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. :-)
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.
Like Sofia, I am resisting the temptation to write an entire essay. (I have half-succeeded.)
I appreciate much of what is said, here. It is continuous with the phenomenological tradition in psychiatry, with which I have some sympathy. But Jaspers' famous contention that delusion is somehow 'by definition' unintelligible has always been, well, disturbing. It seems overly simplistic and general, and it seems to amount to casting the delusional person out in a manner that could be damaging. I'm not really a fan of jargon like 'othering', but it's tempting to use that term here.
The point is not that one *cannot* dismiss delusion in this manner and still be sensitive to another's suffering (and so I do appreciate, Dr. Gipps, your reply to Sofia), although it is also not difficult to imagine the one leading to the other. (Given the centrality of rationality to our understanding of humanity, when we dismiss another as irrational, we are in moral danger of dismissing them as inhuman as well. Alas, it happens.)
Here are two (of some other) concerns that one might have about *presuming* (it seems almost *a priori*) that delusion is 'unintelligible' (in the sense described in the interview):
1. It is indeed a *presupposition* about the extent to which the sorts of thing that people do or say might be 'meaningful' (in the relevant sense). Perhaps there is a straightforward philosophical disagreement (or difference in temperament), here. I'm not very willing to specify in advance what beliefs and actions may be intelligible, and I see no grounds whatsoever for making those specifications in advance. I find the whole philosophical idea of 'hinge commitments' to be pretty unintelligible itself, and certainly not defensible. (This stance does not inevitably dissolve into relativism.) Instead, let's just talk, and then maybe I'll come to a (tentative) judgment, not based on some pre-determined ideas about 'what one cannot possibly hold rationally', but just based on our talking, *this* talking. (Lot's more to say here, in the 'essay version' of this comment!)
2. While I'm sure that some patients can respond well to attempts to establish some genuinely therapeutic relationship even while some of their beliefs or experiences are being dismissed as unintelligible, I'm equally sure that some will not. I've certainly been in that situation, where a doctor made it clear that my questioning whether I am a human being (I have been pretty strongly gripped by that concern at various times) 'doesn't make any sense'. Maybe it is unfortunate (for a psychiatric patient) to be a trained philosopher, but the 2 or 3 times that doctors have tried to argue that my concern is unwarranted, their arguments have been manifestly 'not very good'. And when they don't argue, but simply let it be known (directly or indirectly) that such thoughts are out of rational bounds, I, too, shut down. That's the end of our discussion.
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. :-)
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.
Like Sofia, I am resisting the temptation to write an entire essay. (I have half-succeeded.)
I appreciate much of what is said, here. It is continuous with the phenomenological tradition in psychiatry, with which I have some sympathy. But Jaspers' famous contention that delusion is somehow 'by definition' unintelligible has always been, well, disturbing. It seems overly simplistic and general, and it seems to amount to casting the delusional person out in a manner that could be damaging. I'm not really a fan of jargon like 'othering', but it's tempting to use that term here.
The point is not that one *cannot* dismiss delusion in this manner and still be sensitive to another's suffering (and so I do appreciate, Dr. Gipps, your reply to Sofia), although it is also not difficult to imagine the one leading to the other. (Given the centrality of rationality to our understanding of humanity, when we dismiss another as irrational, we are in moral danger of dismissing them as inhuman as well. Alas, it happens.)
Here are two (of some other) concerns that one might have about *presuming* (it seems almost *a priori*) that delusion is 'unintelligible' (in the sense described in the interview):
1. It is indeed a *presupposition* about the extent to which the sorts of thing that people do or say might be 'meaningful' (in the relevant sense). Perhaps there is a straightforward philosophical disagreement (or difference in temperament), here. I'm not very willing to specify in advance what beliefs and actions may be intelligible, and I see no grounds whatsoever for making those specifications in advance. I find the whole philosophical idea of 'hinge commitments' to be pretty unintelligible itself, and certainly not defensible. (This stance does not inevitably dissolve into relativism.) Instead, let's just talk, and then maybe I'll come to a (tentative) judgment, not based on some pre-determined ideas about 'what one cannot possibly hold rationally', but just based on our talking, *this* talking. (Lot's more to say here, in the 'essay version' of this comment!)
2. While I'm sure that some patients can respond well to attempts to establish some genuinely therapeutic relationship even while some of their beliefs or experiences are being dismissed as unintelligible, I'm equally sure that some will not. I've certainly been in that situation, where a doctor made it clear that my questioning whether I am a human being (I have been pretty strongly gripped by that concern at various times) 'doesn't make any sense'. Maybe it is unfortunate (for a psychiatric patient) to be a trained philosopher, but the 2 or 3 times that doctors have tried to argue that my concern is unwarranted, their arguments have been manifestly 'not very good'. And when they don't argue, but simply let it be known (directly or indirectly) that such thoughts are out of rational bounds, I, too, shut down. That's the end of our discussion.