Psychodiagnosis: Entering the multiverse

And of all of these things, the Albino whale was the symbol. Wonder ye then at the fiery hunt?

Herman Melville, Moby-Dick, or The Whale

The great field for new discoveries...is always the Unclassified Residumm.

William James, "The Hidden Self"

To get to know the individual is comparable to a sea-voyage over limitless seas to discover a continent; every landing on a shore ore island will teach certain facts, but the possibility of further knowledge vanishes if one maintains that here one is at the center of things

Karl Jaspers, General Psychopathology, Vol. 2

In the sixth edition of his textbook, Compendium der Psychiatrie, the German psychiatrist Emil Kraepelin presented a nosology differentiating between two major forms of psychosis: manic-depressive illness and dementia praecox. Although he believed that mental illnesses were caused in the main by genetic factors, he observed that manic-depressive disorders were periodic in nature whereas dementia praecox was seemingly typified by progressive neurodegeneration over time. Although he was wrong in this latter observation (why the disorder was eventually renamed schizophrenia), Kraepelin pointed perceptively to the patterns of symptoms — this as opposed to their merely quantitative listing upon which a DSM-determined modern world has been subsequently reared. Recurrence is the hallmark feature of manic-depressive illness; this, observes psychiatrist Nassir Ghaemi, rather than the specific poles of melancholia or mania, is the critical thing.

Kraepelin’s thoughts concerning mood disorders were broad and in certain respects of a piece with current conceptions of a “bipolar spectrum” — very different from the reigning nosology, which beginning with its third iteration in 1980, initiated a division of manic-depressive illness into separate groupings of unipolar and bipolar types. We are talking about a range of biologically driven phenomena and patterns of symptoms that often occur simultaneously. The diagnostic manual notwithstanding, most depressions are mixed in nature and typified by conjoined manic and depressive elements. When mood episodes occur separately, there is a strong case to be made for the primacy of mania. Mania is the flame, suggests Koukopoulos and Ghaemi, and depression the ash.

At the age of 66 or 67 (precisely the moment I now find myself in my earthly sojourn), my father — hitherto a strikingly composed and self-contained man — fell into the throws of mental illness that came out of nowhere that anyone around him might have foreseen. He was diagnosed with Major Depressive Disorder, a sudden onset of profound despondence accompanied by insomnia, intense guilt, racing and obsessional thoughts and ceaseless agitation. After the briefest trial with a tricyclic antidepressant, he ended up in a hospital with a cardiac reaction to the specific medication that had been prescribed. This medication subsequently changed; he was discharged even as symptoms and subjective state remained entirely unabated. My father called me uncharacteristically one evening during this time and in a feverishly frenzied state, spoke monomaniacally to a “family pathology” about which he had hitherto said very little at all. Almost thirty years later, I can still recall much of that conversation very nearly verbatim; he had been essentially right about everything. 

In a patently dysfunctional frame of mind, my father expressed nuanced insights about family dynamics which I hadn’t known were there. I tried both to calm and reassure him, telling him that we would continue talking about these things. The following day he repeated these very same thoughts to several of my siblings, to whom my father’s uncanny intuitions appeared wildly disturbed; they had concerns (with which I did not entirely disagree) about safety. My father was hospitalized once again, this time on a psychiatric ward, where after several days of further anguish, a decision was made to initiate electroconvulsive therapy, an oftentimes effective, albeit short-term, intervention for extreme mood episodes. My father’s profundity on the eve of his first psychiatric admission (it would not be his last) were reflective of a sensitivity and enhanced awareness that accompanies depression far more often than it does mania. Disturbance and perspicacity are by no means antipodal. Consider Kierkegaard or Nietzsche. Consider William James or Karl Jaspers. Consider Anne Sexton or David Foster Wallace. There is little need to belabor this point.

