Patients as Informants About the Human Condition, rather than as Deviants from Idealized Norms

We typically think of patients and ourselves as deviants from vague and idealized mental health norms, although we all are much more normal than anyone could have imagined.

I can explain what I mean about seeing patients and ourselves as deviants by an example of the opposite: consciousness-raising groups. The first such groups were the women’s CR groups of the seventies. They made the watershed discovery that we all have feelings we think no one else has. The women in them came to treat one another not as deviants but as informants about feminist issues. Since then we all have been discovering, to our surprise, that we are, much more than we thought we were, members of the human race. This is, I think, the model for what the therapist’s relationship to reality should be. The patient should be seen as an informant (in the anthropologist’s sense) about the human condition rather than as a deviant from some mythical and barely formulated idealized norms. Treating patients this way makes it clearer that what they suffer from the most is seeing themselves as deviant, that is, from not being able to see themselves in relation to our common reality.

We compare ourselves to idealizations. One patient said, “I am standing in the check-out line and thinking how all these people look so placid. They’re not at all self-conscious, whereas I’m self-conscious and obsessing all the time. Why can’t I be like them?”

I said, “OK, I think you’re right. Probably most of them are not self-conscious or obsessing to the degree that you are. Maybe most of them are basically blank. Like think of military pilots who can land a jet plane on the deck of an aircraft carrier in a storm. They can’t possibly be someone who obsesses or gets self-conscious. But when when they are not flying the jet, these pilots are not likely to be any more introspective. They are not likely to be poets or psychologists. So when they are in a check out line, that’s it; that’s all that’s happening. They specialize in taking themselves for granted, in focusing on the outer world. You specialize in being introspective; you just haven’t perfected it yet.”

Consider clients who say, “It’s very hard for me to say, ‘I love you’ to my partner.” They always think that their problem is that they can’t say “I love you” when they mean it, rather than that they can’t say it when they don’t mean it. They never think of Hollywood or Beverly Hills, where, we are told, there are a lot of people who say “I love you” all the time and to almost everybody. They have an idealization in mind; the reality is something else. I was talking about this issue once in a workshop and someone said that what is going on with these people who have trouble saying “I love you,” is that they can’t enter into fraudulent contracts.

That way of putting it gets my point across. It makes a big difference whether you think that the patient has trouble saying “I love you” because he is afraid of intimacy or because he is afraid of being phoney. It isn’t that seeing it this way solves his problem, but it does solve his problem about his problem. Now he can really think about this fear of being fraudulent. Otherwise, he just thinks he has to get over his difficulty saying “I love you.” As by trying harder. That only means tying himself in knots.

Now suppose that this client did have a fear of intimacy. Our automatic assumption is that he shouldn’t. Meaning that it undoubtedly was appropriate in his past relationships, but is no longer appropriate in the present. This will coincide with patients’ belief that they have to get over their fear of intimacy. As if there is no good reason in the present. A fear of intimacy just seems neurotic; after all, what is there to be afraid of? But that’s our idealizing thinking again. We’re thinking of an ideal state of intimacy rather than what it actually means to be in an intimate relationship with someone.

One of my patients once got off what has become one of my favorite epigrams. I call it the Andrea principle. She said: “Every new relationship is a new set of rules and a new way to learn how you are a creep.” Think it over. Then think about whether the fear of intimacy is neurotic.

I don’t mean that that’s the solution to the whole problem of fear of intimacy. It just solves the problem about the problem. Now the person can really think about how intimacy is dangerous and about how ill-prepared for that he or she may be. Rather than tying himself in knots, thinking he has to get over the fear, that the fear was the obstacle to intimacy, rather than that it was realistic. The belief that the fear is unrealistic, and that he should get over it, intensified his lack of preparedness to deal with the hazards of intimate relationships and undermined his confidence in his experience, further intensifying the fear.

Consider fear of commitment, another one of these hand-me-down insights. Again, the assumption is that there really is nothing to fear. But what commitment actually means is entering into a contract to be reliable. And one of the results of the psychological revolution of the twentieth century is that our tribal reliability-morality has come in conflict with a whole new morality of authenticity. So now it is unclear whether you should promise to always love somebody, or whether you should promise to always be honest about whether you do or not, or about whatever your feelings actually are.

So a fear of commitment can be a fear that you will not be able to be reliable, but perhaps this is an archaism, a shibboleth—cf. “I love you.” Thinking about it this way allows you to focus on the problem, rather than being self-condemning about it.

Another example of mental health norm mongering is the relatively new requirement that we should be open and vulnerable, especially in therapy. Now, the reality is, of course, that it depends—which would be obvious if it were not for the way the idealization makes us feel unentitled to consider the reality. We even take for granted that you should be able to be open and vulnerable, even though few people are able to successfully accomplish it. It requires having developed the ability to manage relationships sufficiently adequately to insure enough safety to make it possible to take the risk. Another piece of reality in this connection is that being open and vulnerable is a whole new concept; being stoic is still more popular and we’re much better at it. As for the therapy relationship, the reality is that it can be one of the most difficult. Much of what makes it difficult is the idealization that it should be the easiest. If that piece of reality were more accessible to us rather than lost to denial, the therapy relationship would be much easier to cope with.

Moving to diagnostic categories, people with multiple personality disorder and borderline conditions (which is a variant of MPD) make especially valuable informants. They not only inform us about moods and subselves, they also demonstrate the advantages of splitting, what I call going out of character. The MPD patient suffers, of course, from the typical presenting complaint of memory gaps. Where we have moods, the MPD patient has alters. Yet what the alters demonstrate is the way that subselves can be called out in different contexts or, most relevantly in different relationships.

What it comes down to is that in seeing symptoms as deviations from idealized norms, one looks for what is invalid about them. In seeing symptoms as representative of real issues, the ego analyst looks for what is valid about them. Both angles are always present.

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