While it is difficult to tease out the degree to which psychological, social, familial, constitutional, and organic factors influence the picture we see when dealing with many personality disordered persons, in this as in other psychiatric conditions, both the physical and the mental aspects of the person are affected.”Mental”, like other illness, is both physical and psychological, and ultimately spiritual in that it shakes the person to his depths and forces him to confront himself.We as healers, attempt to effect a change in the person that comes to us for help. A complete state of health is not brought about by the alleviation of the symptom alone, nor in bringing the patient to a position where she conforms to society’s or our image of what she should be. Overcoming illness would rather seem to involve a return of the capacity to creatively affirm oneself. Health might be described as a state of wholeness of the individual in the world.There will be struggles but the patient will be able to continue and not flee from life. In health tthe person is able to be and hence express herself creatively, thereby gaining fulfillment. As Freud said, “One is able to love, work, and play.”
The healer helps by dealing with the three aspects of the person’s nature: her body, her psyche, and her spirit. The interventions range from doig something to the patient like providing medication to being a catalyst whereby she is better able to heal herself.
The importance of biological factors is quite clear in the organic brain syndromes and reasonably certain in psychotic illnesses such as schizophrenia and major affective disorders. In panic disorder as well there is some evidence of perhaps a neurochemical imbalance resulting in spontaneous anxiety states which are not precipitated by symbolic phenomena. In such cases it is clear that physical therapy in the form of medication has a role to play in the healing of the individual.
Anxiety has been thus far described as being a manifestation of our existential estrangement from ourselves and the world. In coming to know ourselves in the world we break the unconscious identification with the totality. The result is a profound sense of separation in which our dependent position is all too evident. In an attempt to avoid conditions of anxiety and despair we join one another as a society which provides us with the support to affirm ourselves. We may not have been blessed with the biological, familial, cultural, and other factors which help in the creation of these supports. In such a situation, the person faces his creatureliness, his worthlessness alone and sets about, in his own way, to evade the problem, to shield himself from the anguish inherent in existence. Torment arises out of conflict; in a no-win situation, the person is led to despair. The person becomes his own worst enemy, precipitating in the end what he most feared.
The person comes to understand himself in the psychotherapeutic situation. As the transference unfolds, the patient is able to develop a relationship with nature and its transcendent powers. In the safety of the therapeutic setting, he can begin to explore himself and the world. Though he may initially gain strenghth by using the therapist as a source of power or someone to be manipulated in a self-expansive way, as the therapy progresses his conflicts come to life within the relationship and brought to his attention.
Clearly the intervention can go only so far as to provide the patient with the therapist’s impressions. Ultimately it is the patient who changes, who becomes himself as he chooses how to react within the relationship. He attains a cohesion of self not in understanding the interpretation and not solely by his sense of being understood; rather he becomes himself by his his acts.
Psychodynamic psychotherapy is but one in a number of techniques used in our field. What may be a common thread, what may be involved in the bringing about of change is the identification of the problem which is then set in a theoretical framewok and, perhaps with the help of the therapist’s suggestions, the patient’s acting on it. The key element of all therapies: behavioural, cognitive, psychodynamic, short and long-term, what ulimately effects change is what the patient does (including introspection).
In chronic illnesses as in other cases where we see the patient through aspects of his existential condition, there is a part of healing which involves ministering to the patient. One helps him to accept himself with the illness and adopt an attitude of thankful dependence. This would sound quite condescending if our human condition were any different; but it isn’t. We have no less trouble accepting ourselves, letting down our guard and admitting our lack of self-sufficiency. We may be even more dependent on the social structure into which we have been fortunate to forge for ourselves an enviable position. We are brothers and sisters in the human condition.
As the patient comes to the recognition of both his and the therapist’s inability to lift him above this human condition, we may see a transfer to the real source of power. He doesn’t have to please his parents, hisboss, his society, or his therapist, but rather has to find acceptance and strength in his depths, in the very power that creates and maintains him.
Abelief system won’t do; the answer has to be as real as the anxiety and despair that he is.
A lot has been said in the last forty-five minutes. What is left to say in closing? One thought that might come to mind is that mid-life crises make for unusual Grand Rounds. Perhaps we can review briefly what has been discussed.
We looked at the idea of the person and saw how she might be described as multidimensional. The person firstly exists. She does so as an individual participant within the larger universe. The fact of her existence makes her a concrete, living truth which is a creative and dynamic unity. Ultimately she becomes who she is through the free expression of her will. Through her actions she makes the potential a reality. The person participates in her creation from a universal basis which can be understood in terms of the psyche and the physical universe. The person is a psychophysiological unity which presents a paradox to our finite reason. The person is separate making her an individual participant in the world. Separateness is felt as aloneness and in the experiences of anxiety and despair. We are anxious of the possibility of, and despair of the realities of death, condemnation, and meaninglessness.
Our ills have physical, psychological, and ultimately spiritual dimensions. They are ultimately spiritual because suffering involves the totality of the person and brings him to a recognition of his existential aloneness
Healing’s aim is to re-establish the wholeness of the person in her world. Physically this means an intervention involving matter: surgery, pharmacotherapy, prosthetic devices and so on. Psychologically, it means bringing her to a recognition of her conflicts. Spiritually speaking, healing involves the development of an attiaude of acceptance and thankful dependence. In psychiatry these three separate healing roles are adopted through the administration of medication and the “talking cure” both of which are carried out in an atmosphere of understanding as two persons share their solitude.