulfilment & joy. With an animal in such an unfinished state how could
it be otherwise?
But coming to terms with this is very hard.
None of us ever completely does so. This reluctance to accept our condition is
indeed one of the things that makes us human. It means accepting that all our
views on how life should be lived & what is a healthy state of existence
are of necessity provisional. We always have to be ready to question &
explore them again.
In understanding mental distress therefore
& in trying to help those suffering from it we are immersed in making
ethical judgements about what is good & healthy, & what is bad &
sterile. This work is so difficult intellectually & so demanding
emotionally because there is no book of rules we can fall back on in making
such judgements. To try to help those in mental turmoil is to come face to face
with the fundamental uncertainty of the human condition.
Accepting this uncertainty in our condition
& being able to live creatively without taking flight from it are as close
as any of us can come to health. Other than this there is no way mental health
can be defined.
*
The acknowledgment of this unfinished state
of the human animal, & consequently the essentially problematic nature of
cure & health in its mental life, is the defining characteristic of
psychoanalytic therapy & is what distinguishes it from all other
psychotherapies & all other treatments for emotional distress.
Psychoanalytic therapy is an education in scepticism & in irony. What seems
bad today often seems good tomorrow. Many of the things that we think at first
are healthy for us turn out not to be so, & many things we have feared turn
out to nurture us.
Should such a widely experienced condition
as depression, for instance, be regarded as an illness? There is no simple
answer to this question.
The experience we call depression can be
associated with many different underlying mental states. It can come & go
throughout a person’s life for no obvious reason, or it can appear for what
seems the first time in response to a significant traumatic event such as a bereavement
or unemployment. It can be moderate & episodic, or severe & chronic, or
alternating with periods of mania where everything seems possible. But it is
always distressing &, usually, it drives the person who suffers it to seek
for a resolution to it. However it is not an illness in the way that mumps
& chicken pox & cancer are illnesses.
Depression can be a sign of weakness &
poor health. But it can also be the response of an essentially healthy
individual to distressing & unhealthy circumstances.
Hamlet for instance is the portrait of a
man suffering depression. But is he sick? Or is he a man of integrity sickened
by pathological & corrupt circumstances? These questions are famously
impossible to answer. And this is why the play is a centrepiece of Western
literature: in the ambiguity of his condition Hamlet is a symbol for us all. We
all experience distressing loss at different times in life. To be human is to
develop & to develop is to be always vulnerable to loss. To respond to such
experiences in an emotionally appropriate & fruitful way may well involve
periods of depression, & sometimes these may be severe, resulting in
significant incapacity.
Like Hamlet, King Lear too suffers
depression. Should we regard him as sick? His history is more complex than that
of Hamlet & we have to guess at a lot of it – just as we have to do in
psychotherapy. Initially he seems reconciled to old age & to handing over
the kingdom to his daughters. But as the action proceeds his behaviour shows he
is anything but reconciled. Everything he does ensures that the one daughter
who genuinely cares for him, Cordelia, will renounce her inheritance. He wants
to deny her the world, about which, as we quickly see, he feels deeply bitter
& resentful. He manoeuvres like a bad-tempered child so that Cordelia is
left with no choice but to come with him into death. Is this illness on Lear’s
part? It is very hard to see how it is anything other than illness. Death &
destruction triumph everywhere in this story – or almost so.
And yet, for all its extraordinary drama, King Lear is nothing more than everyday
life viewed through a powerful magnifying glass. Sibling rivalry, parents who
are over-dependent on their children, wars over inheritance, opportunists
driven by envy exploiting the misfortunes of others, & well-meaning
intervention on the part of people who have no understanding of what they are
dealing with – what is all this but daily life?
Whatever form depression takes it is always
the reflection of divisions within the individual between different needs.
Hamlet is notoriously divided & driven back & forth by different
inclinations & tendencies. Lear’s actions are a constant contradiction of
his expressed wishes & intentions. And so it is in real life.