Karl Jaspers’s General Psychopathology is an infinitely complex work written and revised over the course of several decades by one of the more brilliant and correspondingly moral voices of the last century. Jaspers envisioned psychiatry/clinical psychology as a “hybrid scientific discipline,” one integrating Erklären (the analysis of “objective causal connections” or simply put “explaining”) and Verstehen (an “understanding of psychic events from within” or more simply “understanding”). He noted the limitations of the “somaticists” (who lack “access to the inner life story”) and just as pointedly, the constricted purviews of the “psychomythologists” (who forgo empirical scrutiny). “On the one side, a purely medical perspective,” observes philosopher Matthias Bormuth, “and on the other a primarily psychological one.” What was needed, Jaspers urged, was a meticulous navigation of uneasy waters between the Scylla of “brain mythology” and the Charybdis of hermeneutic “psychomythology” — a middle ground between science and the humanities. Whether one is patient or doctor or occupies altogether another role, matters of comportment loom irrevocably large. Essential for one who dares to breach the metaphorical divide between subject and object and so “begins to encounter” oneself is a givenness to what Jaspers calls “existence-philosophical reflection.” From this recurring lodestone and practice, one engages in “philosophical life conduct,” a pervasively moral way of being constituting an ongoing work in progress.

In many ways, I have been an almost unwitting adherent of the philosophical reflection articulated long ago by Jaspers. Five years ago, I traveled to Vancouver with my wife and very young daughter, picking up an old friend in Portland along the way. I had been invited to a meeting of the American Philosophical Association in order to provide commentary on Bormuth’s book Life Conduct in Modern Times: Karl Jaspers and Psychoanalysis. I was looking for new blood, different epistemologies and perspectives. With advancing time and maturity, humanistic psychology had become, for me personally, increasingly redundant and often dull. Awe-based psychology was brilliantly and beautifully laid out by James well over a century ago. James’s metaphysics, however, did not avoid science any more than Jaspers’. (James, in fact, founded his laboratory at Harvard four years before Wilhelm Wundt; what he opposed, as Eugene Taylor noted, was “the ever-narrowing definition of science itself.”) James and Jaspers sought to broaden, deepen and even heighten its scope. (“Science lights,” Melville mused evocatively, “but cannot warm.”) Matthias and I connected at once. We met over lunch and several beers the following day and have become increasingly close friends since that time.

“The essence of science,” observes Ghaemi, “is its incompletability.” Even so, “the extraordinary fragment counts for more than any — merely apparent — completion.” The “extraordinary fragment.” Jaspers’s “ciphers of transcendence.” “From the broken fragments of my heart, I will build an altar.” This is the ancient Judaic prayer with which some years back I inscribed copies of my book, Ethics and Lao-Tzu, a collage-like meditation in which an account of my work over many years with an extraordinary young woman suffering with Dissociative Identity Disorder of astonishing complexity (one in which successive “layers” or “worlds” of experience emerged over time such that only over the course of several decades were inner and historical narratives gradually revealed). Kristina’s story and the parallel story of our therapeutic relationship bore witness to my book’s thematic touchstones. 

A prominent humanistic psychologist questioned my very incorporation of a diagnosis, implying that doing so was objectifying or reductionist or perhaps depersonalizing in some way. Yet it would have been fatuous — indeed, grotesquely disrespectful — to suggest that a woman hospitalized psychiatrically more than sixty times was somehow free of mental disturbance. Moreover, the manifold dialogues, correspondences, dreams and artwork included in my book were anything but reductive or objectifying. In an official review of the book, the case narrative was overlooked entirely. To be sure, certain colleagues offered perceptive commentaries and critiques, yet some of the most thoughtful criticism has come from readers far outside our fold.

Considered circumspectly, several diagnoses apply. Viewed from a place of Verstehen, Kristina is a multiple personality — there are many composite selves, inner voices and sets of eyes. Viewed from a place of Erklären, Kristina’s suffers with Schizoaffective Disorder. The dissociative identity hears the voices of “alters” inside her head, while the schizophrenic or schizoaffective individual hears voices predominantly without. There are multiple “worlds” of dissociated alters and experience within Kristina’s mind, each successive emergence having allowed client and therapist to jointly travel backward in time in reconstructing a macabre yet extraordinary life story. There are, additionally, two persecutory voices experienced as emanating from the outside, voices that have been omnipresent since childhood and would seem to be sequelae of two of the most vicious perpetrators during Kristina’s mortifying youth. Psychiatrists observing from the outside are right in diagnosing Schizoaffective Disorder, but immersed in a dizzyingly intricate inner architecture and narrative, I correctly diagnose Dissociative Identity Disorder. Kristina’s longstanding psychiatrist, not without reason, suspects an atypical mood disorder as well. “Absolute diagnoses are unsafe,” the famed humanistic physician William Osler once observed, “and . . . made at the expense of the conscience.” We ought bear in mind the limits of discernment and what Jaspers refers to as “the enigma of the individual.”

