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The existencial approach in psychiatry
Existence itself, the beingness or mode of being proper to an individual, cannot be studied or described as if it were an object to be apprehended by some form of immediate awareness. Even if one were to claim that such a direct intuition of another's existence can be attained, it still would not be possible to communicate the content of such a vision. For all properties we ascribe to a person and by which we try to characterize his peculiar, individual being, designate relations with the world wherein he lives. All that we are able to say of him is that he responds to certain aspects of the world in this or that manner. And we understand him, so far as this is feasible at all, only when we realize what particular view of the world prompts his behavior, his utterances, and determines his whole being. Understanding another means, in fact, precisely placing oneself on his "standpoint" so as to become aware of the manner in which the world appears to him.
EXISTENCE ITSELF, the beingness or mode of being proper to an individual, cannot be studied or described as if it were an object to be apprehended by some form of immediate awareness. Even if one were to claim that such a direct intuition of another's existence can be attained, it still would not be possible to communicate the content of such a vision. For all properties we ascribe to a person and by which we try to characterize his peculiar, individual being, designate relations with the world wherein he lives. All that we are able to say of him is that he responds to certain aspects of the world in this or that manner. And we understand him, so far as this is feasible at all, only when we realize what particular view of the world prompts his behavior, his utterances, and determines his whole being. Understanding another means, in fact, precisely placing oneself on his "standpoint" so as to become aware of the manner in which the world appears to him.
To understand the poet one must go to the poet's land, and to understand poetry one must visit the land of poetry, Goethe remarked. As the second part of this saying shows, the land is not simply a geographical region, nor the sum total of customs and suchlike things, but the totality of the world that is peculiar to the poet and the totality of the world-interpretation which makes up the sense of poetry.
Each of us lives to some extent in a world of his own, at least as long as he leads an "authentic existence." "All men awake live in one common world, but in sleep everyone rushes away into a world of his own." This word of Heraclitus remains true. It is, however, not only in sleep that each has a "private world." Some small corner of privacy is proper to everyone. The more this private world invades the common world and transforms it, the less understandable the person becomes and the more abnormal he appears.
Appears, at least, at first sight. For it is possible that one arrive at an understanding also of a widely divergent world if one is capable of making clear to oneself how and where this private world differs from one's own and from that shared by the great majority of one's fellows. Our ability to discern the peculiarities of such private worlds has developed notably in recent times. We have come closer to understanding for eign nations and strange civilizations, past ages and worldviews very different from our own. Cultural anthropology has made great progress in this respect, although many of us still are victims of what has been called the "ethnocentric predicament," the naive and unquestioned assumption that all that is foreign must be measured by the standards to which we are accustomed.
That which cultural anthropology has achieved in its field may be compared to what the existential approach has contributed and will contribute to psychiatry. Now, to explain what this contribution may be, one could summarize various studies which have been published in recent years. They deal predominately with cases of schizophrenia, some with neurosis, or with manic-depressive states. These studies are accessible, and to report on them may well be tedious and amount to mere repetition. I think it, therefore, preferable to outline the promises —to a large extent we have as yet only such— one may expect the existential approach to fulfill. That is, I shall try to avail myself of this approach to characterize briefly several types of "abnormal worlds" and therewith of abnormal modes of existence as they become manifest in the several world pictures.
One word may be in place on the notion of the types to which I have just referred. Distinguishing and describing types is not the same as constructing a classification. A class is defined by a certain number of properties which have to be present for an individual being subsumed under the class. There may be additional features present which then may become the basis for the distinction of subclasses. But the essential features have to be there. Consequently, there are no "borderline cases" as long as we have to do with classes. There may be intermediate classes, but each class is strictly defined by a minimum of indispensable features. A class is formed by establishing this minimum number of traits; one assembles a multitude of individuals which one believes to resemble each other in several respects; one ascertains which features are found with each individual, and thus arrives at forming a class. An individual is or is not a member of such a class and no individual is more representative of its class than another. The alley cat is not more and not less a feline animal than the lion.
In forming a type, one proceeds by a totally different manner. Here, the starting point is not found in an assembly of individuals but in one single individual which appears as particularly characteristic or, as Ernst Kretschmer said, as the "most beautiful case." Beautiful here does not have aesthetic significance but denotes rather the togetherness of characteristic features in fullest development. Types therefore, have no definite boundaries; they merge into each other, they mix, and they allow for assuming "borderline cases." Most divisions in medicine, especially in psychiatry, are typologies rather than classifications.
An individual belongs to one and only one class. It may be said to be a member of another class only if this class is constructed on the basis of totally different diacritic features. This univocity of definition is absent in the case of types. It is, therefore, also possible that there be typologies of different kind which overlap and combine in many ways.
This is quite apparent in psychiatry. Historically speaking, the typological viewpoint prevailed up to the second half of the nineteenth century when in France first, with Moreau, Morel and Magnan, later in Germany with Kahlbaum, Hecker and particularly Kraepelin, attempts were made at classification. But even then the typological viewpoint did not lose its significance. This may be clearly seen in the reference to, say, depressive states, stupor, persecutional ideas, and so on in the description of "classes" of mental disease.
The "abnormal worlds" of which I am going to speak likewise are types and not classes. Moreover, they are types which do not coincide with other types psychiatry may distinguish. It is quite possible that patients with very different diseases, that is diagnoses, live in largely identical worlds, as it is possible that very different worlds may be observed in patients suffering from the same trouble.
One more preliminary remark must be made. I have said that one has to enter, as it were, another's world to understand him. This entails also that one be aware of the fact that words may mean to him, and so all sorts of events, what they do not mean for us. If we take these words as we are accustomed to understand them, we risk misunderstanding profoundly the other. One will fail to understand, for in stance, a man getting suddenly restless and apprehensive if one does not take account of the fact that a black cat, crossing his path, means to him much more than it does to us. We see a black animal, he sees a sign of evil portent.
