Category Archives: 1988 Rounds

L.F. Canella M.D. F.R.C.P.(C). (1988)

Within the field if Psychiatry one finds a wealth of information and a variety of often conflicting approaches. This diversity reflects differences in the way we integrate the material into a meaningful system for our selves. The particular orientation would be an expression of one’s own background and interests.

As I have neared the end of my residency program, I have felt it necessary to pull together the facts and information I have been accumulating. These rounds offered an incentive to organize my thoughts and clarify the field of psychiatry for myself. During the course of the next forty-five minutes I would like to share with you some ideas on what it means to heal the sick person.

In doing so, I will be taking what might be termed an existential position. It is existential in that a basic premise holds that “the essence of man is his existence.” What this means to me is that the truth about us isn’t merely intellectual, but is rather a living truth. We are too concrete to be grasped in our entirety, by the rational mind. We find ourselves, we become ourselves not so much through the analysis of our actions but rather in the choices we make, in what we do, which includes thinking. In a finite sense, it can be said that we create ourselves.  We are centred on being from which our structure emerges. No matter what the distortions in the structure, that which makes us human remains. These ideas form the basis of what follows.

Though the basic premise I quoted is from Sartre, from what I understand of his works, he probably wouldn’t go along with many statements I will be making. The Existential writer that has been most influential on my thinking would have to be Paul Tillich.

The title “Healing the Sick Person” suggests three questions that have been with us since humankind first began to reason. They are: What is human nature? What is the nature of the ills that befall us? and What can be done about the situation?

In formulating a response, I will be elaborating on the central idea of the person. The view that I would like to present is this, that the person is a dynamic unity and a living truth which is centred on being and possesses a structure which is a manifestation of being.This structure can be described along the two dimensions of mind and matter. Like other paradoxical phenomena in nature, our totality presents as only one aspect at a time to our finite reason. The person is an individual participant within a larger structure, which is in turn an expression of infinite creativity and freedom.This creativity is finally manifested as the finite expression of free will. There is a structure, but the person is not static; the person is someone whom she becomes as a result of what she does. The intellect cannot reach the person; being who she is, doing what she does, the person is illumined by being revealing itself.

In discussing sickness, I hope to make an argument for the view that suffering is ultimately a state of spiritual alienation having physical and psychological dimensions. Whatever the illness, suffering ensues because a person is affected. The illnessreveals her existential finitude. If it is valid to describe illness as affecting us physically, psychologically, and spiritually, then it follows that healing involves three types of intervention. The task in healing is ultimately to bring about a new wholeness of the person within the world. In itself, this might be described as a priestly function. The healing that brings the ill person back to physical health is that done by the physician. The Psychiatrist provides a third type of healing which assists the patient with his psychological problems: his conflicts, his irrational fears, his maladaptive patterns, and so on. Though listed last, the Psychiatrist is probably most likely to take on all three roles. Unfortunately with rising trends towards an organically oriented psychiatry, we run the risk of perpetuating the illusion of a mind-body split and in the process perhaps doing away with our discpline altogether. Unless our focus is on the totality of the person, we as psychiatrists will either be absorbed into physical medicine as a sort of pharmaconeurology or into religion or other organized systems of belief such as psychoanalysis.

The primary concern in Psychiatry has to be the person. We don’t treat mental illness per se, but rather attempt to alleviate the individual’s suffering by intervening in the appropriate manner. There is no mental illness outside of the person so that if we are battling Schizophrenia, for example, we may end up battling our patient.

But what is a person? It seems we will always fall short in attempting a complete description. The answer is simple on the one hand; you and I are persons. Here and now, this is the reality of a person. Yet what am I? Searching for an answer, the solid becomes nebulous. One may turn to books, analysts, to Gurus on the other side of the globe, to find what is closest- oneself. Though we seek a rational explanation, we find ourselves not as descriptions, not as solutions to a problem, but in the act of being ourselves. Understanding, science and knowledge in this light become a form of art, a creative activity, a personal relationship with the world and an expression of oneself in the world.

