I - Experiential Psychopathology
Experience is all that an organism (individual, family or society) has been subject to or undergone in life. In the organism that we meet today is found the end result of the whole of its experience until now, beneficial and harmful. Here the view is held that all psychopathology arises from harmful experience – hence experiential psychopathology.
Experiential psychopathology regards psychopathology as having arisen from harmful experience – all the harmful events the organism has been subject to or undergone in life.
Experiences are seen in actual, real terms, as they occurred to the organism and not as assumed to occur by someone else at the time or later. Translation into any other than real terms is not required. The only truth is the event as it occurred. Events must not be fancied, manufactured, or distorted. Symbolic meanings cannot replace facts. It follows that no weight is given to schools of thought which rely on the translation and interpretation of events in the light of accumulated and stereotyping dogma. Truth cannot be limited in this way. To reveal, clarify, describe, is permissible, but to translate into other terms is distorting. Harvey (1) repeated the saying of his teacher, Fabricius, “Let all reasoning be silent when experience gainsays its conclusions”.
The events to which an organism can be subject are legion. Every possible event can be met by any organism. However, so infinite are the possibilities that it would be extraordinary if any two organisms were to meet the same two sets of events. Thus an organism has to be understood against the background of its own unique experience. That is its life experience. Most organisms meet predictable common events; some meet the unusual; some meet both.
The possible combination of events is infinite. Thus variation is great. To expect that all combinations of circumstances can be covered by a few well described situations, even if fanciful and intriguing, serves merely to limit the truth and produce dogma. Experiential psychopathology allows a new beinning in the understanding of the disorders of psyche; it implies starting from a tabular as and relying on careful observation, deduction, and experimental verification.
Experience must not be confused with the process of learning. Learning is concerned with specific data, is deliberately acquired, formal, guided, regulated, and only a part of experience. Experience is concerned with general data, is unsought, often informal, often unregulated, not always discerned, and includes learning. Each is important. But experience would be limited if regarded only as learning.
The family moves through its experience and sends of epitomes of itself, individuals, to found new families, and both individual and family are significant organisms within another and larger organism, society. Thus we must take account of the experiential psychopathology of each, individual, family and society. Each is equally significant as a phenomenon, but in clinical practice there are operational advantages in taking the family as the functional unit.
The Basic Psychopathological Process
The psychopathological process is understood in terms of the experiential process – all the adverse events the organism has undergone in its life experience. A “process” is defined as “a continuous series of events”.
The organism is either an individual, a family or society. The organism is especially vulnerable to adverse events in its early history and early damage will influence subsequent reactions to events.
The fundamental need of the organism (individual, family or society) is to function harmoniously; harmony results from conformity with the biological rules or “cosmic plan”. This harmonious functioning can be disrupted by a number of agents, noxious or harmful agents, physical and psychic, acting on the fabric of the organism – either psyche or soma, or both. For its defence the organism employs a number of coping devices against the noci-vectors.
If the coping devices are only partly adequate or fail there is a resulting dysfunction, morbid process, which may or may not be appreciated by the organism. The morbid process reveals itself by indicators; if only the organism is aware of these, they are termed symptoms, but if they are apparent to others as well, they are terms signs.
The psychopathological process is an amalgam of the psychic nocit-vector, the coping mechanism of the psyche, its damaged fabric and the indicators of this damage.
A purely psychically based medicine is as valueless as is a purely organically based medicine. A holistic approach is alone acceptable. Therefore the fabric of the organism must be conceived as a whole – soma and psyche, and the impact of disruptive agents considered as they apply to both. Thus we have to practice a medicine of the whole psychic and somatic entity – psychosomatiatria – and in the case of an individual, pananthropic medicine (healing of the whole man). However, the effects of physical noxious agents are so adequately covered in medical texts as not to need discussion here. The emphasis will be on the effect of psychic, rather than physical, disruptive agents. Thus, we consider the effects of psychic noci-vectors (psychic – from psychic source; noci – harmful; vector – a force with direction) on the somato-psychic organisms – Individual, Family and Society.
A “vector” is a force with direction. “Noci” indicates its harmful, adverse, damaging, noxious nature. “Psychic” displays that it arises from a psychic or emotive source. The adverse effect of a psychic noci-vector on an organism is felt throughout that organism, both in its somatic and psychic parts; a psychic noxious event can as readily produce migraine as it can anxiety.
Here is an example of a powerful psychic noci-vector operating on an individual organism: After intercourse a husband says to his wife, “I did not have an orgasm because I am saving it for someone else”. One might expect a marked physical and psychic hurt reaction from the wife; she could be expected to be sick, angry, tearful, miserable. A reverse vector, and a beneficial one, might be as follows: A husband sitting on a settee says to his wife, “I think I shall always sit on this settee rather than on a chair, then I can always have you close to me”. The wife might be expected to glow, physically and emotionally with pleasure.
Psychic noci-vectors can be actual or threatened. The psyche has the endowed property of anticipation and can maintain itself in a state of anxiety while anticipating stress. The psyche of the individual or the group also has the property of imagination and can thus set up internal stresses that can be damaging.
The essential nature of communication is as follows: Organism A conveys a meaning to Organism B and this alters the relationship between them. The meaning conveyed may have varying degrees of acceptance by B, depending on its degree of beneficiality; it may also convey varying degrees of harmfulness. In psychopathology we are concerned with harmful communication. What has been described is the simplest interaction. Normally B reciprocates and a continuous process of communication is initiated which continues for varying periods.
In the above we have considered only two psychic organisms, A and B. Interactions may be more complex. A and B may be groups of people, e.g. families interacting with families. Again, A and B may be psychic organisms within a number of organisms and a complex psychic pattern of communication occurs among all the protagonists – a transaction. In this transaction the fortunes of A, or any other psychic organism, can fluctuate from moment to moment; at one instant a number of psychic sources collectively convey pleasant meanings, at another they band together to convey hurtful meanings. The meanings may even be contradictory.
Communication, then, is a complex pattern of transactions. Benevolent communication leads to harmonious functioning in the recipient. Malevolent communication leads to malfunctioning in the recipient. This applies to any organism – individual, family, society, or group within society.
The psychic part of the organism during its experience acquires attitudes, as explained previously. An attitude, with its related beliefs, myths, interests and values, is to assume an opinion in relation to an object of thought, i.e. to endow an object with qualities. These qualities can often be graded in opposites, e.g. love at one extreme and hate at the other. It is also possible to make a scale of degree, e.g. much love, some love, neutral, some hate, much hate. These attitudes or opinions dictate the meanings conveyed to other psychic objects. At the receiving end they may be acceptable. On the other hand they may be so unacceptable as to do considerable damage; in this event they constitute psychic noci-vectors. An attitude cannot be separated from its context, e.g. in one setting an individual may feel strong hate towards one person, but convey love to another person in the same setting. The term “vector” takes account of the attitude as a force and its directive quality.
In estimating the effect of a psychic noci-vector a number of factors have to be taken into account. These will be briefly described. They are concerned with source, meaning, conveyance, dynamic qualities, vulnerabi8lity, latent period and restitution factors. The chapter will conclude with some illustrations of psychic noci-vectors.
Psychic noci-vectors must come from a psychic source – individual or group psyche. An individual may be beset by forces from others within the family as individuals, or groups of individuals, and from individuals and groups within society. A family can be beset by individuals within the family, or individuals or groups of people outside the family. Society can be beset by individuals or families or groups of people within society.
As the family is the basic unit in society, it is of special importance. It is the unit within which the founders of new basic units, families, are forged. Psychic noci-vectors from the preceding families can do great damage to the functioning of the present family. Again, psychic noci-vectors in the present family can do great damage to the epitome of itself which it sends forth into the future to found new families. Within the family are the closest interactions, those that last longest, the most significant and intense, and those likely to be reinforced again and again through time. A family can produce the most benevolent of vectors and at the same time the most malevolent.