By way of introduction I shall speak first of two worlds which are not abnormal in the sense of psychiatry, but which nonetheless differ from the world in which we, adult and "normal" people, live. I refer to the world of the small child and to the world of people born blind.
Many think of little children as if they were adults on a reduced scale. They are not, of course, and one of the main differences is that they have to live in a world made for adults where all things are too big. A world where all resistances are great, and many attempts are condemned to failure. Moreover, it is a world the laws of which are unknown; the unexpected may happen and does happen any time. Events are unforeseeable and adults unpredictable. Newly acquired knowledge may prove unreliable. It is a strange and unknown world in which one would be utterly lost without the protection of the all-powerful parents, and sometimes even they fail one. Dr. Maria Montessori has suggested that children ought to live in a world commensurate to their size, strength, and ability. But this can be done only for a few hours a day, in a Montessori kindergarten. Most of the time the children exist in an adult world. No wonder that they create for themselves another world which in a subtle manner penetrates into the "real" one and often is quite unknown even to the most loving parents. No wonder either, that much of what the adults do appears as quite silly to the child. He complies with the demands made on him, partly to avoid unpleasant consequences, mostly however, out of an attitude which could well be described as one of generosity. But no one will understand the reactions of a child —they are frequently rather baffling— unless he realizes that these reactions are dictated by and in agreement with a world view quite unlike that of the adult.
The case of the congenitally blind is another one. He is grown up; he participates in the life of others. They think that they understand him and he thinks that he understands them. This is undoubtedly true to a large extent. But nevertheless, there are profound differences. The seeing person believes that the world of the blind is the same world as his own, minus the data of sight. That is, minus light and color. This belief is supported by the fact that the blind uses the same words and, apparently, means by them the same things. This, however, is far from being the case. When the blind refer to "distance," the underlying experience is not at all that which is connoted by the same word in the speech of a seeing person. To the latter, distance means "far off" in the sense as this is a visual experience. The sky is distant, so is the horizon when we look out on the sea or the great plains. Distant are the blue misty hills and all the objects which appear as small, while we know them to be big. Of all this the blind person has no experience. To him, distance is represented by the experience of so and so many steps or such a time of walking, may be of riding on a train. A word like "skyscraper" denotes to him, perhaps, a long ride in an elevator but the underlying metaphor is meaningless for the blind. How does he think of time? Morning and evening, night and day do not exist for him. Time can be for him only the duration of some activity or the rhythm of daily life. Thus the two fundamental categories which determine our experience of the surrounding world, assume for the blind a totally different signification. The most common expressions of ordinary language must have another sense for him too. We say: This thing is not here, and base our statement on visual awareness in the overwhelming majority of such occasions. Not here means to the blind: Not within reach, or not to be touched by a series of well known movements. That something is not "at its usual place" is for us an immediate intuitive knowledge. For the blind the result of a more or less lengthy inquiry. Then there are the innumerable metaphors —whose metaphorical origin we forget most of the time— which are derived from visual experiences. Insight, something is clear, I see, can't you see that this is the best way? —the list could be continued indefinitely. But these few indications may suffice to show that the world of the blind is not ours minus color and light, and that the same words carry other connotations for him than for us.
This brief consideration of the world of the blind may also serve as a pointer for the manner in which an "existential" analysis of abnormal worlds will have to proceed. We must reconstruct the structure of the worlds of our patients out of their utterances, their conduct and the rare explanations they are able to furnish.
The rather sketchy descriptions of abnormal worlds I am going to submit, do not claim to be definitive and even less to be exhaustive. They are meant as illustrations of what the results of an existential consideration may be and they will, I hope, be sufficient to enable us to envisage the scope and the limitations of the existential approach in psychiatry which question will be the topic of my last lecture.
I believe that one may distinguish three main types of abnormal worlds each of which comprises several sub-types. I designate these three basic types as: defective, transformed and perverted worlds.
I. Abnormally defective worlds are found with feebleminded people, in cases of agnosia, and in the several forms of dementia, by which term I refer here only to demential states resulting from organic alterations, as in paresis, senility, in consequence of arteriosclerosis or other diffused cerebral destructions.
a. The world of the feebleminded may be described as a closed world. We are accustomed to speak of degrees of mental deficiency and to base the distinction of these degrees on the data furnished by intelligence tests. We attribute to a person a certain "mental age" which normally corresponds to the "chronological age" and is below the latter in retarded individuals. We know, of course, that a man of, say, twenty years, with an intelligence age of twelve is not the same kind of person as a twelve year old child. He is intellectually retarded, but in general physically grown up. His behavior differs in many respects from that of a child, and so does his world.
For the world of the normal child is essentially an "open" world. It expands continually. Not only does it expand objectively, but its capacity of expanding is a basic feature in the world as it is experienced by the child. The closed world is surrounded by walls which are unscalable and dense, but also invisible. In other words, the inhabitant of this world is unaware of its limitations. For him no "beyond" exists. Only to the outsider does this world look like a prison, not to him who dwells there. All challenge by the unknown, and even more by the unknowable is absent, consequently absent also are the worries caused by the problematic nature of existence and the anguish which responds to the threat by the wholly unknown, the wholly other. To the simpleton all things are simple.
This does not preclude that such a person, provided the defectiveness be not too great, may manage to lead a satis factory and even a useful life. And it may well be —precisely because of the lack of problems— that he be on good terms with his fellows. Again, it is only when envisaged from the outside, objectively, if one wants to say so, that his "being with" does not measure up to the demands of an "authentic" existence. It happens even that he display a good deal of naive sympathy and understanding because his attitude in regard to others is not "overcast by the pale hue of thought."
b. Another, widely different world, is that of people afflicted by agnosia. This world may be designated as perforated. There are "holes" in it, and the patient is in general aware of them. He knows that he is no longer able to perform certain actions or to cope with certain situations which previously were to him a matter of course. A large part of the world in which he lived has been cut away. Tasks which were once simple, with which he dealt in an almost automatic manner, have become impossible and confront him with "catastrophic situations" ( K. Goldstein).