In attempting to describe what a person is, we can begin by noting that we can understand him in terms of different dimensions. There is one person but we can talk about his existence, his structure, his physical and his psychological properties.

The person clearly exists and he does so as a dynamic creative unity. Vision, hearing, touch, thought, and feeeling are manifestations of the person, elements of his totality.

Though fate determines various innate qualities in addition to the time, family, and culture he is thrown into, it is his will that determines which direction he takes and hence the choices that are open to him in the future. Though he does so in a limited, finite way, the person willfully creates himself and his place within the larger structure.

When we try to understand the person as a structured being, we assume that there are basic events whose interplay is responsible for the complexity of phenomena. Our reason tries to elucidate their nature and views them as universal principles. If we view being and structure as fundemental aspects of the person and hence the universe of which the person is an expression, the relationship between them can be pictured as a ground of being from which the structure is eternally created. Perhaps this can be made clear by describing my speaking here. Clearly this experience is the latest of links that constitute the chain of my history. In one sense I am here because of things that happened in the past. This explanation is not sufficient however. My being here is generated into existence at this moment. My life might be likened to a wheel with being at the centre, creating me at each particular time. This image may convey a sense of how the structure might be seen as a manifestation of being which is at the heart of all things. Focussing strictly on the structure, we can observe that it has physical and psychological aspects. We are biological entities made up of the same stuff as the rest of the universe and not merely subject to its laws or solely expressions of these laws; in fact, we are the physical laws. We are not only physical beings but have an additional mental dimension as well. We go about in a world of symbols. We can describe the experience of being here in terms of biological processes which are part of the material universe or as psychological phenomena which are manifestations of the world of the psyche. In order to understand the person more fully, each of these dimensions, including those of being and structure, are necessary. None is sufficient however; and ultimately too, all explanations must fail to reach and encompass the person who is the explanation itself.

The intellect is finite: we get only fragments of who and what we are. Ideas of wholeness, of being, of free choice and so on tend to be ignored by scientific disciplines to a large part. This is true of psychiatry as well; the focus is on structural elements which can be predicted and manipulated. Observations and conclusions involve the isolation and organization of events. Distortions occur when we forget that the understanding we have is only one aspect of whatever totality it is we are studying. In that case we must consequently be ignoring other possible attributes that belong to the object of investigation. For example, in medical school we learn about the human body partially through the dissection of cadavers. Something of the gross structure of a human being is preserved as proteins are denatured and the natural process of decomposition is unable to procede. While the dissection lab provides us with an opportunity to develop mental images of muscle and organ, structure and functioning, in the end we are studying neither life nor death. In histology, the slides we pour over endlessly have about as much to do with living tissue and the person as does, say a rock from the pertrified forest with wood and the original tree. Though these methods are necessary in providing us with information about ourselves as physical beings, they can affect one’s view of what constitutes a person. It is easy to imagine that the cadaver is a human being, that those remains were once inhabited by a person. The person has in fact died; the person was the totality of the living body in the world.

In Psychiatry we are learning more about ourselves now that we can do receptor assays and P.E.T. scans, and with increasingly sophisticated statistical studies. Otherwise undetectable patterns are made visible by such techniques. However, because the technique only focusses on certain variables, the understanding that evolves will be only one among many. Distortions occur when one adheres to only one aspect as representing the whole. In effect, the person, the relationship between oneself and the other

is a fountainhead of sensations, impressions, feelings, and ideas. The person is a mystery, the more we know the more profound the mystery.

We’ve looked at the person in terms of his structure and his being. Perhaps we can say a few brief things about the person as mind.