A deeply upsetting event like the death of
someone close to us (as Hamlet has experienced), or being made redundant from
the role that has defined us (as Lear has experienced), will provoke intense
divisions within us; for instance, those between the profound needs that are
satisfied by love & work, & the quite different need to come to terms
with a new reality that is unfamiliar & disorienting. Only someone with no
imaginative grasp of the reality of human life would expect a person who had
experienced events such as these not to
go through a period of emotional distress.
But often the events determining the
conflicts underlying the depression are less manifest than this because they
didn’t happen last week but in the more remote past. People who have
experienced the death of a parent while they were children, for example, or who
have been unloved as children, are likely to be prone to periods of depression
throughout the rest of life. Why would they not be? They have suffered
important losses & have been denied important needs. These losses are a
part of what defines them. But at the time of such experiences the pressures of
growing up & trying to deal in a practical way with the rapid series of
challenges that childhood & adolescence bring are intense. At this period
in life the brain & the mind are still rapidly developing & there is
little time for integrating these experiences in a developed way into emotional
life. Often, it is only when a later upsetting experience intervenes to disturb
the fragile balance that has been established that the fault lines of older
conflicts are opened again. This kind of case, where depression is caused by
the combined emotional effect of contemporary events & events from years in
the past, is the typical one & the resulting distress will be more severe
& harder to resolve than one caused by present upsets only.
Nevertheless, the point at which depression
becomes sufficiently severe or destructive to be classified as an illness
rather than as an appropriate response to loss is impossible to determine with
precision.
However, when we do decide that the degree
of emotional dysfunction in depression is such as to constitute an illness it
is still not an illness like a physical illness. The historical events to which
the depression is a reaction are integral to the identity of the person
suffering it. They have significance for the patient because they represent
crucial battles in his war to achieve autonomy. To try to resolve depression by
pretending that the historical events of loss or trauma underlying it lack this
significance is to pretend that the patient is just another animal without a
history & without a future. Yet, to the extent that contemporary psychiatry
encourages the view that the roots of depression are to be found exclusively in biochemistry, this is
what it is doing.
But what is the logic in studying &
treating man as if he were something other than what we know he is? What would
we think of a science that insisted on studying a bird as if it were a species
of fish? Is not this determination to distort the human subject itself
symptomatic of something deep & unacknowledged?
*
In most cases, anyone with good empathetic
skills can understand the causes of conditions like depression & anxiety.
This is not the difficult part of psychotherapy. What is much more difficult is
identifying correctly the particular drives & conflicts in play. This is
demanding & intricate work because, curiously enough, we expend a great
deal of energy in trying to hide these from ourselves. Human beings have a
strong propensity not to know, not to wish to know, the causes of their own
distress.
Why might this be so?
In the case of depression caused by reaction
to bereavement for instance, our feelings for those we love & who are
closest to us are always complicated. Love, even in the strongest of us, always
involves some measure of dependence, & therefore some measure of resentment
& anger. And dependence is something we are all ashamed of. We do not like
seeing it in ourselves. So we try not to see it in ourselves. And so when we do
lose someone we love we usually get very confused about why we feel the way we
do & what it is we really feel.
Freud suggests for example that Hamlet’s
confusion & his inability effectively to take revenge for the murder of his
father can best be understood as reflecting the mixture of love & hate he
feels for his father. The irony is that, in spite of all his insight, Hamlet is
not able to acknowledge the resentment he feels towards his father other than
in an indirect manner, in his condemnation of everything in the world except his father.
As a result of this propensity to hide from
things we feel ashamed of in ourselves we often fail to identify traumatic
& significant events in our past. It is not that we forget that such events
took place, it is that we don’t recognize their full emotional significance for
us. Patients in psychotherapy will often report they have suffered periods of
depression throughout their adult lives for no obvious reason they can identify.
When it is pointed out to them that they lost a parent in childhood, or that a
parent was brutal & unloving towards them, they are, at first, often amazed
that events this far in the past should still have significance for them.
By & large this is the rule with memory.
Human emotional life is so complex & entangled that we are never aware of
more than a fraction of the whole significance of any given event in our past
(& still less so in our present). But with events that are especially
charged with difficult emotional significance – that is, those involving
emotions we are ashamed or frightened of – this is particularly true. We do not
wish to understand fully our reaction to such experiences. To do so means
having to question assumptions about ourselves that we don’t want to question.