But the loss he has suffered is much greater than that. He is no longer able to cope with previously relatively simple situations and problems. Something has disappeared from reality itself. It does not matter whether one attribute this diminution to the loss of "categorical thinking," with Gelb and Goldstein, or to the loss of a "symbolic function" with Sir Henry Head. What really matters is that "meaning" has disappeared from a great umber of experiences, and what remains is mostly the surface of things. Things are just that as which they appear in immediate awareness, but they do no longer point beyond themselves at something they "mean." Where once there became visible "behind" things, something other than the thing itself, there is now nothing. Thus, thirteen playing cards are just so many things, different from each other but their togetherness as a "bridge hand" is not apprehended. Consequently, one aspect of the given that is present to the normal mind (even if not always expressly noted) is absent. The world is, as it were, flattened out; it has lost its depth. Whatever a mode of being one may attribute to "meaning," it is no longer there; its place is empty. The patient afflicted with agnosia is, indeed, faced, in the "catastrophic situations," with the Nought and, therefore, responds with intense anxiety.
Perhaps, one should not refer as a "world" to the milieu or ambiance wherein these patients live. A world properly deserving this name has no holes. It is a consistent structure. It may be wider or narrower, open or closed, peculiar in several respects, but whatever it is, it is a structured whole. Such considerations, however —so far as they are pertinent in the present context— are suggested even more than by an analysis of the "perforated" world by that of the situation found with states of mental confusion and will be better taken up then.
c. In a certain sense the "Perforated" world is also a closed one, inasmuch as the transcendence of the actual and concrete situation towards some region "behind" or "beyond" has become impossible. To use a not too appropriate metaphor, one might say that the closed world of the feebleminded is closed on the horizontal level but nonetheless retains, if not much, at least some of its depths; whereas the perforated world, corresponding to the loss of symbolic or categorical interpretation, abstractive insight, is not so much restricted on the horizontal level as deprived of its depth.
d. A world which is diminished in both dimensions is a shrunk world; it is that of dementia. More correctly, it is a shrinking world which process ends with the disappearance of anything resembling a world.
There is no need to speak of this world at greater length. The phenomena of mental decay in paresis, arteriosclerosis, and old age are sufficiently well known. Senile dementia, however, seems to possess certain peculiarities which distinguish it from other demential processes, at least, in certain cases.
The aging person is more frequently and more poignantly aware of the dwindling of his mental powers. He may be, precisely for this reason, responsible for, not of course the process, but the rate by which it progresses. This may sound rather paradoxical and requires explanation.
A lesson may be learned from studying the attitude of people who realize that their bodily strength is failing them. To many this appears as a catastrophe especially in these days which have made an idol out of youthfulness. Instead of enjoying the many pleasures life may still afford, these people look only back. They compare the present with the past and discover nothing but losses. In older times there were definite compensations, because old age enjoyed a great prestige, was seen as "venerable," believed to be able to contribute advice by virtue of experience, and so forth. But in a rapidly advancing age, experience does not count as much as it did once. The "senate" of to-day consists no longer of the "seniors of the people," and the "elders of the church" are often anything but "elders." To many, growing old is a misfortune, even a tragedy. They have to "retire" and do not know whereto. They feel useless; they deplore the loss of the rôle they played before, however small it may have been. Conscious only of what is gone, unwilling to see what may be left of positive possibilities, they "give up." They do not care to make use of the capacities which still are theirs.
It is not probable that by this attitude the process of senescence be accelerated or intensified but one can hardly doubt that sometimes its manifestations come more to the fore. It seems also that depressive states are frequently caused by this attitude and are not direct effects of the cerebral alterations. Furthermore, the preoccupation with the past may likewise be more of an active withdrawal than dependent on the destruction of more recent memories. To live in the past is to live in a world that is significant because it is that wherein the person holds a definite place and has not become superfluous.
For the world of the senile is characterized by a sense of loss which sometimes may assume such an intensity that it becomes intolerable and escape into an imagined world the only solution.
If the flight into the past has its consoling effects, it is, at the same time, a factor that enhances the sense of loss and renders the person so afflicted even more aware of his present situation. He would be better off did he not recall what has been and is no more.
When the recollection of the past and the disregard of the present do not amount to a sense of loss, the return to the former assumes the form of dreaming more than that of actual remembering. Concurrently, it is only the momentary present that counts. Then, the world is shrunk even more since it has also lost the background which, more or less consciously, subtends all knowledge of actual situations.
That in the total picture of senility, there may be a co-opera-tion of organic and sychogenic factors, becomes sometimes visible in the fact that such a person may suddenly prove capable of achievements which seemed to have been lost all together. So far as I can see, we still lack a thorough phenomenological and "existential" description of the several states of dementia.
II. The transformed worlds present a group of very different pictures. They have attracted greater attention than did other abnormal worlds. In fact, the larger part of studies inspired by existentialist considerations deals with cases of schizophrenia. The world of the schizophrenic is but one of several such transformed worlds.
a. There is, first, the disrupted world in states of mental confusion. As I have pointed out, the typology of abnormal worlds does not coincide with any other grouping of mental disturbances. Thus, the kind of world of which I am going to speak now may be found with very divergent cases.
It is to these cases if to any, that the qualification "all coherence gone" applies. Not that the world of daily experience would disappear; it persists but is, as it were, submerged and pervaded by the spectres arising from nowhere. Things appear that do not belong in the setting; uncanny and incomprehensible events follow each other without any sense being revealed in their succession; the most common objects seem to assume a new but hidden and therefore menacing aspect. Two worlds, as it were, which have little or nothing at all in common, combine.