All psychic organisms possess the capacity of imagination. New thoughts can be generated out of the raw material of the psyche. These thoughts need not be expressed, but they can be altered according to immediate experience. There is a capacity to anticipate attack, even to exaggerate or diminish the force of probably attack, and to visualise its results. Thus people as individuals, or as groups, are prone to worry. Such thoughts can become psychic noci-vectors themselves. Thus there is attack from within – intra-psychic trauma. A possible setback is assumed to happen although it may never happen. It may be exaggerated. The event may show that it could not have happened, or was not as disastrous as expected. People “worry before it happens” or “jump their fences before they come to them”. People or groups made insecure by previous experience are especially prone to anticipate stress. Thus, this state of anticipatory anxiety is to some extent manufactured. Others are in an expectant state, a state of tension, because of the anticipation of real stress.
The effect of a communication is dependent on the meaning conveyed. The recipient interprets from the message the attitude of the other party on the point at issue. The attitude may be for or against him and vary greatly in its quality. The meaning may be open or overt, e.g. fear of being dropped or a threat of aggression; or hidden and covert, e.g. a husband becomes greatly anxious when his wife is giving birth because of the loss of his mother during his sister’s birth. The recipient may even be unaware of the source of anxiety. It may be simple or subtle and in the latter event take on the character of a hint, innuendo, implication, insinuation or intimation. Again, some vectors of low threshold value may not reach the awareness of the recipient – subliminal trauma. The message cannot be separated from its context, e.g. in one situation an exclamation conveys joy and in another alarm. The same word or act may be interpreted as friendly by one person, while another person in the same setting sees it as hostile; the interpretation depends upon the meaning to that person or group and this is dependent on a host of factors such as previous experience, vulnerability, age, etc.
Meanings can be conveyed to others by the absence of action, e.g. not to send a birthday card to one’s child may be as significant as to have done something hurtful. Again, parents may not tell their children that sex is taboo, but the absence of discussion conveys the same meaning. Dylan Thomas relates in “Under Milk Wood” how the prostitute passes the women gabbling at the village pump and how she senses their hostility “by the noise of the hush”. These negative noci-vectors may escape the on-looker. What is inappropriately not said is as vital as what is said.
Some physical vectors, though immense in power, may have little effect on individuals or groups. Physical or material lack have no effect unless they injure the psychic worth of the person, e.g. economic status may be important because the grandparents demand it and without it the image of self suffers, or because it leads to psychic stress, e.g. poverty may mean continual personal degradation, disturbing neighbours, etc. Physical hazards may even be advantageous to the psyche; external hazards such as earthquakes, floods, forced migration, persecution, war, may have the result of bringing people together so that the quality of communication actually improves.
Psychic noci-vectors may be contradictory, i.e. the same psychic source may emit simultaneously two or more messages with conflicting meanings. Or the conflicting, or different, messages may come from a number of sources. The organism, as will be seen later, can cope with such contradictions up to its own capacity.
Psychic noci-vectors are communicated, as with any vector, through the five senses. The commonest avenue is through speech. Verbal symbols have meaning which is conveyed to others in this economical fashion. But non-verbal communication can be equally compelling. Sometimes a composite message is conveyed by an amalgam of the five senses, or by combined verbal and non-verbal behaviour. Very subtle messages can be conveyed in this fashion. Within a family, economy of expression takes place over time and much can be conveyed by grunts, mannerisms, affectation of speech, gesture, etc.; these meanings may not be apparent to those outside the family circle until they become attuned to them. Fortunately, most people and families talk about the same things in the same way.
A noci-vector can have varying degrees of strength or intensity. Effect depends on a number of factors, but given a certain degree of vulnerability or sensitivity in the recipient, the greater the strength of the vector, the greater the effect. The use of strength is sometimes calculated by the sender so as to produce a wanted degree of effect. Often the vector is not under control and no calculation made of the probable effect, indeed there may be surprise at the effect created.
Communications may occur once or be repeated a number of times. The latter probably brings a considerable accumulation of effect. Once a vulnerability has been established, repetition of the same psychic noci-vector brings increasing damage; repetition even after the gap of years can still bring a response.
The number of psychic noci-vectors must be taken into account. There is probably a limit to the number of sources to which an organism can pay simultaneous attention; knowledge about this is least exact with respect to families and social groups. It seems that an individual can only pay attention to five or six other people at one time. Groups over about seven in number begin to fragment – this happens also to large families. Thus, an individual can be traumatised by up to seven noxious agents but beyond that number he has difficulty in conceptualising individuals as individuals. Another related limiting factor is that of span of attention; it is difficult to pay attention for long periods of time without reaching a point of exhaustion.
The programme of attack and reaction may pass through a sequence. It may escalate to the point of exhaustion on either side, or until another factor intervenes. A husband reacts to being ignored by aggression; the wife reacts to aggression by withdrawal; wife is upset and ignores husband; he becomes hostile; wife withdraws; husband’s hostility increases and wife withdraws further; as the situation escalates, a point is reached when wife looks like a rejected, deprived child; a new factor now appears – the husband identifies himself with this deprived child, the child he was long ago; his hostility turns to tenderness and the vicious circle is broken.
The psychic noci-vector may operate over a short or long period of time. Time is an element that has tended to be underestimated. In the past much attention has been given in psychopathology to the nuclear incident – one devastating incident at one moment in time. Significance has to be given not only to the acute stress, but also to a long-drawn-out sustained stress. To the former there is considerable, but not complex, capacity to adjust; all the adjustment mechanisms are urgently brought into action. But for the latter the capacity to adjust is much less, for the threshold of coping may not be reached, and the adjustment may not take place. Time, therefore, is a significant factor and the experience may be stamped into the psychic organism, making eradication difficult.
To pinpoint the momentin time when a psychic noci-vector was operating may be of great value in diagnosis for it may supply a clue as to the nature of the psychic noci-vector, e.g. abdominal pain at breakfast on each school morning, and never at weekends or in the holiday period, implies a relationship between school and the abdominal pain. The more obvious the indicator, usually the easier it is to make the association.
Vulnerability is general or specific. Some situations would cause trauma to most people – e.g. a new, unfamiliar situation. It can also be specific due to a number of reasons. There may be a constitutional weakness, e.g. of intelligence, that might make understanding difficult. Again, the sender of the message may have special significance to the recipient and this would make the latter vulnerable. Or, the recipient may have developed over time a susceptibility to that type of stress; in the case of a family member this may be dependent on experience in his preceding family, which not only subjected him to that experience but did not allow the appropriate coping mechanism to develop. Time may have reinforced a vulnerability. For example, a child’s lack of social confidence springs from the family’s inability to encourage him in his first social situations; the family then encourages him to avoid social situations; it reinforces his anxiety over the years; thus lack of social confidence is maintained and he is now vulnerable to the stress of social exposure.
Age of the recipient is a factor that influences the effect of a psychic noci-vector because it influences the capacity to give meaning.
A young child has a brief memory span; it is not clear how much can be retained in the first few months. This may be a biological protection to see the child through the trauma of birth. Later, as the cerebral centres develop, the capacity for memory increases. Thus after about the age of two the sensitivity to psychic noci-vectors increases. There is evidence that early memories can have far-reaching effect on behaviour, e.g. aversions to types of food laid down in the early years last a lifetime. Early experiences that dictate early reactions may influence later behaviour because, at an early age, they are the raw material of behaviour for that person. However, the young are also protected, especially in the early months. A child’s intelligence grows only with the years and a child does not develop the capacity for abstract thinking until about eight to ten years; thus the more subtle attacks on him may not have meaning. The child has the quality of “innocence” too, i.e. he can react in an open unbiased way, if allowed to do so, as he has yet no inbuilt prejudices. It is a calamitous mistake to assume that the child’s mind behaves and reacts like the adult’s mind. This is an important area, capable of elucidation by careful experiment; it is no longer necessary to rely on speculation in this field, which has benefited greatly from the work of developmental psychologists.
