Developmental psychologists Vygotsky and Trevarthen describe a process by which the caregiver and baby enter a dialogue straight after birth. Communicating through verbalisations, facial expressions, movements and mutual attention to the world of objects, they begin to influence each other’s emotional states and behaviours.
There is a gradual maturation of this dialogue, from the use of objects, to signs, and to language. The mother’s voice is gradually internalised by the child, forming an inner speech through which it regulates its own emotions and behaviour.
Throughout this process, words become a means to symbolise complex, higher mental functions. From words come our thoughts.
“When the mind is thinking, it is simply talking to itself, asking questions and answering them, and saying yes or no”
– Plato, Theatetus
From words to worlds
The words that form our thoughts are not static symbols. TS Eliot wrote that “the past should be altered by the present as much as the present is directed by the past”, and the Russian philosopher Mikhail Bakhtin applied this concept to words: “Everything anyone has ever said always exists in response to things that have already been said and in anticipation of things that will be said in response. All language and the ideas communicated is dynamic and relational”.
For Bakhtin, words carry only fragments of meaning, with a more complete meaning arising only through an exchange of words (dialogue) with others. This could mean that our language, our thoughts, and the world we compose in our minds, are constructed largely through our interpersonal relationships, rather that on empirical truths. Here, Bakhtin was influenced by postmodernism and social constructivism.
What do I know?
“Man is the measure of all things”.
– Protagoras, ‘Truth’
The Sophists of Ancient Greece argued that there was only relative truth, as information could be collected only through sense perception, and all individuals sense and perceive things differently. Shakespeare has Hamlet express similar thoughts when he says to Rosencrantz: “there is nothing either good or bad, but thinking makes it so”.
The emphasis shifted from subjectivity to objectivity with the Enlightenment, starting in the 17th Century. Supernatural and superstitious beliefs gave way to empiricism and determinism, to the work and the world of Galileo and Newton. Primacy was given to certainty, logic, and a single ‘Truth’. The world, and the brain, came to be to be seen as a machine.
In the 18th century, Kant challenged the Enlightenment viewpoint by suggesting that our minds are incapable of fully understanding the world. He divided the world into what we could know, and what we could never know. The 20th century French philosopher Derrida added that our capacity for knowledge was restricted by the limitations of language. The Romantic philosophy movement held that it was possible to reach the world beyond our usual experience, but not through logic, rather through feeling and intuition.
These reactions to the modern empirical (or positivist) worldview led to the concept of ‘postmodernism’, and renewed value on subjectivity and the existence of many simultaneous truths.
Social constructivism is a branch of postmodernist thought. This is the idea the meaning we ascribe to the world is created through interaction with other people – via language. Bakhtin was influenced by social constructivism, and thought that the way in which one develops, and how one truthfully sees oneself, is influenced by others.
“The stream of human knowledge is impartially heading towards a non-mechanical reality: the Universe begins to look more like a great thought than a great machine”
– Jean James, physicist
Western psychiatry rejected subjectivity for a positivist paradigm – a striving after objectivity – that began with the phenomenology of German philosopher Karl Jaspers. Phenomenology, as Yakeley et al note, is the attempt to describe and classify observations of conscious subjective experience into an ‘atheoretical’, ‘objective’ nosological system.
Critics of this paradigm highlight the neglect of meaning and interpretation within meetings between clinician and patient. The dangers they point out were illustrated in the case study in Part 2, in that instance an individual with psychotic symptoms.
The ‘construction of psychosis’?
Social constructivist ideas have significant implications for the concept of psychosis and other mental distress. Rather than being located within the head of the sufferer, psychosis may be seen as existing in the space between people. The ‘patient’ is merely the unfortunate person in whom the problems manifest most vividly. The problems are constructed within a social network.
“[Psychosis is] a creative and ingenious survival strategy…not an abstract symptom of illness to be endured, but a complex, significant, and meaningful experience to be explored”
Perhaps most psychotic symptoms are not symptoms of an illness, but rather a strategy to survive strange and traumatic experiences, a sane reaction to insane circumstances? As such, psychosis could be seen as more normal that it presently is, a natural human tendency. Indeed, it is much more common that most people imagine – studies of young people have shown over 25% have psychotic experiences.
Through a psychodynamic lens, psychosis can be seen as defence against intolerable realities. Whilst the non-psychotic aspects of mind integrate and coordinate realities, the psychotic aspects of mind tries to dispense with realities.
“Mankind cannot bear very much reality”
– T.S. Eliot
Expanding on this idea, perhaps longstanding/chronic psychosis is an outcome of inadequate treatment – either treatment started too late, or the wrong response to a misunderstood process?
Psychosis is easily misunderstood. Hallucinations and delusions often appear bizarre. Perhaps though, there is method in the madness: “People who have survived atrocities often tell their stories in a highly emotional, contradictory, and fragmented manner which undermines their credibility and thereby serves the twin imperatives of truth telling and secrecy…” (Herman, 2001).
‘Empty speech acts’?
Giving the person time, space and an opportunity to be listened to, can often reveal meaning in these ‘symptoms’. Hallucinations may include real traumatic events in one’s life, grandiose delusions may reflect perceived personal deficiencies, and paranoia may be the projection of negative thoughts of self onto others. Eventually, a history of trauma tends to reveal itself. John Read et al provide strong evidence of a causative relationship between psychosis and trauma.
As a profession, we continue to pursue attempts to reduce psychotic symptoms to objective observations. We ignore the possibility of meaning, preferring to label and pathologise the ‘symptoms’. This risks alienating and invalidating the person in distress, who may be attempting to communicate experiences that do not yet have words. In doing so, could we be missing an opportunity to harness their own valuable resources?
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