The mental state of these patients has often been compared to that of a dreamer, not quite justly; because when we dream we live in the dreamworld, "rushed away into the private world of the sleeper," and do not know of the real world around us. But in mental confusion, the fantastic world of the delirium is, so to speak, spread out over that of reality. The customary and reliable points of reference no longer offer any means of orientation. Between the single phases of normal, natural events, other elements are interposed which deprive all happenings of the meaning.
One may ask whether such an ambiance still deserves to be called a "world?" However little this world resembles that of normal experience, it is nonetheless some sort of world inasmuch as it retains remnants of the basic principles of order, namely space and time. Things are one beside the other, events follow each other. Many known things, too, remain what they are, even though they are mixed with others of a strange nature. Order, however, is what makes up a world. The disrupted world shows a minimum of order, but nevertheless some order. Let me note in passing that a clarification of what is meant by the term "world" is an urgent need, especially in view of the existentialist statement that man's being is essentially being-in-a-world.
If this be so, then the mode of existence proper to the individual afflicted by a state of mental confusion is a much changed one. He has no means of being "at home" in this world of his because it is continually changing. That he loses "orientation," does not know where he is, nor is certain in regard to time, may be largely the consequence of this alteration of his world and his being. When he returns to normalcy the patient often refers to his state as like a dream. But what makes him say so is less the phenomenal likeness of mental confusion and dream than the discontinuity between his prior, now remembered and resumed existence and the episode of confusion.
The world of the confused is disrupted and incoherent at any moment because the fantastic world breaks in continually into reality. (Of course, to call the mass of hallucinations, interpretations, vague apprehensions a "world" is not quite appropriate; but after all, we speak also of the world of dreams.) His existence, accordingly, is precarious. It lacks the support by a reliable world. It is, however, doubtful whether one may speak here of an "unauthentic" existence. If it were permissible to use quantitative terms in regard to existence, one might characterize this mode of existence as "weakened."
It is also, for obvious reasons, an insecure existence. This insecurity, however is only one kind of that existential modification designated by this name. There are several kinds of insecurity, a fact often overlooked. The insecurity of the mentally confused is that of a man "at loss" because he has lost the support by an intelligible and orderly world. It may become, secondarily, the insecurity of one menaced by an unknown peril, ending in anguish, because out of an unintelligible and chaotic world all sorts of unforeseeable dangers may arise. In this respect it resembles the insecurity of children in darkness.
b. The incoherence of the confused world may be said to be manifest both in the cross section of every moment and in the longitudinal dimension of the sequence of events. Another is the incoherence of the world in mania which results in an unstable world. Here, during each short span of time the world is orderly enough; but there is no order in the succession of these single aspects. The patient in a state of manic excitement is, in general, not bewildered. He feels rather at home in his world and does not notice that this world changes from one moment to the next. This instability is related to an equalization of significance, that is, to the fact that every event, every idea, every impulse attains the same degree of relevance and, hence, becomes paramount as soon as it emerges into consciousness.
This transformation may be described also, in terms of configurational or Gestalt psychology, as a levelling down of the difference between "figure" and "background." Or, in the vocabulary of William James as a failure of the "substantive states" to achieve preeminence over the "fringes" that surround them. Because no "figure" is cut out, as it were, sharply enough to engage attention and to achieve significance, every detail of the "background" becomes equally relevant or, rather, equally irrelevant.
This description refers, of course, to the more extreme cases of "flight of ideas"; but it applies also, though in a less pronounced manner, to less marked disturbances, even to such states which hardly can be called abnormal in the sense of the clinic, as those usually labelled "hypomania." In periods of elation also, the cyclothymic person may give evidence of his living in an unstable world.
This world is wide but shallow. The rapid alternation of world-aspects does not allow for either concentration or searching examination. Living in such a world, however, affects existence in many cases astonishingly little. It is well known that even rather extreme states of this kind are not recognized as abnormal by lay observers. (This may be particularly true in an age which appreciates activity so much more than leisure and contemplation that even relaxation becomes something to be "done.")
The impact of a mass of incessantly changing impressions and ideas often overwhelms the individual so that he feels caught in a sort of "vortex," whirled around in a welter of data none of which he can consider, even though it may appear to him as worth while; but it slips away as soon as it has emerged.
It is difficult to find an appropriate qualification for the mode of existence within such a world. One aspect of this existence, at least, may be characterized as a "lack of seriousness," if by this term we designate an attitude enabling the subject to credit the several data of experience with an adequate value or significance. In this sense one may speak also of an unauthentic existence since authenticity entails an attitude in regard to the content of experience such as to be proportionate to the "objective" nature of things and ideas.
c. The disrupted world in confusion and the unstable world in manic excitement are certainly transformed worlds. The transformation, however, does not go too far. The normal world, that wherein all people awake live, remains back of the transformation it undergoes. It is overlaid by the fantastic contents in the first case, dissolved and rendered inconsistent in the second, but preserves most of its fundamental traits. We have to do with another kind of transformation in the case of two other kinds of transformed world of which the first is the estranged world in depersonalization.
As in the foregoing discussions and the present one, the clinical designation or classification of the mental state is of no importance. Whether the syndrome of depersonalization occurs in a state of melancholia, in the course of a schizophrenic process (as an episode in certain cases of neurosis), it is, at least, the same in its basic aspects.
The name "estrangement of the perceived world" was used first, so far as I know, by C. T. Oesterreich in 1907. It was suggested to him by the statements of the persons themselves whom he studied. In fact, nothing is more common in such cases, than hearing them describe their world as having be
come strange in a manner the precise nature of which they hardly know how to characterize. Taken in a strict sense many of these statements appear as contradictory and logically impossible. They attribute to certain data properties which seem to exclude each other. Things are at the same distance as they were always, but they appear as far away. They have the same size, but seem to be smaller. People look the same but also are profoundly changed; they move as they did before, but something is absent. They appear as automata rather than as living persons. The colors are the same, but they are also different. As life is absent in persons and animals, so some quality is missing in colors which appear as "dead," without lustre. Men and animals have become lifeless, mere machines; but human beings are still definitely distinct from beasts.