In his essay “The Hidden Self,” William James contemplates multiple selves with characteristic curiosity and largesse:

It must be admitted . . . that, in certain persons, at least, the total possible consciousness may be split into parts which coexist, but mutually ignore each other and share the objects of knowledge between them, and — more remarkable still — are complementary. Give an object to one of the consciousnesses, and by that fact you remove it from the other or others. Barring a certain common fund of information, like the command of language, etc., what the upper self knows, the under self is ignorant of, and vice versa.

Kristina elaborates the phenomenon with conjoined humor and poignancy in an email captioned “Green Aliens in Uncomfortable Human Suits:”

Then I keep thinking, “Why do we even care. Why do we try so hard to keep these relationships?” It’s not who we are. We’re not like these people, these single entities. It’s like we’re aliens in people suits trying to pass ourselves off as human. And sometimes our green tentacles come popping through and make people recoil. And we say, “Oh, sorry. The truth is I’m an alien — please accept me.” Then the shared world says, “Oh, we accept you, but here, let’s cut off those ugly green tentacles so that I feel more comfortable with you living in my neighborhood.” The truth is that people can’t accept what they don’t understand. They’ll sometimes go through some measured steps to make it easier to believe that they understand. For instance, “If I don’t see the tentacles, then it will LOOK human. And if it LOOKS human I can more easily demand that it act human. If it acts human than I can accept it as human.” And all the while the alien knows what it is and knows that the thing which the single entities accept is only a human suit with amputated green tentacles. The single entities do not accept the authentic being underneath. And it seems to me that if the single entities cannot accept the actuality of this alien being, then their caring for it is not genuine care. So, the alien being has to decide what it will do. It can either continue living in the human suit and nurse its bleeding appendages or wrongly believe that the acceptance doesn’t stop at the uncomfortable human suit but goes deeper. Or the alien can learn how to dissociate from the need to be accepted and shed its human suit and know it will scare everyone away. The authorities might even drag it to some prison to run tests and try to keep it away from the general population, since it’s much easier to lock up an alien being for being misunderstood than to lock up a thousand people for misunderstanding.

Kristina also has her moments of aesthetic beauty and even awe. Here it is the “inner guide” Cara who writes, dubbing her thoughts “The Inner Ocean:”

Knowing deeply what is lost, the past that brings us closer to knowing despair more fully is directed also at understanding — accepting what caused this broken connection between heart and mind, emotion and knowledge, understanding and experience. I am at the shoreline of a wide ocean moved by life. At times it crashes to the shore, breaking and destroying. In wonderment, this power is respected and left alone. Other times, rolling in, the ocean slowly changes the sands and people play happily in its serenity. All is a symphony. In my mind, I hear its rhythm. The waves are the composition, beautiful and breathtaking in their fervor, renewing in their tranquility. Inside is like this ocean.

Cara Peale

In the midst and even out of misery, there is poetic vision of a sort that Jaspers refers to as the “Transcendent” or “Encompassing:” 

We stand silenced in awakened understanding. Our souls hollowed out by the noise of others, we lean inward and become a house of people, empowered by necessity. Our resilience becomes the walls. Our hopes build roofs; our anticipation: the doors. Our transparencies become windows. Our reality becomes the ground; our expectations: the sky. Silence becomes the night; our vision: the light. Intuition becomes our roadway; revelation our universe.

Cara Peale

What, I wonder, is reductionist about this? James, too, was interested in facts and phenomena “with no stall or pigeon-hole” and forewent the compulsion to forcibly pin it all down.
James measured high along the manic-depressive continuum with a decidedly a bipolar cast. His impulsive, Swedenborg-immersed father seems to have been wildly bipolar. In youth, James identified morbidly, at moments suicidally, with the character of Hamlet. He seems to have settled into a sort of contained hypomania during his mature, most productive years. Family-protected records pertaining to his hospitalization at McLean Hospital have never been released. One senses, nonetheless, an underlying melancholy to his work that renders it uniquely penetrating and rich. Jaspers suffered with periods of significant depression, as did our own Rollo May. One of the two finest psychotherapists Rollo ever knew, Freida Fromm-Reichmann died, Martin Buber once remarked, of a “broken heart.”