In the senium, again, the results of age may need to be taken into account; the memory span decreases, intelligence wanes and abstract thinking becomes more difficult. Recent events, in particular, are quickly forgotten. But the sway of inbuilt prejudices is great.
A psychic noci-vector may appear to have had no effect because there is a latent period between the action and its result. This may be due to a number of reasons: (i) There is a state of shock – it can be seen in bereavement, for instance. (ii) The event may call for immediate action and thus attention is given to this and there is not time to work out the meaning of the event. Later, when the emergency is over, the meaning of the event becomes apparent and its effect shows itself. (iii) When the effect is somatic, it may take the organ concerned time to show evident signs of damage, e.g. a woman quarrels with the neighbour, but the swelling in her neck, due to the reaction of her thyroid gland, is only apparent many days later. Thus, the connection between the stress and its effect may be lost. To be able to tie the indicators of stress to an event is of great value diagnostically.
Psychic noci-vectors may be counteracted by chance restitution factors. For instance, a foreman becomes antagonistic to a man at his work. The man reacts by anxiety, yet he cannot take the obvious step of finding alternative employment. His anxiety increases. He becomes ill. He loses his job because of his absences. He now has to take another job and does so with marked improvement in himself. Thus chance operates to counteract noci-vectors. Examples of restitution factors include – marriage to a compatible partner, death of hurtful parents, loss of harmful husband, a new teacher, change of neighbours, a pleasant playmate, etc. One of the aims of vector therapy is to systematise the deployment of restitution factors, which are then not left to chance.
Some psychic noci-vectors may be shared by a number of people – there are hazards common to all – e.g. failure to have children; undertaking a pioneer role with consequent colleague and social antagonism; children leaving home with consequent adjustments; death of a spouse or child or relative; denial of intercourse because of physical defects; separation due to war service; relating own experiences as a child to the nurturing of one’s own children; illegitimate births; loneliness of old age; hospitalisation of spouse or child; problems of accepting new developmental roles; cultural clashes, etc. All these are common hazards, and ability to cope does not appear to be due so much to the strength of the stress as to having developed a right attitude in the past – usually in the preceding family. A sign of good psychic health is the capacity to adjust to life’s inevitable hazards.
A few of an infinite number of examples of psychic harmful interactions would be:
|Intra-psychic||Guilt at illegitimate birth of a child; fear of pregnancy|
|Spouse-spouse||Retirement of and therefore prolonged contact with a disliked spouse; intervention of a third party in marriage; disparagement by spouse.|
|Parent-child||Rejection and lack of love; blame for any lack of achievement; depreciation of child’s worth.|
|Sibling-sibling||Birth of an unwanted rival; rivalry for parental affection.|
|Group conflict||Mother and sisters accept a new child; father and brothers reject it.|
|Family-society||Employer using his position to make sexual advances; working under a father who is antagonistic; angry teacher; teasing by schoolmates; critical neighbour.|
Attitudes are conveyed in ordinary but often devastating phrases, such as : “Don’t do that”; “Go to bed, for heaven’s sake”; “Take that”; “You were wrong there”; “You won’t go to heaven”; “God doesn’t like that”; “If you don’t do this, then . . . “; “You don’t like me”; “I hate you”; “At one time you were so good”; “You are 100% selfish”; “Keep quiet or else”; “If you do that, you will upset your mother”; “Don’t ask any questions but do as you are told”; to a plump girl – “You must be attending slimming classes”; to any middle-aged woman – “Your children must be quite grown up”; to anyone – “It is all your fault”; to a wife – “Other people’s homes are tidy”; “Your are ugly”; “I won’t have a child by you”; “to a husband – “I once had a smart husband”; “Everyone gets promotion but you”; “You behave like your mother”; “Go to hell”; “Don’t touch me”.
When the organism, individual or family, is under attack from psychic noci-vectors, it has to meet the attack and, if possible, contend successfully with it and defend the integrity of the “idea of self”. Thus it has to cope by the use of a number of devices or expedients to meet or attenuate the effect of the attacking agent and repair its damage. Coping involves defence, adaptation, and reparation. It is the price the organism has to pay to preserve its integrity.
The coping devices may be completely or only partly successful. If partly successful, then the organism is left with a handicap. This may be general or focal, i.e. sensitivity to any stress or to one stress only, e.g. social intercourse.
Just as the psychic noci-vectors are acquired through experience, usually within the preceding family, so too are the coping devices. The child imitates, consciously or automatically, the devices adopted by his fellow family members of any age. Sometimes by chance he comes across a device that for him, in a particular circumstance, appears to work. This will be his special device until experience causes an adjustment or change. He may use it even at times when its employment is inappropriate. Thus some of the coping devices are employed in common by many people. Others are particular to a person, stamped on him by previous experience, and become his “stock in trade”. The same applies to a family or to any larger group.
To contend with the opposition, the whole functioning of the organism may be called to action. This will include the endowment as well as the acquired aspects of the psyche. Not only does a coping device need an apparatus for its execution, but it consists of an attitude and is associated with a feeling tone or mood; mood is especially evident in the more acute and automatic reactions, e.g. aggression.
The acquired aspect of the psyche can react by use of either automatic or directed devices. The advantage of the automatic devices is that they are immediate and overwhelming. But they may be ill-directed, inappropriate, and diffuse. The automatic devices are primitive, e.g. anger and flight. The directed devices are slower, more acute, and sometimes highly sophisticated, e.g. sarcasm and carefully-thought-out acts. Animals are more dependent on automatic response and homo sapiens, on directed response.
In an acute attack, the organism may be forced to react by shock – the centres of defence become exhausted. This passive state has the advantage that the organism cannot grasp any further significance in the attack and thus its influence is reduced. Exhaustion of attention is an important merciful defence mechanism of the organism. It is likely to be reached earliest in acute trauma. In sustained trauma the threshold of exhaustion is seldom reached, hence the powerful effect of long-drawn-out stress.
The attack may be directed at one aspect only of the self and thus only a local defence is required, e.g. an attack on the person’s social status. The attack may also be directed at a number of aspects or on the whole self, e.g the statement “I hate you”.
A study of the ways by which well-adjusted people react to attack will expose devices that can be employed in therapy, e.g. forgetting is a fundamental biological coping device; yet at times in therapy we make forgetting impossible by repeated recollection of previous mishaps. Constructive phantasy, hope, is another healing device.
The use of a particular coping device may be dictated by the situation. The appropriate devices must be employed in a given situation and this may limit the choice or dictate the employment of one device, e.g. faced with a deaf-mute, a non-verbal response is essential.
The nature of the attacking agent may determine the most appropriate response; its source, the meaning conveyed, the senses used for conveyance, its dynamic qualities (strength, number, repetition, sequence), whether acute or chronic, short or sustained, the vulnerability of the organism to that trauma, and age are all elements which determine the response to stress. A source within one’s own psyche has to be handled differently from an external source. Normally the defence involves the same senses as those used by the attacking agent, but not always. Usually, the more acute and severe the trauma, the more severe and automatic the defensive response. A sustained attack calls for a sustained defence. A repetitive attack calls for a discontinuous response – with the possibility of learning the most effective response in between attacks. A number of noci-vectors may have to be met by the psyche with an equal number of defensive vectors to match them.