Firstly, it would appear self evident that we are symbolic entities. We move about in a web of socio-cultural interrelationships providing us with a wealth of experiences and the framework for heroic action. We are able as intellect, to speculate about reality and to reflect on ourselves. We emotionally need and hunger for one another. We hate and love, achieve greatness and suffer profound remorse. This is a world of meanings and magic. In the case of currency for example, what might otherwise be thought of as specially fabricatated paper bearing a leader’s likeness, is a source of power within the social network. Such meanings are agreed upon and are also imposed on us. They are like spirits having no substance in themselves and no separate consciousness, but enormous power. The strife in the Middle East, Northern Ireland, South Africa and so on attest to the negative impact and force of symbols on people’s lives. 

The works of Freud, Jung, Kohut, and numerous others in the field of psychiatry are attempts at describing the nature of psychological entities.

Psychic events, perceptions, symbols, emotions are expressions of the person; they in fact, are the person. One is happiness or sadness. These feeling states, though they may seem extraneous events that happen to oneself, are who one is at a particular moment. When one is joyous hungry or in despair, the feeling state permeates the entirety of his being in the world. Psychological phenomena, in the psychophysiological unity of the person, are also physical events. The other aspect of the paradoxical entity which presents itself on one hand as a mental event is also stuctured along the lines of brain physiology. For this reason mental phenomena can become distorted or lose their connection withon another. The person’s structure can be influenced by symbolic phenomena as well as by changes in neural structure or brain chemistry.

We should perhaps at this point briefly review what science tells us about the physical dimension of the psychophysiological unity which we are. We can speak of ourselves as being essentially matter undergoing the four interactions of nature which are weak and strong intranuclear, gravitational and electromagnetic forces within relative space-time frames of reference.

From this basis, the Carbon atom is possible. Because of the Carbon atom, biochemistry is possible and hence biology. Within the basic structure of the universe lies the possibility of evolution and hence ourselves. Wether this is interpreted to mean that life is a chance occurance, or the converse, that there is a meaning, destination which was set at the beginning of time, it remains a valid fact that the structure of Carbon makes possible the process by which increasingly complex molecules combined in a primordial soup covering the earth and formed the first cells.

The double-helix DNA structure makes possible the production of cellular proteins in addition to its own self-replication. Cells, complex collections of biochemical reactions, reproduce as long as they can incorporate new material within themselves and overcome destructive elements. With increasing specialization of cell function , increasingly sophisticated organisms were possible and we ourselves emerged.

We can imagine one-celled creatures meeting and avoiding physical elements in the environment by undergoing membrane and intracelluar changes on contact. Just as the single cell “feels” its surroundings, we “feel” our’s, though with infinitely more sophisticated and specialized means. We are able to react to a greater range of stimuli and with a greater repertoire of behaviour.

Looking at behaviour patterns, we note greater malleability as we progress through the evolutionary hierarchy. Fish, for example, are able to move in unison probably because they perceive and react to the same stimulus in the exact same manner. Anything more than the most basic kind of learning in these schools would be disasterous for the group as each fish would go its own way based on its own experience. With us it is our families, our culture which directs what is to be perceived and how we are to react. Our perceptions and behaviours are malleable and must be learned. Because of this, we are more adaptable an more in need of one another than other animals. Here we see again the psychophysiological unity of the person: culture is possible because of biology and biology is possible because of culture.

The experience of this paper, for example, would appear to include the paper and an infinitely complex array of neurological events. All these elements are inherent in the experience which constitutes a unity.

Perception and understanding require not only the objects being studied but also our intact nervous system. One can there fore describe any experience as the universe, in the microcasm of the person, reflecting back and understanding itself.

Even though one can talk about unity and wholeness, the very real fact remains that one is separate. One doesn’t, in a state of everyday consciousness at least, experience oneself and the world from its foundations in being. The reality that ideas about psychological forces, atoms, and molecules relate to, though it is who and what one is, remains a mystery.

Perhaps the entire process is unconscious because of its total involvement in the moment. One would continue to be frustrated in finding oneself and the ground of ones ground because the reality of oneself would lie not in the image that develops but rather in the act of thinking itself. Whatever the answer, though I read, speak, move my hands, I remain impenetrable darkness which my intellect cannot illumine.Theories and ideas are all very fine, but who and what am I really?How and why does this occur? The abyss surrounds me.