It is my opinion that humanistic psychology should itself engage in a process of philosophical refection if we as a community are to contribute meaningfully to a literature concerning diagnostics going forward. This is an enterprise that is more nearly the province of individuals (as Kierkegaard and Nietzsche long ago attested) as opposed to specializations or self-anointed cliques. (We are talking about something quite at odds with the training endeavors of “masters” or “experts,” conceptions and terms Jaspers found abhorrent. “Serviceable,” he chides ,“are those who can be trained.”) If enough of us are able and willing individually to do this, we might pick up somewhere in the vicinity where James and Jaspers suggestively left off, in the realms of rarified understandings. It is ludicrous to think that an informed rapprochement with science will somehow attenuate our humanistic stirrings or roots. Bormuth observes:

What is truly innovative about Jaspers’ psychiatric approach lies in the unusual reception of the humanities as a scholarly tradition and its application for his psychopathological method.

A methodological approach I attempted — yet again, by and large unwittingly — when writing my book. “The basic misery of human life is an existential, not a medical fact,” observes Ghaemi. Even as the unadulterated “objective look” will forever be insufficient, its wholesale avoidance no means makes us look good. “God is the sum of all possibility,” the Yiddish Nobel laureate I. B. Singer once opined, “and Time is the mechanism through which potentiality achieves sequence.” 

My father inches ever closer to death. As I write these words, he is exactly one week shy of his 95th birthday. By the time you read them, he will almost certainly be gone. (“The light gleams an instant,” observes Beckett, “then it’s night once more.”) The last decades of his life have been punctuated by long periods of excruciating suffering that have been difficult to endure or even behold; very few people are able to wholly take it in. Diagnostically, it is a near-classical instance of mixed depression that is recurrent in nature and not precisely to be found in the official manual. (Politics and zeitgeists inevitably inform science, though they are hardly one and the same.) It ought to have been treated with mood stabilizers, but antidepressants and, at last, stimulants constituted conventional psychiatry’s perseverative routine. Effective psychotherapy is often out of the question to the extent that severe underlying mood disturbance remains unaddressed. 

I tried several years back to get my aged father to take one final trip to Boston for a consultation. Nassir and I had become good friends by this point in time. He was willing to remain at the hospital, where he directed a mood disorders program late on a Friday afternoon in order to accommodate us, but I was unsuccessful in my attempt. My father insisted that he was too old to make the trip and when I pressed him further, acknowledged that he would be made anxious by a psychiatrist who likely would have quite different ideas than the one with whom he had worked for so many years, one supported by others en famille. At this point, I relented. My father had always been the family’s vicarious sufferer, a role and sensitivity, I now see clearly, underwritten in part by a biology destiny. My decision upon reflection was to accept my father’s right to suffer in his own way and on his own selfless terms. 

Movingly, my father and I have become closer through these final, often tremulous years. Our relationship is now typified by intimate expressions of affection that did not characterize its relative youth. In his Principles of Psychology, James writes reverently:

We draw new life from the heroic example. The prophet has drunk more deeply than anyone of the cup of bitterness, but his countenance is so unshaken and he speaks such mighty words of cheer that his will biomes our will, and out life is kindled at his own.

I have come to believe that my own hypersensitivity (somewhat better camouflaged now than it was in earlier times, though I discern it in my daughter with a kind of solicitous simpatico) is a variation on the theme of the same subset of features that has tormented my father during the past thirty years. In my case, it is expressed in terms of a certain predilection toward melancholy conjoined with an anxious mind rather than intemperate disturbance on an entirely different order of magnitude. (I should note that my daughter jokes that the most inexplicable thing about her father is his hilarity. “One must not think slightingly of the paradoxical,” writes Kierkegaard, who published at times, intriguingly, under the pseudonym Hilarius Bookbinder, “for paradox is the source of the thinker’s passion, and the thinker without paradox is like a lover without feeling — a paltry mediocrity.”) Temperament, research suggests, is about 50% attributable to genetics — another empirical finding humanistic psychology generally overlooks in its inattention to matters of biology. I have given more than a little thought over the years as to why I often feel estranged even among existentially inclined practitioners and why also I often feel I have something singular to say. On this score, Kierkegaard observes that the collective’s predicament is like someone “who is traveling to regain [her or] his health: always one station behind.” We need our outsiders and mood disorders; this is really my point.