In a well-balanced organism, the coping devices are usually controlled, well directed, and, usually, successful. The less-balanced organism has so many weaknesses that its response may be ill-judged. Excess of anxiety leads to inattention, dithering, indecision, and even to a misunderstanding of the nature of the attack. A balanced organism may suffer considerable attack and be able to respond appropriately. For example, a loved person is lost (almost like losing a part of the self). At first there may be a stunned response with apparently little reaction; this is followed by maximum grief; this fades as reparation sets in – forgetting plays a part and there is a realistic reappraisal of the situation and a deployment of its assets. In the unbalanced, guilt, anxiety, hostility, may be superimposed on grief.
In children, the coping devices, especially the directed, tend to be simple. They get more complex with age. They are crude in simple folk and sophisticated and subtle in the intelligent, e.g. the latter may believe it is better to have an adverse decision than no decision – at least it allows of a trial operation.
Psychic noci-vectors may be contradictory. The same psychic source may emit simultaneously two or more messages having conflicting or different meanings. Or the conflicting or different messages may come from a number of sources. This can cause bewilderment in the recipient, but not madness. This occurrence is so frequent in day-to-day life that organisms quickly develop obvious ways of coping with it. Given a number of different or contradictory messages, the recipient can:
- Ignore them all, claim they show lack of agreement in the senders, and use them as an argument for following his own policy.
- Behave according to the resultant of the forces bearing on him; his behaviour may please all his assailants or none.
- Select the one message that most appeals.
- Select the message that is most compelling or strongest.
- Do nothing.
Coping involves establishing attitudes which are strongly held, these are attempts to adapt and they may clash with the attitudes of others and therefore be destructive and maintain the opposition of others. Such attitudes are difficult to change, as they are considered essential by the self as coping devices. They are easier to dissipitate if the coping becomes unnecessary, i.e. the threat is diminished and security increased. Hence in therapy it is essential to produce security, or coping devices against insecurity must continue to operate.
Examples of Coping Devices
The whole organism can be brought into action in any attack and one or many of the devices below brought into action. The devices can be divided into those that are primitive and automatic, and those that are directed.
There are three groups:
- Those involving aggression, such as verbal hostility (abuse, swearing, sarcasm, cynicism, etc.) or non-verbal (ignoring, depriving, punishing, tantrum, physical harm, homicide).
- Withdrawal in verbal terms (silence) or non-verbal (to move away, to hide, to contrive not be noticed, apathy, sleep, suicide).
- Anxiety – to be in an anticipatory state. The alarm mechanisms are kept on the alert – sometimes for a lifetime. Anxiety can be displaced on to objects, themselves harmless, which are associated by chance with the fear situation – thus phobias are created.
Any apparatus of the organism may be implicated:
Perception – any of the sensations from the five senses may be exaggerated or dulled, e.g. an inability to hear. In a state of heightened tension, meanings may be misconstrued and harmless objects regarded as the subjects of suspicion, leading to paranoid states. There may be partial or complete denial of meanings.
Memory – The normal machinery of forgetting is a healthy defence against stress and always comes into play in time. It may operate inappropriately and too early. In the process of remembering, events and meanings may be projected on to the wrong person.
Realistic Thought – Healthy reactions include apology, understanding, toleration, relating to previous experience, forgiving, diversion, avoidance and insightful rationalisation to find effective answers, rationalisation in humour.
Unrealistic Thought – Lying, attention-seeking and hysterical behaviour, attention-seeking by regression or illness, selfishness, meanness, overprotection arising from fear or guilt.
Phantasy – Daydreams, overcompensation leading to boasting, snobbery, etc., identification.
Behaviour – Overactivity (illusion of action), obsessions and compulsions (an attempt to control and predict events so that they can be anticipated), conformity, perfectionism, hypermorality, and artificial aids such as rhythmic activity, (thumbsucking), chewing gum, drugs, alcohol, excessive sexual activity.
Physical – The whole of the organic apparatus also responds protectively. Its responses may lead to psychosomatic illness – not to be confused with hysterical behaviour. In the former there is no contrived illness; it is an inevitable result of psychic trauma. In hysterical states there is a simulation of illness because of the overwhelming need of the organism to cope. Illness is a common method of avoidance and widely employed.
Damage to the Organism
Like all elements in the cosmos, human organisms – individual, family and society – are controlled by the formulas governing the universe; they are part of the “cosmic design”. One of these formulas is the need to function harmoniously. The cosmos, the universe as an ordered whole, remains imperfect and therefore the possibility of dysfunction is still an essential ingredient in it. Evolution strives to reduce dysfunction. Our developing awareness of psychic matters and our striving for psychic self-improvement are parts of this movement onwards. As the universe evolved, man developed the capacity to evaluate life experience and change it, to produce harmony. Therefore, man is driven on by a need to be harmonious and this in action is creative. This creative capacity is part of the cosmic endowment. The origin of this process, its rules and its regulation is a mystery.
Evolution affects both physical and psychic matters. Each has equal worth in the universe and, furthermore, the physical and psychic are linked. For this last reason there is value in considering psychic matters in known physical terms, as long as it is appreciated that each has in addition qualities of its own – even if at opposite ends of an elemental spectrum. Just as a caress can lead to a pleasurable physical sensation, so psychic communication can lead to a pleasurable feeling. Psychic messages are needed to satisfy the intra-psychic processes of behaviour. In the cerebrum there is a sensitive highest level functional area that can function harmoniously or unharmoniously. It seeks pleasure and harmony. It has a capacity to want this, i.e. given an equal choice of harmony or disharmony it will select the former. Possibly there is a regulator or governor, imposed by the developing plan of the universe, that works towards harmony.
The organism moves through time directed by its place in the cosmic plan; the motivation of the organism is beyond its control, it dances to the tune set for it in the pattern of things. The organism has a capacity to understand and react to situations but this capacity is the result of previous events and is thus, again, controlled by the cosmic plan.
Homeostasis, maintaining the constancy of the internal environment, is one factor in good functioning – as it is in its other sense, maintaining the balance between internal and external environments. Homeostasis, in both its meanings, is not as fundamental as the need for harmonious functioning, but it is an indication of good functioning.
The organism has an endowment of a physical and psychical apparatus, e.g. an apparatus that allows it to think, an apparatus which has a number of properties that can be developed to an optimum capacity, i.e. a determined degree of intelligence for a particular thought apparatus. The human fabric, somatic and psychic, is complex and composed of multiple, different, but linked elements. Experience acts on this endowment. Experience can be beneficial or harmful, good or adverse. As the result of experience the organism accumulates added characteristics. (“Properties” denotes the endowed entities, “characteristics” denotes the acquired entities.) If the experience is beneficial, the organism manifests indications of good functioning; if adverse, it displays indications of malfunctioning. Usually, in its imperfect state, it shows indications of both.
The fabric of the organism, be it individual, family or society, is the area on which the psychic noci-vectors operate, its most vulnerable part being its acquired characteristics. Within the fabric is found the morbid process – either organic or psychic pathology. In both the organic and psychic areas there are not only changes due to the noxious agent, but also changes due to attempts to cope with the agent, when coping devices come into play. Thus what is seen in the fabric following damage is due both to the damage caused by the noxious agent itself and to the attempt to cope with the agent; there may be great elaboration of the coping devices.
The organism is always under day-to-day fluctuating trauma, which can be neutralised, or can leave behind small blemishes, e.g. cat phobia, like a bunion, is inconvenience, but not a threat to the basic integrity of the fabric. Even so, the weakness can fare up, e.g. if a person makes a living by looking after cats, it would be a liability, or a bunion is a serious liability to a runner. Again, if a person with cat phobia married a woman who is fond of cats the strain on the relationship might be severe.
There are degrees of disability; few people are completely well and unblemished, e.g. at any time a twinge of indigestion under psychic trauma may become a stomach ulcer, perforate, and so threaten life.