The world has become radically transformed, but nevertheless is the same. And so it is also with the individual's self-awareness. He is the same and not the same, "I have lost my self or my ego;" a proposition which, indeed, seems to negate itself. "This machine here, that's not I," said a patient of Ball.
The subject is depersonalized but not deindividualized. He is, to the contrary, intensely aware of his being one, but one among many other individuals which are, so to speak, nothing but individuals. That is, they are singulars, but distinct from each other only by their being each of them a one. They differ, of course, and are recognized, given their customary names, even handled as always. Nevertheless, they have lost some otherwise indispensable characteristic. The world is flattened out because everything has the same significance or rather, has none at all. It is an ice-cold world, for there is nothing to appeal and no one to whom an appeal may be addressed. The differentiation of beings, their rank according to dignity or importance, has vanished, including the ego. Therewith disappears also, all meaningful context. Things stand one beside the other without being related. They are sharply set off individuals, but everyone stands for itself alone.
It must be noted that this world is deprived of all features which might give rise to a value judgment. This is true not only of positive but also of all negative values. The mood of the depersonalized is one of indifference. Not that indifference, however, which certain philosophies have preconized, for it is not the indifference in regard to what does not deserve consideration as contrasted with some highest good. The depersonalized is neither a Stoic nor a Christian aseete. He is, as he himself tells us, —nothing. At least, nothing resembling a human being as he remembers himself to have been. He does not deny that he exists (and this distinguishes his attitude from that in Cotard's délire de négation), but he exists in the same manner, or his mode of existence is the same, as that of all other things.
This levelling down of all values to indifference entails chiefly the higher values; those which are more or less directly related to what is specifically human. Although the depersonalized is unwilling to admit it, it is nevertheless a fact that he is not indifferent regarding lower values. He prefers sleeping in a bed to lying down on the hard floor, or eating decent food, to a badly cooked meal.
It would, therefore, not be incorrect were one to characterize this estranged world as one that has been "dehumanized"; for it is, indeed, the truly human aspect which has disappeared. And there is a certain logic in the fact that with the human also all other life loses its nature, and the actions of living beings become those of mere mechanisms or automata.
I have referred above to the curious modification of the experience of space. Things seem to be far away although they are also at the same distance as ever. The individual doubts not in the least that the things on the table are within reach, or that he will have to make the same number of steps to cross the street. Because, apparently removed to a greater distance, things appear as if spread out on a plane. There is little depth in the spatial world of this type. This phenomenon may well be correlated to, and expressive of, the equalization, the levelling-down process to which everything has become subject.
Time forbids any further elaboration. I can only hope that this rapid sketch has shown the peculiarities of the estranged world and the modification the existence of the person undergoes therein.
d. The prototype of transformed worlds, and that which has attracted the greatest interest of those who want to apply ideas of existentialist philosophy to the study of mental cases, is that which is found with schizophrenics. I propose to call this world a transmuted world. It is, in fact, often so far from our own customary world picture that many have declared it to be quite unintelligible. It has also been claimed that the utterances of these patients are meaningless, empty sequences of words without any reference to something objectively given. It cannot be gainsaid that our attempts at understanding what such a patient means, or to ascertain whether he means anything at all, often prove to be unsuccessful. But there are enough cases —and their number has grown considerably in recent times, partly in consequence of the "existential approach"— in which we are able to penetrate behind the apparently meaningless and to discover some features proper to the transmuted world. Such observations are, perhaps, not conclusive, but they are certainly suggestive and justify the presumption that, at least, a minimum of intelligibility may be found in other cases also.
Schizophrenia is a name which, as we all know, covers a multitude of diverse clinical pictures and processes. It is not all certain that it is just if we comprise (following Kraepelin to some extent but most of all Bleuler) all these cases under one name. One has to remember this, especially in view of an analysis of the transmuted world, because by far not all cases labelled schizophrenic live in such a world, at least, not in one which is completely transmuted. The extent to which the transmuted world, which is private to the patient, invades the common world of his normal fellows, varies considerably. Sometimes only certain sections of the common world become transmuted, so that the individual may fit into his environment and not get involved in disastrous conflicts.
Furthermore, it must be noted that the "autistic" conduct, the withdrawal into a private world, is not necessarily the same as living in a transmuted world. The world of the daydreamer, for instance, may be extremely "unrealistic", but this need not amount to a transmutation. This private world consists of elements which are improbable, contrary to the actual state of affairs, but essentially constructed out of data of common experience. In fact, although the world depicted in a day-dream may be very improbable, it is seldom impossible in the strict sense of the term. The impossible cannot happen, but the improbable may. In rare cases it has happened that the most fantastic day-dream became reality, but the transmuted world never agrees with reality, not even with an improbable one.
Leaving aside certain borderline phenomena, found with nocturnal rather than day-dreams, one may say that the elements of reality retain in these vagaries of the mind their original, commonly accepted nature and significance, however fantastically they be combined. The transmutation of which we speak, to the contrary, endows these elements with a new nature. They cease to be simply things and properties, events or sequences, and become the revelation of another hitherto unknown world.
This is seen with particular clarity in those cases in which the onset of the disease —or at least, its manifestation— amounts to what has been aptly called the "experience of a world catastrophe" (Weltuntergangserlebnis). This is not an experience of the "last judgment" or something similar, although references of this kind are not unfrequent. If one world comes to an end, it is another which emerges, one which is bewilderingly new, dawns only gradually on the subject, and exists side by side with the prior world, superseding it howeve,by virtue of its much greater significance or relevance. The world of ordinary experience becomes, as it were, "transparent" and opens up a vista on another world.