We exist in a state of estrangement from ourselves and the world. The reality of the person is for the most part unconscious; this unconsciousness  may be understood as a manifestation of an aspect of being which might be termed separation. This separateness is not a consequence of underlying physical forces, but is an irreducible aspect of reality; we are separate to the core of our being.

Consciousness is a totality of sensation, perception, thought, and so on. It is not a force in the dimension of the physical that weaves psychoneurological events into this cohesive unity with aspects of the material and syymbolic worlds. Likewise no physical law explains how the beingness of one’s individual world is cut off from the rest of the universe.

Separateness is integral to individual existence; it defines the person who is alone in thought action and death. The greatness of humankind lies in the individual’s separation from the whole. Becaus of this one is able to know and love the other; one has a separate and hence free will which makes possible heroic action. We exist as ourselves ultimately because we are separate from the rest. Though we are chance occurances in other respects, our aloneness gives us infinite significance. The person’s life is unique; it is irreplaceable, to be lived by that person alone and never again.

This condition of separateness or finitude, though miraculous and at the root of who one is, this fact of existential aloneness is also the ultimate horror.

Separation is the source of anxiety and despair, the demons and monsters that guard the gates to one another and ourselves. Anxiety and despair arise from the encounter with nonbeing. We become anxious and afraid when faced with the possibility of losing something we love, something which is a source of meaning be it a person, a position or role, an object, or parts of ourselves such as our minds, our capacities to act effectively, or especially ourselves in our entirety. When the possibility of loss becomes reality, when we are brought face to face with the reality of separation from the beloved,we enter into the state of despair. Anxiety and despair involve us totally. Emotionally, we are in turmoil, in pain; things are confused; we want to retreat. Physically, our hearts race; we breathe heavily. There is on cure to anxiety in the sense that if we balance the chemistry or the psychic forces, the source of anxiety will be abolished. What there is , is the challenge of heroic action. It is when our attempts have all failed, when the possibility becomes reality, that we enter into a state of despair. We have reached our limits; we are vanquished. Nonbeing is victorious. Helpless, we  see the days stretch ahead empty. With the loss of the loved object, one’s ties to the world are cut; other loves cannot lift the emotional weight of one’s existential aloneness. One longs to die but can’t. As long as reason is intact, suicide is no option. It offers no victory over the fates that have driven one to this point. There is no victory over death, no escape from guilt. To bring about one’s own death is to merely hurt others, there is not even the satisfaction of a last heroic act of rebellion against God. Suicide is madness; there is no escape. This is the existential reality of despair whose approach is signalled by anxiety. These are conditions of spiritual malaise which the person becomes as he is confronted by his finitude.

Neurotic anxiety, we understand as a signal of unconscious conflict. What this means is that we are free, that we can act in any manner. The rigid patterns need not be adhered to. These patterns, this character armour was conditioned and continues to operate in an attempt to avoid anxiety, the awareness of finitude, and the possibility of despair. Neurotic anxiety is psychopathological in that it is, as Freud stated, a private suffering. Anxiety in neurosis can be seen as existential anxiety which has been associated with an idea, memory, situation or object in order to have something which the person can control or avoid and thereby continue to otherwise function as normally as possible. One is able to avoid despair by manipulating its symbolic representation. At the point that the patient comes to us, the patient is acutely aware that her strategies have failed; somethging is not right. Nonbeing threatens and the result is neurotic and characterological symptomatology.

Anxiety as a state in which we are faced with our finitude, manifests itself in three forms: the first, perhaps foremost, is the anxiety of death; the second is related to our will, our actions, and is an anxiety associated with the possibility of final condemnation; thirdly is the anxiety that emerges when a sense of meaning to our lives is threatened.