Discussion will now be centred on the damaged fabric, as it affects the simplest organism, the individual, then the special aspects of family and society will be discussed.
The organism consists of a somato-psychic apparatus. This is made up of its endowment and its acquired part. The organism is subdivided into a number of systems, each of which is served by an apparatus with properties and capacities. Here we are concerned with the psychic system, the organic substratum of the brain and the other systems that serve it. The cerebrum has a number of sections with apparatus, properties and capacity; some are associated with feeling tones or moods. The general aim of the organism is laid down by the “cosmic plan” of which it is a small part.
The organic brain makes psychic functioning possible. Sensations become percepts in its reception areas by consulting previous experience held in its memory areas. Percepts can pass to the thought areas and creative and original ideas can be formulated by manipulation of new material and old material stored in the memory. Action is initiated through the motor areas. This endowed machinery can be damaged. Intoxicants can disorganise it. (So, in the author’s belief can the agent responsible for encephaloataxia, where the agent strikes at the endowed machinery of thought.) The “higher” properties of thought, imagination and creativity, transcend local areas and require the activity of a number of areas. The ultimate awareness of activity in a feeling tone is termed a mood; some moods are direct and easy to interpret, but others are mixed, complex, and difficult to describe.
The endowment interacts with the environment and through experience develops a number of acquired characteristics, e.g. attitudes (including a central “idea of self”), character, temperament, knowledge, etc. It is this acquired part of the organism which is predominantly damaged by adverse psychic experience.
Some attitudes are complex in that they are composites of a number of basic attitudes. One blends with another to form a composite attitude and this then blends with another basic or composite attitude to form yet another. The basic English vocabulary is of about 1,000 words, only some of which are verbs. The number of basic attitudes that can be covered by these words are few, but they are still sufficient to describe adequately the fundamental attitudes. Blending of attitudes leads to the use of more elaborate words. Exact words must be distinguished from those used merely to hide attitudes; anxiety is a great coiner of abstruse words, as they make the best smokescreen. Basic attitudes are the raw material of society and the produce of experience over time; these attitudes are available to families and individuals. We must differentiate an attitude from mood, e.g. to be aggressive towards someone and the mood of feeling angry. The damaged “idea of self” may set up wrong attitudes in an attempt to cope. These may aggravate the situation by provoking the attacker to strike again.
The “idea of self” is acquired over time due to the interaction of the endowed psyche with the environment. This interaction produces the acquired aspect of the psyche. It is this “idea of self”, built up layer by layer in its many aspects through experience over time, which is attacked by opposing attitudes. The “idea of self” is a summation of attitudes – ideas, beliefs, interests, values, conscience, character. It is complex and has many elements, all of which can be damaged. Some elements are fundamental and important, e.g. notion of self worth. Some are less important, e.g. the notion that one has very good hearing. Any aspect or the whole can be attacked and damaged.
People are hugely concerned to meet “nice” people. A “nice” person is he or she who does not antagonise the “idea of self”, or, better still, actively supports it by praise, encouragement, appreciation, etc. “To be liked” is very important to people. A great deal of effort in social intercourse goes into establishing whether others are “nice’” or “nasty”, for or against one, a support or a threat. A clash of attitudes leads to dislike and antagonism. Appreciation comes from others and thus there is a need for companionship, “belonging” and acceptance.
In a damaging interaction, the sequence of events is as follows:
Psychic noci-vector → awareness of attack (sometimes) → insecurity → attempts at coping → if failure to cope → damage. The chances produced by this total process – psychic noci-vector, damage, and coping – are what the subject notices in himself – symptoms, and what an observer can perceive – signs; these changes are termed indicators and include both signs and symptoms.
Why is there a need to attack? Attack is dictated by a clash between the attitudes held by the protagonist and attitudes believed or known to be held by the antagonist. Disagreement is often mutual. The incompatibility may be very basic and hidden behind superimposed and secondary disagreements. The basic clashing attitudes can be strongly held and have been created by lengthy exposure to experience in the past. The more basic attitudes are created within the family – usually the preceding families. The epitomes of the preceding families come into the present family with strongly held attitudes (sometimes amounting to strong needs – “I need to be loved”, “I need to be protected”).
Attitudes are expressed in the present family and may clash with those of the spouse, if he has equally strongly held but opposing attitudes. Children too, in the present family, soon come to adopt strong attitudes, e.g. “I need mother to love me”. But if father holds the view, “I need all my wife’s attention, as my mother gave me none”, then there is an inevitable clash between father and child. Some of the attitudes are carried down the generations (we have yet to work out all the rules that govern this).
The attack may be aimed at one aspect or the whole of the “idea of self” of the antagonist. The one aspect is selected because:
- It is the attitude of the “idea of self” of the antagonist which aggravates the protagonist most.
- Attitudes of the “idea of self” known to be weaknesses may be selected because of their vulnerability.
The attack arouses insecurity and attempts to cope. The attempts to cope will meet with complete, varying, or no success, depending on circumstances. If the attack is acute, the coping will be assisted by the automatic arousal of mood, e.g. anger or fear. A more insidious attack is less likely to arouse mood. The response may be automatic at the behest of mood. The advantage of this primitive response is that it is automatic, quick, and massive. It also has dangers in not being guided by forethought. Sometimes to interpret the aroused mood may be difficult as a number of conflicting moods may be aroused or they may be mixed and complex. A young woman finds herself unexpectedly pregnant and she may experience a number of moods: “I have done wrong” – guilt; “He imposed this on me” – anger; “Can I manage?” – anxiety. Thus, she may well say, “I don’t know what I feel”. Due to previous experience, people differ in the capacity for arousal of mood, which may vary from excessive arousal to lack of it. More often, thought takes over and directs the coping efforts, of which there are many. If the possibility of further attack persists, then the psyche remains in a state of expectant fear – anxiety.
Damage may be completely repaired, partially repaired, or permanent – unless contrary experiences eradicate it (a sudden loss of confidence may be repaired almost at once by sustained praise and encouragement by an ally).
If there is a failure in coping, then there will be damage to an aspect or aspects or the whole “idea of self”, e.g. : (i) Depreciation of the value of self, “I am unworthy”, leaves a mood of depression (which can be mixed with other moods, e.g. anger or anxiety at the same time). (ii) The thought that the self is to blame arouses a mood of guilt. (iii) That the “idea of self” is utterly worthless, “I cannot live with myself”, leads to the action of self-destruction, either by a negative act of not protecting the self, or by positive destruction of self (suicide can go hand in hand with other attitudes – to be a martyr, to arouse attention, to punish others).
The counterpart of damage to one aspect of the “idea of self” in the organic part of the person would be damage to one organ. The counterpart of damage to the whole “idea of self” in the organic part of the person would be damage to the whole body. Death of the body is the counterpart of complete loss of the “idea of self”; they coincide. Damage to the “idea of self” is the essence of psychonosis, i.e. damage to the acquired part of the psyche primarily (in encephalonosis, including encephaloataxia, damage is to the cerebral apparatus of psyche – i.e. the endowed part).
Aspects of the “idea of self” may be vulnerable to special stimuli. These vulnerable areas have been produced in the past. There may be no awareness of them. They may not be adversely stimulated for long periods of time. Children are very susceptible to damage. This may handicap them in basic functions for the rest of their lives, e.g. abilities to express love to another, to have intercourse with a spouse, to parent children, to relate to people, etc, i.e. from damage and from coping have arisen attitudes which hamper these basic functions.
Severe emotional trauma leads to damage which is at once manifest in a number of ways: (i) The damage may be severe enough to allow the use of the words “shock” or “stupor”. (ii) The coping mechanism must come to the fore and this negatesmore constructive efforts in our activities. (iii)There is the experience of an unpleasant mood, e.g. anguish, anxiety, depression, guilt. (iv) Organic functions and apparatus may also dysfunction. (v) The “idea of self” suffers damage.