It is this aspect of the transmuted world which has caused French psychiatrists to describe, since Lasègue, certain forms, mostly of a paranoid character, as délire d'interprétation. It must be noted that this name denotes the judgment of the psychiatrist or observer and not of the patient, since the latter is not aware of any act of interpretation, as if there were first some datum which then would be comprehended as having a peculiar meaning. This meaning is immediately visible; it pertains to the datum much as does the meaning of a well known word pertains to the auditory phenomenon. The inhabitant of the transmuted world knows in an immediate awareness what things mean, just as the superstitious person knows what it means when a black cat crosses his path. Neither the one nor the other proceeds by way of interpretation, that is, by applying some rules, making use of a sort of dictionary, to realize what the occurrence means. In general, one has not to do with anything like an "augurial" procedure, but with a primordial intuition. Simple sensory data become heavy with significance. A girl walks on the street and seeing the wind lifting the tableclothes in a sidewalk coffeehouse "knows" that the end of the world is near. A light glides over the wall and the man there "knows" that he has to be prepared for some as yet unknown but portentuous event. And so on; examples abound in literature and in the experience of every psychiatrist.
Not always, of course, does this new world suddenly reveal itself. It may become apparent also in a succession of slowly progressing phases, sometimes interrupted by long intervals. But it is under all circumstances, a novel world. Living in a novel world entails existing in a novel manner. This new existence, or mode of existence, together with the strangeness of the world renders explicable, or so it seems to me, certain characteristic features. If things are new, present aspects hitherto unknown, and appear in relations the like of which did not form part of the previous world, it becomes inevitable that new words be found for the new experiences. The frequent neologisms thus become intelligible, not always in their precise meaning, but in their occurrence.
Something other, too, may find an explanation if account is taken of the novelty of both world and mode of existence; namely, the similarities between the mentality of schizophrenics, children and primitives. Such similarities undoubtedly exist, though they may be less pronounced than it is often assumed. An explanation has been proposed, and widely accepted, which rests on the notion of "regression" on one hand and that of Lévy-Bruhl's conception of primitive mentality on the other. This latter conception had been severely criticized by cultural anthropologists, e.g., by Malinovski, by philosophers, so by Cassirer, and by psychologists like Biihler. It has been repudiated completely by Leévy-Bruhl himself in the notes he had made in preparation of a last work which he could not publish any more. In these notes he says, in so many words, that the profound differences he had believed to exist between primitive and advanced mentality, in fact do not exist at all. Hence, even if one were to consider as legitimate, the parallelism of individual and cultural history, as advocated by Freud, the theory of "regression" to an "archaic" mode of mentality loses its support. The said similarities, however, can be explained by the fact that all three groups, the primitives, the children and the schizophrenics, share one fundamental experience; that of having to exist in an unknown world whose nature and laws are hidden and mysterious.
The new world is strictly a transmuted one, that is, it does not replace the old world so that the latter would disappear. The new world becomes visible "behind" or "through" the common things which remain the same on the surface but become "transparent." A new significance is bestowed on them and, accordingly, their relations among themselves and with the subject are altered. Phenomena which normally would not attract or deserve attention may achieve paramount importance.
The realization that such an individual lives in a transmuted world may help us to understand many traits of his behavior and many of his utterances which otherwise appear as most puzzling. Thus, one need not assume the existence of wholly unmotivated "cross-impulses" (Querantriebe, as Kraepelin said) which come to interrupt an action, if one may understand the patient's conduct as determined by world-aspects which are obvious to him but unknown to us.
It is, however, not enough that we understand by penetrating, as far as is possible, into this transmuted world and envisaging its peculiarities. Many more problems have to be solved which even the most accurate visualization of this world leaves untouched. I shall return to the question of the limitations of the existentialist approach in my last lecture. For the present, it must suffice to point out that by describing this world as a transmuted one, nothing is said of the peculiar form this transmutation assumes in a particular case, nor of the factors which determine some more or less typical symtoms (as, for instance, the complaint about strange physical influences, the presence of "voices," and so on.)
f. The last of the transformed worlds is the fragmented world in anankastic syndroms. The usual descriptions of such states stress the compulsory nature of the symptom and its nonsensicality; hence, two aspects of a purely subjective character. This applies both to compulsory neurosis s.str. and to phobias. The patient is helpless in face of the compulsion; he "has" to think, to imagine, to do certain things; he is the passive victim of his anxiety even though he knows that there is no intrinsic relation between crossing a street and being stricken by a heart attack. All this is too well known to need further exemplification.
What has not been remarked sufficiently is that the situations in which such experiences arise possess certain characteristics which render the peculiar reaction possible. Although the agoraphobic, for instance, knows that a street in itself is harmless, it appears to him exclusively under the aspect of a place where death may strike. The man who feels compelled to pick up every slip of paper because he might inadvertently put on it his signature, knows quite well that a torn envelope, a streetcar ticket, any bit of paper is just that. It means to him nothing but an opportunity for writing his name on it. To the scrupulous person every action is nothing but an occasion for sinning, and so forth.
In other words, the object, content of thought, situation, which releases the compulsory reaction is not apprehended in the totality of its factual relations, in the multiplicity of the meanings it has within different contexts, but seen detached, as it were, from all other connections but the one which stands out in the patient's experience.
It has been often noted that sentiments or reactions of disgust are particularly frequent in such cases. A brief analysis of disgust may throw some light on the structure —or, better perhaps, the absence of structure— in a fragmented world.