Because we are expressions of and centred on the eternal Now of Being with which we unconsciously identify, we have a sense that time passes while we remain still. You may look at the clock and find that you’ve spent the last hour or so reading. There is a sense that the time has gone while you were sitting taking in and thinking about these words. Time is not really external to us however. The person is a historic being; she exists at a particular time. In fact the person or collection of persons is the actual time in history. Our actions, our being at a certain moment in the context of the past and future defines that historic moment.The person is a condition of transformation, of becoming. Nonbeing then is withus not only in projected form as an everpresent and unavoidable possibility, but in every act and in the surrender of each moment to the next.

Though the person makes himself whom he becomes, he does so only in a finite way; he does not generate himself in relation to the larger whole on which he continues to depend for both physical and emotional nurturance. Necessity makes us eternal children, dependent on family, friends, society, and the larger universe. The anxiety of dearh would include not only theeventual demise which our aging process relentlessly pursues, but also the weak and dependent position that we are in and which puts us at the mercy of the fates and other people.

The anxiety of guilt can be seen as an offshoot of the anxiety of death in that the person’s actions may have consequences leading to her annihilation. It is not only the fates that determine the course of a person’s life but also her decisions, her actions. It is through the person’s actions that she becomes who she is. The peron is her life; this is the only life that person can have. Will she be able to create a life with meaning or one which she would rather have not lived? The burden of the universe is on one’s shoulders. There is more at stake than deciding on the validity of a value, it is one’s own concrete existence that is on the line.

Because life is concrete, because it is real, one may find at times that one is called upon to go against the universal norm. Life can be profoundly ambiguous, especially in those situations that matter most. In such circumstances one is never sure wether one is choosing for life and fulfillment or succumbing to some destructive influence. One may be compelled at times, in full appreciation of the ethical choice, to make an exception. There are times when rival goods make any choice result in evil. There may be so much to lose and one’s motivations so unclear that one is forced out of one’s ethical system. One is compelled to act outside the rules because they do not capture the truth about the concrete situation of oneself. One acts in an expression of pure will, fully responsible but having nothing to appeal to as a defense against condemnation. This in fact is our existential condition. It is our individual life that is at stake; it is our happiness. Perhaps the anxiety would not be as great if we didn’t know who we were, how we have acted. One’s past, if not one’s present, reveals the power one has over one’s destiny; given the ambiguity of existence, how is one to act with the totality of one’s being? It is so much easier to escape into self-righteousness or, conversely, lawlessness.

In the end who is there to convince? Who is it that one is trying to justify oneself to? Who is it that is sitting in judgement and hears the appeals to the Bible, Cosmopolitan, one’s parents or society?

The person creates his life; given the reality of ambivalence, can he ever be happy with what he, out of his circumstances, has brought into existence? Can he accept this?

The person is a paradox which is reflected in his will which drives him in separate directions. The  awareness of this condition is the experience of guilt. In affirming himself with the totality of his being, he takes on the nonbeing inherent in the act of becoming who he is. In being himself he accepts himself.

We are estranged from that which tells us who we are and why we are here. The anxiety of meaninglessness relates to a loss of ultimate concern which gives meaning to our activities, especially our struggles. We can endure anything when it has a purpose; without one we are unable to perform even the implest of tasks. Without a central purpose, we are driven from devotion to one object, to another  and another, as in each case we find either the meaning vanish or that what was a state of creativity, turn to indifference or aversion. The anxiety which arises, as the finite mind is met with paradox, is the result of the growing awareness of separateness and lack of universal participation.

Coming to consciousness, becoming oneself entails a self-affirming act on meeting one’s nonbeing. the encounter brings about a realization of separation; one  realizes one’s position as an individual participant within the whole. The anxiety is a barrier which, through the act of self-affirmation, is taken into oneself and thereby becomes the driving force urging the person to act heroically.

During infancy, one might imagine there being, in psychoanalytic terms, a state of primary narcissism. The person here is continuous with the larger structure and in a state of unconscious wholeness. This wholeness would be felt as good and eternal, it being an aspect of the creative self-affirmation of all existence emerging from the void. At birth the person is endowed with certain characteristics and a set of life circumstances. It is a pluripotential state from which one brings oneself into existence as one relates to what the fates bring.