Long-drawn-out engagements may produce an escalation of coping and damage. The engagements may only cease after exhaustion on one or both sides. The coping devices, physical and psychic, tire, thought tires of producing more countering arguments, the centres of mood are completely discharged, and the damage done demands a respite.
The physical response of the body is automatic, although it may be influenced by previous experience. Some responses are coping devices – the action of brain centres, the autonomic nervous system and the hormonal pattern as a reaction to aggression and fear – to help fight or to aid flight. Primitive mechanisms prepare the person for either. With both there is an accompanying mood. Secondary ill effects can develop from using this machinery excessively. These ill effects may be local. The local response may be determined by a weakness in a particular system, which has been produced by previous psychic experience involving it, or by organic weakness, e.g. an existing arthritis gets worse. A local response may also carry the full weight of an idea, i.e. cerebral mechanisms may dictate a small lesion at a particular highly meaningful point, for example, blush associated with shame. In addition to the acute reactions, chronic stimulation over a long time can also have its physical counterpart – no psychic condition is free from a reflection in the physical sphere.
So close is the tie between the acquired and the endowed physical apparatus of psyche, the cerebrum and the nervous system, that damage to the acquired part is reflected in bodily change also. A depressed person shows physical changes – pale skin, lifeless facies, flaccid limbs, constipation and slow pulse (unless there is concomitant anxiety). Acute fear may cause perforation of the stomach, or the hair to turn white or voiding of urine. The physical change in a person may belie his insistence that he has no problems. Again, we see the need to practise a medicine of the whole man and to assess the physical condition of a psychonotic sufferer.
Here is an example of a traumatic exchange. The analysis of a brief statement by a daughter concerning a quarrel with her father a few minutes before displays how, on both sides, the attack is directed at the “idea of self” (both father and daughter are present in the interview):
Therapist: What happened in the last hour then?
Daughter: He was being 100% selfish. Driving along, he wouldn’t let me open the window. He had the heating full on and I was suffocating and I was very tired. He swore at me and called me a yob and God knows what, because I wanted the window open.
Father’s attack on daughter during quarrel:
He would not open window — i.e. would not listen as she is unimportant
- attacks her notion within her “idea of self” that she ought to be loved by father.
He kept the heating one — i.e. he is overbearing – he attacks her notion of adulthood within her “idea of self”.
He swore at her — i.e. he debases her – attacks her notion of adequacy and self respect within her “idea of self”.
He calls her a yob — i.e. he makes her feel inferior – attacks her notion of self respect within her “idea of self”.
Summary: He is aggressive, both verbally and non-verbally. His mood is of anger.
Daughter’s attack on father during interview:
He was selfish — i.e. attack on the altruistic notions within his “idea of self”.
He would not let me open the window — i.e. he is unreasonable – attacks his notions of a responsible adult within his “idea of self”.
He had the heating full on — i.e. again unreasonable, as above
He swore at me — i.e. he uses bad language – attacks his notion of fairmindedness and rational notions within his “idea of self”.
He called me a yob — i.e. he is unfatherly – attacks his notion of fair play towards adolescents within his “idea of self”.
Summary: She retaliates after the event, she is verbally aggressive and hostile. Her mood is of anger. She conveys attack in two ways: (i) directly, and (ii) in statements of fact which carry implications of criticism.
Conclusion: Father attacks her during quarrel. She attacks him during interview. Both are aggressive and hostile and hurl hurtful attitudes at the other aimed at damaging the acq2uired “idea of self” of the other. The mood of both is anger.
The present exchange points also to the basic attitudes from which they spring. He dislikes her as a rival for the mother’s affection. She fears him because of his continual attacks on her. At this moment she is stung into attack and hopes that in the presence of the therapist father is less likely to retaliate.
The fabric of the family must be briefly described before consideration is given to its damage, additional to that of the individual, by the psychic noci-vectors.
The family is a somato-psychic entity derived from somato-psychic fragments of preceding family entities. The endowed organic part consists of its individual members together with its collective possessions. Its endowed psychic part includes a cerebral apparatus in a number of individuals, which, collectively, allows of rapid communication amongst its members. Meanings are conveyed, percepts are formed, memory is consulted, thoughts are conceived and fresh ideas flow out through the motor systems, both to other family members and to the external world. The collective apparatus has a number of feeling tones – more complete and diverse than in the individual and more often an amalgam of feelings.
The family system continually changes due to interaction within itself and interaction with the environment outside. Thus, it acquires general characteristics – knowledge, attitudes (beliefs, values, interests), character, conscience, temperament, aims, skills, role playing, control and decision-making machinery, arrangement and climate.
The psychic noci-vectors can be aimed at any aspect of the integrated structure of the family. There is awareness of attack, insecurity is created, there is an attempt to cope and its failure leads to damage of some aspect of the family fabric. The family differs from the individual in that the structure is looser and there can be conflict, giving rise to noci-vectors, between elements in the family. Frequently, the noci-vectors arise from clashing attitudes brought by family members from preceding families.
The “idea of self” is built up by the family over time and is a complex summation of characteristics – ideas, beliefs, interests, values, conscience, character, temperament. Any of these can be damaged. Roles may change, the controlling and decision-making machinery may fail or weaken, integration is lost, conflict is increased and the climate becomes tense, traumatic or hostile.
The threat of attack causes insecurity – long-drawn-out insecurity produces continual anxiety and tension; the whole family, or fragments of it, await renewed attack. Strong moods are generated – of guilt, anger, and fear. Shock may be the initial reaction. Efficiency, harmony, confidence and cohesion are lost. Fragmentation may occur and finally the family may break up completely.
Not only does the psychic part of the family react, but so does the somatic. Somatic illness springs up in various parts of the whole – in individuals or dyads or sub-groups. Sometimes the whole family is affected. The expression of the somatic illness may change its locus as the dynamics change – indeed therapeutic intervention on a locus often merely moves the somatic disorder to another part of the family.
Family members involved in a pathological family process become a part of it and, as epitomes of the family, move on to produce potentially pathological families in the future.
Society, like the family and individual, is a somato-psychic organism. The somatic aspect consists of all individuals, families and groups within it together with its material possessions. The psychic endowment consists of the collective cerebral endowment of all its constituent parts together with the complex pattern of interaction between its multitudinous parts. Over time, like the family group, it has acquired an immense superstructure of attitudes, etc. It is this superstructure which is vulnerable to psychic trauma.
From the interaction of its parts – ethnic groups, political groups, families, individuals – can arise many areas of conflict producing potent psychic noci-vectors that threaten and harm it and its constituent parts. Society has yet to achieve the harmony which would fulfil the master plan devised for it. It has yet to find the correct pattern of functioning. Its parts are disharmonious and thus conflict and noxious vectors are inevitable. It has been especially unable to understand and control its psychic aspect.
Society is nearly always understood in economic, or material, or geographical terms. But the underlying psychic implications go unevaluated. Selfishness must lead to irresponsibility, “playing the market”, and economic crisis. The crisis is studied, its toll in money is compounded, but its psychic origin remains overlooked. Hurt pride leads to a desire for revenge and self-expression which in turn can lead to war. As important as the statistics of wasted finance, the number of dead, and the economic consequences is the need to evaluate the psychic origin of war.