Disgust or nausea is primarily a reaction to the presence of organic matter in decay, or to products of life which have lost their connection with a living being and assumed an independent existence. Many people refer wonderingly to the biochemist or the physician as men who by force of habituation have lost all sense for the disgusting. This criticism overlooks that the absence of the disgust-reaction is proper to these men only within the setting of the vocational activities. Under the conditions of ordinary life they are as liable to feel disgusted as anyone else. One and the same thing, indeed, may appear as disgusting or lack this quality according to the total situation in which it is encountered. The hair one admires and loves as a feature of a beloved person becomes disgusting when combed out or dropped say on the tablecloth. The "disgusting" things the biochemist or the physician handle, belong into a meaningful context, that of diagnosis, research or treatment. They do not, therefore, appear as isolated from life but rather as reinstated into a vital context and thus endowed with significance. It is only when these things are encountered in isolation, separated from every possible significance, and thus utterly "out of place" that they may release the reaction of disgust.
Another not unfrequent trait may be traced to a similar origin: pedantry. For pedantry aims at creating a fragmented world. Every thing has one place only; each action can be done only in one way; to every hour belongs one and only one performance. Thus there are elements each of which has only one significance, stands only in very narrow, sharply defined relations and loses contact with the rest of being. Pedantry may also be viewed as a means of defense by which the invasion of the world by the unexpected is to be precluded. The unexpected, however, reveals inevitably relations hitherto ignored, and in a world that is fragmented such novel relations must not be allowed to arise.
Although this bare outline needs to be filled in, I have to pass over to the third and last group of abnormal worlds.
III. I call this type that of perverted worlds because the main characteristic is a profound change in the order of values. What constitutes a perversion is, indeed, the fact that a value achieves paramount importance which is none, or a disvalue, or occupies a low place in the axiological order.
a. The world of the melancholic is of this kind. It is what I would term an emptied world. It is emptied inasmuch as have disappeared all positive values from it. There prevails throughout a negative aspect. The world, including the subject himself, is emptied of all goodness. All that is, was, or will be is essentially evil.
I believe that the suicidal tendencies in melancholia can be understood against this background. Being says an old principleof philosophy is essentially good, or goodness and being are convertible terms. What lacks all goodness is, in truth, no longer being. It has become nothing. To go on existing in a manner which is fundamentally that of non-existence becomes an intolerable paradox. It is of common observation that the danger of suicide is greatest not when the depressive state is at its height, but when it is either developing or, even more so, when it is beginning to abate. For the far going inhibition of all activity prevents that such ideas become determinants of actual conduct. A certain amount of vital energy is, it seems, required for an individual drawing, as it were, the consequences from his experience of being totally deprived of any goodness.
When all goodness has disappeared from the world, all differentiation vanishes likewise. The world becomes uniformly evil; not in the sense that it fails to measure up to some ideal —in the sense in which a moralist may condemn the world— but because all is reduced to the lowest level of being; or, however paradoxical this may sound, to the level of non-being. Action becomes impossible since to act means that a state of affairs be envisaged which is presumed to be better than the one prevailing at present. Where all such vision is precluded, action cannot take place. Therein may be found, at least, one reason for the complete inertia of many melancholics.
To this world that has become empty and stripped of all goodness corresponds an equally empty and valueless existence. But existence and absence of all value are mutually exclusive. To exist means to be endowed with value. The mode of existence in melancholia is, therefore, thoroughly unauthentic. One is reminded of Kierkegaard's notion of despair, that is, the unwillingness —be it without the subject knowing of it— to accept one's situation, as an individual not less than as a representative of human nature. There is often a definite note of aggressiveness, as if the individual resented his having to be human, and being desirous of revenging himself on the world.
The fact of spontaneous recovery from a phase in manicdepressive insanity may be viewed as indicative of this unauthenticity; for therein becomes apparent the persistence of the ostensibly denied existence and its goodness. Otherwise, return to normalcy would be rather unintelligible.
It will be a task of a further development of the existential approach to furnish a more detailed description of the mode of existence found with melancholies. A careful comparison of depressive states of different origin may point a way. For the present however, it does not seem that one can go much farther beyond a very general outline of the main traits characteristic of the emptied world and the correlated "hollowed out" existence.
b. To the emptied world applies the name of "perverted" in a somewhat restricted sense, since perversion entails the replacement of a "normal" order or values by another one which is not commensurate to the average human condition; whereas the emptiness referred to amounts to an elimination of all positive values. There are two forms of abnormal worlds which particularly deserve to be labelled perverted because here some value is given primacy over all others in contradiction to the conditions of normal, authentic and fruitful existence.
The first of these two perverted worlds is the egocentric world of neurotics. Neurotic egocentrism differs from "normal" egoism, even from that naive form in which the egoist is unaware of his attitude. The difference, however, is not easy to grasp or to put in words. Most neurotics will protest against being called egocentric; they pretend to be just the opposite. The egoist admits that he cares only for his own advantage and will justify this behavior as natural (unless it suits him, in a particular situation, to assume the rôle of the altruist). The words of the egoist ring true, those of the neurotic ring false. The former's existence is closer to authenticity, whereas that of the latter is almost the prototype of a certain kind of unauthenticity; for unauthentic existence does not always consist in conforming to the pattern of the group, in thinking, acting, talking as "one does." There is also an unauthenticity which implies the aspiration at "being different" without, however, the person becoming truly himself. If the egoist's plans do not realize, he has failed. If the neurotic cannot see his claims fulfilled, he has suffered defeat.
The unauthentic existence which is based on conformity, on losing individuality to become like all the others, is not at all alien to the neurotic. He, too, will try to conform; sometimes in a truly protean manner so that he is another in different situations. In most instances, however, his conformism will break down. He will get involved in conflicts or feel not sufficiently appreciated, misunderstood, or become resentful and cease —to use this to-day fashionable expression— to be a "good mixer," because his mode of unauthentic existence is basically another. While the conformist "falls" to the level of the average (Verfallenheit an das Man is Heidegger's illuminating term), it is the aim of the neurotic to rise, if one may say so, above himself. Striving for a place in the order of reality to which he is not entitled, and being somehow aware of this, the neurotic feels guilty and becomes a prey of anxiety.