The infant awakens to himself as a separate entity through hunger. His structure has to incorporate other structure be it material or psychological into itself. The psychophysiological event of anxiety that comes with hunger is the trigger and the core of the demands for food and affection.

The person develops into himself as a separate entity as he meets anxiety at each developmental level. At each stage he is met with the facts of his finitude and separation from the totality. He finds himself standing alone on his strength. Freud,Bowlby, Mahler, Klein, and many others have described what they see as occurring during the period of child development. The early history is clearly important as it forms the foundations of the personality and because one is usually never as weak and dependent on others.

 One becomes who one is, in the exercise of one’s will. The truth about oneself is revealed in one’s choices, in what one does. The choices may be limited: our freedom is finite. But it is freedom none-the- less to become what we will.

At times, in the course of one’s life, however, one may try to forge ahead heroically but is rendered impotent by the paradoxical quality of our finite existence. One’s efforts are not enough and meets oneself as weak, powerless, and insignificant. To avoid despair one is driven to find greatness in oneself or borrow it from a powerful other.

The fact of our existential position remains and emerges with the full force of anxiety and despair whenever it is reawoken by disappointment. As outlined by Self-Psychology, a fragmented, regressive state ensues as once again the illusion is seen through and the person attempts to retreat from the overpowering experience. Occurring in small increments however, the confrontation with one’s limits allows one the opportunity to overcome his condition in reality. Onecomes to a growing awareness of oneself. In one’s solitude one is also able to see the other, not as a mirror providing one with an image of oneslf, nor as a source of power and direction, not even as a twin who enables him to love and accept himself. In the end one is alone in being oneself not as an image or a role, not living on borrowed strength and love. One is the truth of one’s own will.

In terms of drives, we can understand the situation as involving the sublimation of prerational forces. There areyearnings within us that seek expression. The task in life might be seen as, not so much a refinement or redicection of these yearnings from their original aims, but rather the discovery and creation of rational objects to give them fulfillment.

Many, if not most of us are able to get through life without extreme incapacitating episodes of anxiety and despair. Our innate abilities, our determination, the support of family, friends and society are enough that we are able to manage. We take an the reality of nonbeing, of our existential separation in small doses which we overcome and are thus able to grow.

The family and the larger social structure provide us with the opportunity to be cared for and to go on to care for ourselves and others. Religion and secular systems of belief provide us withmoral codes that guide our will in avoiding self-destructive trends. They also offer justification for self- acceptance; we feel we are right in feeling good about ourselves because we have adhered to the code that we see as defining the ultimate good and bad. The family and social stucture provide us with roles and statuses in which we gain a sense of meaning and immortality. In a healthy society the vast majority of members are made significant in their position.

Societies differ in the degree of maturity they ask of the individual. In some, the leader, like Dostoyevski’s Grand Inquisitor, takes on his subject’s guilt. In surrendering the decision- making onto him, they are relieved of the burden of freedom. He alone bears the responsibility. When the leader is deposed, the individual is left incapacitated until a successor is found. In other cultures it is a societal system, a belief or set of rules that takes the anxiety of guilt from the individual. One knows what is right and what is wrong. In acting in the accepted manner one gains self acceptance. But even social and religious systems can crumble. In defense against the possibility of freedom, the individual either becomes fanatical or turns to lawlessness. Acting without self-reflection, he feels a rush of initial pwer which dwindles as his actions bring him to a condition where his choices become ever reduced and he is led to despair. Morality after all is a description of behaviours that increase a person’s freedom. Though seemingly restrictive, moral codes allow for self-discipline which is the ultimate expression of the will; the free-est will is that which can act regardless of the barriers. Morality in this light is a set of standards which heighten power, which bring one increasing freedom. It is also a formula for avoiding hell, avoiding despair.

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.