Society’s psychopathology is essentially similar to psychopathology in the family. Any facet of society can be damaged. The noxious vectors may or may not be perceived. Insecurity is created. Attempts at coping are made and if they fail there is damage to some facet of society or to the whole of it. The controlling and decision-making machinery may fail, perverse roles are created, e.g. the Inquisition, McCarthyism, etc., integration is lost, conflict increases, and the climate becomes tense, hostile, and traumatic. Continual threats provoke anxiety and tension. Strong moods are generated. Efficiency, confidence, harmony and cohesion are lost. Fragmentation leading to warring factions may be a feature. Finally, the whole society may disintegrate and perish. On a small scale, the impact of so-called “modern” or “developed” society on a different society, e.g. the Australian Aborigines, is a violent illustration of multiple, noxious, clashing vectors on a hitherto fairly harmonious society.
As in families and individuals, the somatic and material aspects of society are involved in the pathological process. The level of physical ill-health is one index of social pathology.
Naturally, the state of society is transferred to its constituent parts – its groups, families and individuals. To understand and improve social pathology is a fundamental way of improving the state of families and individuals. Hence the importance of creating a salutiferous society.
Conflict is not damage. But it can lead to damage as trauma can arise from it. Conflict is a clash or difference between two attitudes. It can arise in a number of ways:
- Conflict of attitudes within one person – “to steal or to be honest”.
- Conflict between two desirable alternatives.
- Conflict between attitudes held by two person – “I want children. You don’t want children”.
- Contradictory attitudes conveyed from one person to another - “I love you. I hate you”.
Guilt is especially likely to occur in people of strong moral convictions when their actions are in contradiction to those ideals. Damage is done to the moral aspect of the “idea of self”. There is an attitude of “I am blameworthy, I should be ashamed” and a mood of guilt. The feeling of being wrong may be so great that it cannot be tolerated: “Such an offensive object should not live and should be destroyed”. Those continually blamed in the past are very vulnerable to blame now. In pure grieving there is a feeling of loss. If there was antagonism to the dead person in the past, there may be not only grief, but also a feeling of being “to blame” and of guilt.
The description given earlier of the functioning of the psyche puts reproductive and sexual activities in perspective. They are major activities of the person, but far from his total, or most important activity. A mood of sexuality is a potent motivator of action, but so are thirst – and many other activities. To explain psychic disorder in terms of sexual dysfunction alone is to limit grossly the knowledge of individual activity. Furthermore, sexual malfunction often arises secondarily to other psychic damage, e.g. in a state of depression there is a loss of desire to eat and also loss of desire for sexual activity. Again, frigidity may be secondary to an inability to express emotion for another person, or anxiety may make sexual performance impossible. Difficulties in sexual activity can cause consequential reactions, e.g. wife loses her mother and is disinclined to have intercourse, husband becomes irritable at her refusal and develops a gastric ulcer. To explain behaviour in terms of stereotyped sexual dogma is to grossly limit the range of human behaviour. It is also a serious error to impose adult concepts of sexuality upon children.
Security, fear and anxiety must be differentiated. In the absence of threat or stress to the self and in a state of optimum functioning and harmony, there is a complete security. Fear is aroused by something which is harmful to the self. The threat is seen and the mood of fear experienced. Fear can sometimes be displaced to harmless objects. It can be exaggerated by introspection when allowed to hold the field of attention and push out ideas that would put the fear in perspective. It is a primitive response and has an attached physical apparatus. Anxiety is a state of anticipation of threat to the self. It is sustained. People talk of being in a state of tension. There is a continuous alerting of the associated physical apparatus. Chronic body changes may occur – loss of weight, moist skin, furrowed face, etc. Because of previous experience, some people expect stress – they are of an anxious disposition. They may react to a minimal stimulus. Such persons are at as great a disadvantage as those who are so non-sensitive to stimulation that their phlegmatic reaction puts them in danger.
Aggression is a primitive coping mechanism associated with a physical apparatus for its performance and a mood of anger in awareness. It has increasingly come under the control of thought. The physical apparatus can even be dictated to put on a sham demonstration of anger. Anger in performance or in threat is one way of contending with attack. Thus it is prevalent in those who are insecure. It can be stimulated by childhood experiences; some families regard it as the first choice when attacked, threatened or anxious. There is an attitude of hostility, an activity of aggression and a mood of anger.
Anomalous conditions of the person due to untraumatic experiences must not be confused with danger, e.g. lack or excess of emotional response (cold or volatile people). A person may display such anomalies without being disharmonious or dysfunctioning, if in an environment where the anomaly is acceptable. For example, a homosexual may be healthy, balanced and happy if in an environment that accepts his way of life; in a different hostile situation, he can become psychonotic, if he is the recipient of psychic stress.
The man in the street, like a family or society, aspires to happiness, a state of psychic and physical harmony, which has its own indicators. Some of the indicators of harmonious psychic functioning are: loving, relating, co-operating, enjoyable sexuality, balanced self regard, security, self-confidence, responsible attainable goals, well-being, productiveness within capacity, hopefulness, creativeness (the capacity for self-improvement). These are associated with physical well-being, e.g. beneficial sleep, sound digestion and elimination, ample appetite, co-ordinated muscle action, sexual satisfaction, clear skin, etc.
In pathology, the psychic noci-vectors strike the psyche of the organism, which responds by deploying its coping mechanisms, and damage to the psyche may or may not occur. This process displays itself by indicators.
An indicator can be any part of the whole process – psychic noci-vector, damage, or coping mechanism. Taking the analogy of a car with dirt in the petrol makes this clear. The dirt in the pipe, i.e. the noci-vector, may cause an irregular movement of the car, the lack of petrol leads to defective combustion and hence loss of power, i.e. damage to its functioning, and the need to press hard on the accelerator to produce more petrol is an attempt to cope. The indicators, irregular motion, loss of power and excessive use of the accelerator, are all due to different parts of the whole process. All are useful indicators of the trouble and together give the experienced motorist a clue to the nature of the disorder. Similarly a piece of shrapnel causing a body wound has a number of indicators – the hardness is due to the noxious vector, the shrapnel, the loss of sensations is due to a cut nerve, and the warmth around the wound is due to the body’s inflammatory coping device. The indicators are not the process itself, they are the parts that can be assessed. They warn the individual of pathology. To a trained observer they may demonstrate the nature of the pathology. Hence the need for a careful examination to identify as many indicators as possible and reach an accurate elucidation, diagnosis, of the pathology.
The organism subjected to the process, or an observer, notices a change in functioning, something different happens from the accustomed – pain, or anguish, or anxiety, or a rash, etc. The change that can be detected by the organism itself is termed a symptom. The change in the organism that can be detected by an observer is termed a sign. Damage to the psyche tends to lead to fundamental changes – grief, depression, withdrawal, guilt, anger, fears, etc. These changes in the self may be so obvious as not to escape the attention of the person. They may be very obvious also to the observer and so constitute signs. An indicator is the part of the process which is noticed – it is not more significant than the rest of the process and is not the whole of it. Indicators – signs and symptoms – are produced by the whole process and therefore all these factors which determine the choice of psychic noci-vectors, damage, or coping, determine the indicator.
The psychic noci-vector, as it influences the place and mode of attack, the damage done, and the responding coping devices, is a factor in determining the nature of the indicator.
The family’s influence on choice of coping devices is great and hence it may also determine the indicator. Given a certain constellation of factors operating, conflict can be resolved only in certain definite ways. A particular form of coping and hence a particular indicator, is inevitable in given circumstances. This leads to diverse and sometimes extreme as well as fanciful ways of coping. No other way of coping is possible.
These coping devices, and hence indicators, can be passed on from one generation to the next. A grandparent copes with is social inferiority by fastidiousness in dress; his son adopts the same coping device – and so does the grandson. In the preceding family men meet attach with aggression, the men of the presenting family adopt the same device, which is also found in the succeeding family. Thus familial communication may be confused with genetically induced traits. Faced with the same psychic noci-vector as on previous occasions, the same coping devices are quickly employed and therefore the same indicators are seen. Repetition leads to a stereotyped process and hence to stereotyped indicators.
