Healing the Sick Person: an Existential Approach to the Art and Science of Psychiatry: Psychopathology and Our Existential Plight

Mental disorders are conditions that may be brought on by innumerable precipitants which reflect the complexity of the structure which we are. As we know when we attempt to formulate a case, an interplay of biological, familial, social and psychological factors is described to help understand the picture with which we are presented.

Our early experiences have a profound influence on us. At no time, except in our last moments are we usually weakest and most dependent on others. As young children, we develop our first impressions of how the world is. We are dependent on our caretakers for physical and emotional nurturance. Disruptions in these bonds, as Bowlby and others have described, have powerful repercussions within the person. Because of our limited physical abilities and understanding of the world, we may become overwhelmed by anxiety and despair by situations that in adult life might otherwise be tolerated. We may be faced with unremitting confrontations with our own weakness. As a solution, patterns of behaviour, a “character armour” develop as a means of handling the challenges, of protecting oneself from the emerging threats.

These patterns of perceiving, understanding, and acting, because they tend to be fixed, become maladaptive at times within the vagaries of life. When they begin to interfere with relationships and other aspects of the person’s life, these characterological traits are seen as psychopathological and can be classified as such under diagnostic systems like DSM III which lists them as Axis II diagnoses. Though these categories help us in conveying to one another a sense of the person we are treating, they, unfortunately also, by focussing only on certain aspects of the person, can deflect our attention away from her totality. They act as stereotypes in this way; but this too reflects the rigidity of the character that the person has become. In spite of this rigidity, the person remains unique and the behaviour patterns to which she clings so ardently and limit the fulness of her life are essentially attempts at avoiding the despair that comes with the reality of individuality.

Reviewing the different types of personality disorder we can posit some explanations of the relationships between the various presentations and the individuals’ existential positions.

Persons within this first group of Paranoid, Schizoid, and Schizotypal Personality Disorders are generally perceived as odd and eccentric. There may feel to be little connection between oneself and a person who presents in such a way.

The schizoid person seems to shun relationships. He turns to fantasy as a solution; human contact might awaken a sense of empty aloneness. In being with the other he finds himself desparately alone. So he avoids people; in order to escape from his existential position of aloneness he runs to aloneness.

Ther are other conditions of self-imposed aloneness where a bridge is maintained with the other but is constructed with hate. Perhaps this might be the case with a particular paranoid individual. Love for him is pain and humiliation; it is felt as a weakness. Unable to bear the experience of losing the other, the loss of love, and unable to stand alone, he keeps the other alive in fantasy as an object of derision and hate, alternating with fear.

Whether a person with a schizotypal personality disorder has a brain dysfunction like scihizophrenia or has developed his character in response to a particularly painful or otherwise inadequate environment, the result is someone living in a magical universe inhabited by spirits and peculiar coincidences, where others may seem deadened at times and so present at others that they appear to be within one’s head. Occult techniques are used to discern what the real world will bring. How is one to jump out of one’s private world to know the reality beyond? Clearly one cannot go beyond one’s own experience as it defines in part who one is; the horror of isolation drives the person further into his own private experience, away from others and hence into deeper isolation.

Then there is the emotional, dramatic, erratic group of personality disorders.

Here are worlds of extremes: good and bad, greatness or insignificance, elation or despair, total freedom or total restriction.

The sociopath cannot bear the burden of responsibility; it is his life but he cannot or will not see anything but how he has been treated. He relinquishes his free choice, opting for non-reflective action. He desires freedom from condemnation but frequently is left with a life of confinement and pain to others and himself.

The weakness and insignificance that is felt by the person with a narcissistic personality disorder is countered by flights into fantasy which must be mirrored by others. An inner sense of lack and smallness makes him feel entitled and causes him to disregard the rights of others. Unable to face himself as he is, he creates himself through others; he creates himself in fantasy. He doesn’t grow emotionally and spiritually as long as he fails to accept and begin from the point of who he actually is.

Likewise the pattern in the histrionic personality disorders; the person, his life feels empty so he fills it with excitement and activity. One skirts the surface in dread of nothingness. Avoiding the experience of there being nothing to life, to oneself, one dramatizes and over-reacts. In the end the shallowness that is created is the nothingness one wished to avoid.

Perhaps the most outstanding feature of the borderline personality is the attept to escape from oneself into the other. To be oneself is intolerable. The neediness is so intense that it drives others away. One is ever brought back to oneself.

Turning to the last group of scared, introverted, anxious personality disorders, we see a failure of heroic action which reinforces guilt and anxiety, thereby making the hurdle ever larger until it is mountainous.

The avoidant person cannot attempt an attack; he runs in response to his lack of strength. But life becomes increasingly impoverished thereby increasing the anxiety. He wants to live, to make real his desires but, this involves a risk. To avoid the risk, to avoid the possibility of failure, he runs to failure. In relational terms, out of fear of being unloved, one runs from the possibility of love.

The dependent person seeks the protection of others who, in turn, are all too ready to project their own weakness onto the individual presenting himself as a poor unfortunate. He may be take the form of a masochist who projects onto a complementary sadist, the terror of death and guilt. He hates his weakness as he ultimately hates the sadist, but he remains in the relationship hoping to eventually manipulate a victory from these forces of evil. The sadist too despises weakness; he overcomes his own powerlessness by subjugating his victim. Though the masochist would vanquish the sadist, he can never allow himself to succeed; to do so would entail his losing his source of borrowed power. Thus the battle continues, both seeking to escape despair into whose pit they find themselves slowly sinking as life grows ever more miserable.

The compulsive too hates weakness, especially moral weakness; there is a proper way to act. His lack of self-acceptance permeates his being in the world. He is indecisive, fearing condemnation in either direction he turns. He insists that others submit to his will in fear of giving in, surrendering , and hence seeing himself as a coward. If only life can be controlled, he reasons, he will be able to avoid death guilt and insignificance. Here again, as the individual attempts to save his life, he finds it slipping away. He becomes what he most feared.

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