Aug 2, 2023·edited Aug 2, 2023

Reading Sofia's comment has me want to make a clarification about the importance of being disturbed by one's patient's disturbance. So, yes, it would indeed be a clear disaster if one were to be freaked out in the consulting room! After all, clinical consultation is supposed to have what psychotherapists call a 'containing function' - that is, the mental health professional is supposed to be able to keep on thinking, and help to start make tolerable, thinkable, dreamable, such experience as the patient finds intolerable. I confess I took for granted, in what I said, that this would be our baseline. BUT there are I think 2 ways in which a clinician can keep somewhat calm in the face of dread etc. One involves not getting in touch with the patient's disturbance, staying in a de-haut-en-bas position in which the patient is an object of clinical curiosity, a paternalistic role perhaps in which the human commonality of patient and doctor is ignored, an I-It stance perhaps, a remote and uninvolved stance. The other involves human connection, inevitably being troubled by the patient's troubles, an I-Thou mode of relating. Here, especially, it's important that the clinician can be in touch with the shame and hurt and wretchedness from which a patient may be on the run in their psychosis. And not just 'in touch with it' as an objective fact 'over there', but as a truly troubling, mind-breaking, dimension of life. ONCE that disturbance has been truly registered in subjective space, then the task of bearing it, of being a useful container, can proceed. But a container which copes by simply keeping its lid on - that's no use to anyone.

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I think that "understanding madness" can only go so far from a third-person perspective. That's not to say that I, because of lived experience, somehow know What It's Like To Be Psychotic, absolutely not. There's so much individual variety. I think we need many voices.

I've absolutely had my share of sheer terror, like Gipps talk about. But I also think that much of my psychotic experiences can be described in, well, rational language. My first paper on this was "psychosis and intelligibility" in PPP, where I argued for the fairly weak thesis that more psychotic phenomena than people tend to assume can be given at least somewhat intelligible/rational explanations. HOWEVER. One of the peer reviewers for the first draft said (quoting from memory) "what would the author say to someone like me, who agree with Jaspers that psychosis is simply unintelligible?" and I was so perplexed by this comment. What would I say? Well, I would say everything I say in this very paper, which you ostensibly just read!

I think clinicians should approach madpeople with as few preconceptions as possible. Neither "this person is probably pretty similar to me and not that weird after all" nor "this person is surely utterly unintelligible and incomprehensible" are good presuppositions - either could be wrong!

Also, as someone who's never worked as a clinician but has lots of experience from the other side of the fence, I'm disturbed by the claim that it's good for clinicians to be disturbed by their patients. Sure, if your only options are to be disturbed or to fool yourself, maybe being disturbed is less bad. But surely the best clinician is one who's genuinely cool when facing madness?

I know this much: the best psychiatrist I've ever had never seemed disturbed by me, and could discuss the most frightening and strange experiences I had in a relaxed and easy-going manner. This was extremely helpful. Moreover, I recently had a meeting with a now retired psychiatrist about an educational program for clinicians. She talked about how many clinicians are a little afraid of psychosis patients, disturbed by the lack of shared reality - but she thought this was a problem which often negatively impacts treatment. That makes perfect sense to me.

Gonna stop now before I write an entire essay in the comments section. :-)

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