This is why we so often react with anger towards someone who tries to explain
how such events are still shaping our lives.
To understand the history of psychoanalytic
therapy & its place in psychiatry & in the world of psychotherapy
generally we must bear this underlying anger in mind.
Those who object to psychodynamic therapy in
the treatment of mental illness generally claim that it is unscientific or too
time-consuming. The implication is that there is some truly scientific, &
quick, & inexpensive, & lasting therapy just around the corner; as if
it were the most reasonable thing in the world to expect a treatment for mental
illness that will combine all these qualities.
But underlying such arguments is the
unacknowledged wish to find a justification for treatments that don’t ask
awkward questions & don’t require us to be more autonomous as individuals.
Every alternative treatment that has been proposed for mental illness is less
demanding on the patient in terms of the honesty & courage it requires from
him than is psychodynamic therapy. This is the true appeal of these therapies.
Everyone wants to be well, provided getting well doesn’t require too much
effort or too much time or too much honesty with oneself. It is as if living
the best life one can were somehow not the most important task every human
being faces.
Every other serious attempt to help patients
with mental illness, whatever philosophy it may espouse, turns out in practice
to be long, slow, at best partially scientific, & of an uncertain outcome.
Rather like psychoanalytic therapy, in fact. But with the difference that
difficult questions about the ambivalence of the patient towards the past &
the future & to the prospect of being cured are avoided if at all possible.
Every effort is made not to challenge the patient by carefully not asking what it
means for him to be cured. Cure is
taken to be either what the patient initially says it is – “I want to get over
the breakdown of my relationship & move on with my life & be free to have more affairs,” – or what the therapist
initially says it is – “You must stop having these trivial relationships &
settle down & get married.” The working assumption is that one or other of
them must know from the outset & without further ado what health means. Psychodynamic
therapy alone acknowledges the fundamental problem here: before we have
explored the divisions within the patient, & before both patient & therapist have learned something about these divisions, we cannot say what
kind of an outcome represents a cure for the patient. Only through a dialogue between
patient & therapist, with each learning important things from the other,
can we arrive at a legitimate notion of health for any patient.
Sometimes despair & grief are
appropriately viewed as illnesses & sometimes they are not. We always have
to make a judgement of an ethical & indeed an aesthetic nature as to what
is fundamentally healthy & what is fundamentally not. But in either case such experiences are a part of our humanity. We
cannot be fully human without experiencing such emotions, without processing them & integrating them &
transcending them. We cannot cure ourselves of these things unless we cure
ourselves of what it means to be human. We need our love & our hate &
these will always inflict collateral damage on us, & on others too. As long as
we live we will suffer harm & we will inflict harm.
There are no easy, quick or simple cures for
mental illness because there are no easy ways of being human. Life is complex
& difficult & painful. It is not impossible that at some time in the
future we shall contrive ways of using science to deaden in a fundamental way
our emotional responses to the vicissitudes of life, & thus change in a fundamental
way what it means to be human. But unless & until we give up the fight of
being human in some such way, life will continue to be complex & difficult
& painful.
It is said that we face a modern epidemic of
depression & mental illness. But all that is really happening here is that
we are for the first time waking up to just how disturbed an animal we have
always been. In our initial attempts to confront this we have been trying to
comprehend it in terms of our pre-existing sciences. These sciences work very
well for other things, so why not for ourselves? This attitude is not without
value. But the way we have tried to apply science to ourselves has been
premature & rather clumsy, & the motivation behind it has been
ambivalent. True, we want to understand ourselves better. But also, we don’t
want to understand ourselves better. Let’s be honest: looking at ourselves is
often uncomfortable.
We cannot simply take the science of physical disease & apply it dogmatically
to mental turmoil. That won’t do. We must go about our work with greater
ingenuity. We must shape our inquiry to the thing we are inquiring about.
Dismissed so often as outdated, Freud in fact still has a great deal to teach
us about how to do this.
*
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