In the final paragraph of Psychology, The Briefer Course, James points wisely toward an enlightened incorporation of science and transcendence:

When, then, we talk of “psychology as a natural science,” we must not assume that that means a sort of psychology that stands at last on solid ground. It means just the reverse; it means a psychology particularly fragile, and into which waters of metaphysical criticism leak at every joint, a psychology all of whose elementary assumptions and data must be reconsidered in wider connections and translated into other terms.

From such lofty observation points, both scientists and metaphysically inclined psychologists and philosophers might one day join forces in bringing our corresponding epistemologies and methods to the next level of awareness. James concludes his book by anticipating the radical empiricists to come with inspired yet humble words:

When they do come . . . the necessities of the case will make them ‘metaphysical.’ Meanwhile the best way in which we can facilitate their advent is to understand how great is the darkness . . . and never to forget that the natural-science assumptions with which we started are provisional and revisable things.

We are foolish to remain preoccupied with paradigms that are circumscribed simply because finer understanding is difficult, complex, even elusive (“Try to get a living by the Truth,” Melville had written to Hawthorne, “and go to the Soup Societies.” Melville knew this from first-hand experience. His novel Pierre, or the Ambiguities cost him both fame and financial success. By the time of his death, newspaper obituaries had to remind readers who he was.) I have tried here to gently urge humanistic psychologists into engagement with critical themes. To look away is surely to do a disservice to our forebears, nor would the world’s fate be enhanced. In the 21st century, it ought to be possible to speak of a turned-on empirical science and yet, as Melville said also, “speak for the heart.” This would be science as its most esoteric, gnostic science. Expressed musically, we would be entering the Third Stream and honoring the late, great Gunther Schuller. 

But this would be another essay entirely . . .

References:

Bormuth, M. (2006). Life conduct in modern times: Karl Jaspers and psychoanalysis. New York, NY: Springer.

Bormuth, M. (Ed.) (2019). Karl Jaspers: Leben als Grenzsituation—Eine biographie in briefen. Göttingen, Germany.

Ghaemi, N. (2013). On depression: drugs, diagnosis, and despair in the modern world. Baltimore, MD: The Johns Hopkins University Press.

Ghaemi, N. (2018). Clinical psychopharmacology: Principles and practice. New York, NY: Oxford University Press.

James, W. (1950). The principles of psychology: Vol. 1. New York, NY: Dover. 

James, W., (1960). Psychology: The briefer course. New York: NY: Harper Torchbooks.

Jaspers, K. (1951). Man in the modern age (E and C Paul, Trans.). London: Routlege & Kegan Paul Ltd.

Jaspers, K. (1997). General psychopathology, Vol.1 (P. R. McHugh, Ed.; J. Hoenig and M. W. Hamilton, Trans.) Baltimore, MD: The Johns Hopkins University Press.

Jaspers, K. (1997). General psychopathology, Vol.2 (P. R. McHugh, Ed.; J. Hoenig and M. W. Hamilton, Trans.) Baltimore, MD: The Johns Hopkins University Press.

Koukopoulos, A. & Ghaemi, S. N. (2008). The primacy of mania: A reconsideration of mood disorders. European psychiatry, 24(2), 125-34.

Melville, H. (1995), Pierre, or the ambiguities. New York, NY: HarperCollins.

Mendelowitz, E. (2008). Ethics and Lao-Tzu: Intimations of character. Colorado Springs, CO: University of the Rockies Press.

Richardson, R. (Ed.), (2010). The heart of William James. Cambridge, MA: Harvard University Press.

Silverman, M. E., Murray, T. J., & Bryan, C. S. (Eds.) (2003). The quotable Osler. Philadelphia, PA: American College of Physicians.

Taylor, (E. Ed.), (1982). William James on Exceptional mental states: The 1896 Lowell lectures. New York, NY: Charles Scribner’s Sons.