It must be emphasized that this is merely description. Nothing is said on the origin of this form of existence. Genetic explanation and existential understanding are two different approaches, none of which can be abandoned; but they can neither be confused with each other.
The neurotic personality has often been characterized as being immature or juvenilistic, especially in regard to the form of emotional responses. So far as this description is right it points at a trait closely related to the fundamental egocentricity. Maturity entails that a person be able to subordinate his preferences to the demands of reality, and this in turn means that these demands appear as a frame of reference of, at least, the same dignity as that of immediate subjective desires. To the normal and mature mind values appear as ordered in two dimensions, one of which may be called that of "closeness" to the ego, whereas the other lets values appear as arranged according to some "transsubjective" principle. Being-in-a-world requires that full account be taken of the world as being-there, independently of subjective preferences. If only the ego-centered dimension prevails, the world becomes necessarily a perverted one.
Beause it is self-centered, the world of the neurotic is essentially a loveless world. It is also a world in which human relations cannot truly unfold. The neurotic makes demands on his fellows, but he is incapable of complying sincerely with the demands of society. His is not really a "being-with" others, for these are degraded as it were, into means for an egocentric end. Human beings and things stand almost on the same level; they are more or less usable tools. Sentiments like admiration, dedication, and devotion, be it to a person or to a cause, are practically absent from the neurotic world. (It is, perhaps, because Freud came to know human nature primarily through the study of neurotic personalities that he coined the term "sexual object" to designate a beloved person.)
The neurotic is unable to "give himself," to abandon his own being for even a moment. He is, therefore, deprived of the experience of "fulfillment" which arises from the communion with another in first line, but also from the restless dedication to something pertaining to the region of the nonego.
I may be permitted to mention, in this context, that I have referred to the nature of neurosis, thirty years ago, as founded ultimately on a "metaphysical problem" (to-day one would say "existential," but this terminology was then not yet in use). 9 This problem arises from the awareness —one may call it, if one so wishes, an unconscious one— of man's essential finiteness and the unwillingness on the part of the individual person to accept the human condition. It is conceivable that the fact of finiteness becomes tolerable, at least to the average person, only when he lives in a real "togetherness" with others, when he exists authentically and, hence, in the mode of "being with."
c. Although I am not fond of coining new terms, I have to do this in the case of the third "perverted worlds" becauseI have been unable to find a suitable name. I call this world, which is that of the addict —taking this name in a wide sense— the pothocentric world. Pothos means desire, wish; and this world is, indeed, characterized by the feature that it is centered around one dominating desire, the fulfillment of which is the indispensable condition, as the individual sees it, for his existence. (Perhaps, "monopothic" would be an even more appropriate name; but it sounds rather too clumsy.)
This description applies, obviously, in first line to the drug addict and the chronic alcoholic. It seems to fit, however, also the passionate gambler, a certain type of voracious eaters; to some extent the man whose life is ruled by excessive vanity, by the craving for social recognition (the "status-seeker" in his most extreme development); the miser; and one who is possessed by the lust of power. Possibly also some of those whom popular parlance calls "sex maniacs."
That this world be centered around one dominating desire and that, accordingly, that which is so desired appears as the paramount value, does not preclude that other values be recognized —provided the main one be realized. But as long as this condition be not fulfilled, the world is empty and a place of torment. The suffering caused by the lack of fulfillment is, of course, enhanced in the case of drug addiction, also of alcoholism, by the physical effects of habituation. But sometimes, at least, not less pain is suffered by the miser who has been robbed of his treasures, of the man greedy for recognition who for some reason loses the coveted esteem on the part of his fellows, the would-be tyrant whose plans are thwarted. It is known that men have committed suicide under such circumstances. A life not affording the satisfaction of the one dominating desire is not worth living. (The expressions "social death" or that a man be "dead for his family" and others of the same kind can be considered as indicative of such an attitude.)
Did time permit to do so, one would have to distinguish several subtypes of the pothocentric world. For instance, it makes a difference whether the dominating wish can be satisfled for a certain period and thus allow the person to return to a more authentic form of existence, as it is with the drug addict, or whether this wish is insatiable and prevails throughout all phases of a man's life, which is the case of the miser.
It is obvious that the existence corresponding to the pothocentric world is one of deepest unauthenticity. It is even farther from authentic existence than is that of the neurotic. For the latter is concerned, if in a perverted manner, with the whole of his being. It is he, as a person, who seeks recognition, craves for power, demands love, and so on. In the pothocentric world, however, the personality ceases to stand in the foreground. Existence, then, consists, as it were, in the quest for the satisfaction of the one and only desire. The world is seen exclusively as a set of situations granting or denying the satisfaction. It is a correct description if a drug addict says that when he is possessed, because of lacking the drug, by the desire for satisfaction he "is nothing but desire."
One would also have to find some criteria by which to distinguish the existence in the pothocentric world from that of a man "possessed," in a monoideistic manner, by some prevailing sentiment. This may be a cause he believes to be of paramount importance, a person whom he passionately loves (or hates), and other attitudes which may be comprised summarily under the title of a "sense of mission." It is, in fact, often difficult to ascertain, in a concrete case, whether one has to do with genuine enthusiasm and "commitment" or with something akin to a psychopathic deformation of personality. One criterion may be found, perhaps, in the degree to which such a person remains aware of his human obligations. A person who disregards these obligations and does not hesitate to sacrifice not only himself but also others to his obsession, can hardly be said to be normal or to lead an authentic existence.
To raise such questions does no longer pertain to the task of these lectures. That one cannot avoid asking them is, be it said in passing, indicative of the relation of psychiatry not only with social but also with moral problems.
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