The psychic pathological process sometimes follows a general pattern, more or less common to many families. In that case, common indicators will be apparent. At other times, the process is special and unique to a family and thus the indicators are unusual.
The indicators of psychic pathology can be either psychic or somatic. Thus an examination of psychic and somatic functioning is required to make a complete assessment of the indicators. Any bodily system can be involved in the pathological process. Indicators of dysfunction in the soma are termed psychosomatic disorders – they are many and diverse. It is rare for careful examination not to expose some psychosomatic disorders when the organism has been subjected to psychic harmful agents. The psychosomatic disorder must be differentiated from the hysterical. The first is an automatic pathological response, e.g. abdominal pain due to bowel spasm at the thought of going to school where one is bullied by a classmate. The hysterical response is a simulated attitude because the need to simulate is great, e.g. the child simulates abdominal pain, which has no related bowel spasm, so as to avoid going to school. The term “hysterical” denotes a special attitude – one of simulation. But many attitudes are adopted without simulation and are not hysterical – the real situation is that a need exists to hold firmly on to an attitude. For example, a child refuses to eat – he cannot do otherwise while caught in a deadlock with father who state, “Just eat and I will not be cross”. The child states “If you stop being cross, I will eat” – and thus cannot eat until father changes his attitude.
As in the field of organic pathology, a particular indicator may be shared by a number of different psychopathological processes. Inability to eat, for example, may arise from severe depression, from a reaction to grief (Queen Mary Stuart’s dog “pined away” and refused to eat after her beheading) from a conflict with the family when food is an issue, from concentration of interest elsewhere arising from severe anxiety and the need to be alert, or from gastric pain produced by acute anxiety. The same is true of organic pathology – dyspnoea (shortness of breath) may be seen in anaemia, in carcinoma of the lung, in pneumonia, and in cardiac failure.
When attempts are made to remove an indicator, the attempt may be successful, but the indicator is usually immediately replaced by another – the substitution of indicators. The process has not changed, but the therapy has produced an additional factor that pushes the process in another direction. This is very conspicuous in families when the presenting pathological member is given much assistance; he is soon replaced by another family member who has become sick.
Indicators of pathology must be differentiated from bad habits. Many attitudes are not the result of psychic noci-vectors, but are wrong attitudes inculcated in a non-stressful situation. To exploit others may be a way of life arising from that person’s values, or it might be a coping mechanism indicating a pathological process. The first is of interest to sociologists, the second a matter for clinicians. This confusion leads to non-clinical procedures being advocated for clinical disorders and to armies of well-meaning citizens attempting a clinical role.
When the organism is fearful enough about its health, it will take one of its indicators as an excuse for seeking help. It may notice only this one conspicuous indicator. It may regard only that particular one as a sign of danger. It may feel it will lead to attention. This indicator is termed “the complaint”, or the presenting symptom. It is crucial to appreciate that the presenting symptom is not the whole process, nor is it more significant than the rest of the indicators. There must be a global assessment to lead to adequate diagnosis. The importance of indicators is that they warn, they lead to seeking professional help, and, taken collectively, they often point the nature of the pathology to the clinician trained in reading the indicators and in systematic examination that allows of a total appraisal, leading to a discernment, diagnosis.
Indicators are not the psychopathological process and attempts to treat the indicators as if they were the process are futile. This can limit the usefulness of behaviour therapy. Similarly, a sign of a stressful process such as a rash, perhaps due to a hurtful marital situation, may be helped by an ointment but leaves untouched the process itself; it can only relieve any secondary stress caused by the rash. The process itself must be treated for effective therapy. The psychic noxious agents causing the process must stop operating or the coping devices must be strengthened, and the psychic damage must be repaired.
Indicators of morbid processes as they present in the individual, family and society will be briefly outlined.
Indicators in the Individual
Like the family and society, the individual reacts as a somato-psychic organism. Thus there are somatic as well as psychic indicators, signs and symptoms, and it is rare for this not to be the case. The somatic indicators are usually multiple and in the nature of the so-called “psychosomatic disorders”. The choice of psychosomatic responses depends on a number of factors – previous trauma involving a particular organ with a reawakening of memory in relation to it; the organic mechanisms of reaction to stress may be overstimulated, with damage to a weak organ; cultural suggestion, e.g. blushing in western society in an index of shame. The selection of the site where damage develops is probably determined centrally by the brain, as the lesions do not follow a segmental distribution, which would be the case in local damage to the central nervous system.
It is usual to subdivide emotional disorder in the individual into certain clinical categories – anxiety states, obsessional states, hysterical states, etc. This practice has grave weaknesses. It pays attention to the presenting symptoms, often elevates them to the status of a disease, and limits the description of the process. The process is all-important and cannot be covered by one or many labels. Each process is made up of such a combination of circumstances as to be unique.
Either psychic or somatic symptoms may be the first to be noticed and constitute the presenting symptom. Age influences the indicators. Hostility may be manifested in an infant by temper tantrums; in a child, by lying; in an adolescent, by rebellion; and in an adult, by criminality. A person is bound by the strength and range of his endowment at a given period of development. There may be resurgence of psychonosis, and hence indicators, at nodal points in development, e.g. school entrance, puberty, marriage, childbirth, menopause, retirement, etc.
Sex gender may influence indicators, e.g. a woman tends to develop signs in the reproductive system. Gastric and duodenal ulceration is commoner in men.
Examples of indicators from 25 patients are:
Bouts of drinking
Irritations of skin
Epigastric pains or discomfort
Numbness in the body
Violent behaviour to wife
Fear of crowds
Cancer phobia and other phobias
Pumping in stomach
Wanting to run away
Lack of concentration
Inability to go to work
Pains in the abdomen
Inability to go to school
Cramps in the hand
“Pins and needles”
Loss of weight
Shortness of breath
Loss of hair
Attacks of panic
Bouts of fever
Failing an exam
Frequent ill health, coughs, colds
Loss of appetite
As can be seen, the above can be divided conveniently into somatic and psychic indicators. In no patient did one group, psychic or somatic, exist alone. Depression of varying degrees is a very common symptom. This was also found to be so in an investigation of symptomatology shown by patients of Dr. John Hall, Shakespeare’s son-in-law, 300 years ago.
Indicators in the Family
The family too reacts as a whole, with both its psyche and its soma. Rarely is a disturbed family without signs of somatic disorders and indeed this may be its most conspicuous feature – and its reason for seeking help. The total range of symptomatology in a family may be great. Indicators arise from the clashing attitudes within the family or between the family and its psychic environment.
Indicators can arise anywhere in the fabric of the family – in its individuals, in its external and internal communication system, in its physical structure (even to proneness to a streptococcal infection), and in its general characteristics. Careful examination will usually reveal that indicators appear in all its dimensions, especially if the disturbance is severe. However, a family group may not manifest dysfunction equally throughout its system. One aspect of it may show disproportionate dysfunction due to the “set” of emotional events at a particular time.
Indicators are strikingly apparent in problem families, because emotionally sick families carry a high degree of psychopathogenicity. In one family, consisting of mother and two children, the following were seen:
Dimension of the Individuals:
Mother — Aggression; rage; despair; depression; panic; lying; stealing; accident-proneness; excessive smoking; alcoholism; attacks of vomiting; fainting attacks; gastric ulcer; enuresis; shaking fits.
Child 1 — Tension; tearfulness; fear of the dark; nighmares; enuresis; lying.
Child 2 — Irritability; depression; enuresis; lack of confidence.
Dimension of Internal Communication:
Mother/Children — Overprotectiveness; rejection; hostility; depreciation; neglect; disparagement.
Dimension of General Psychic Properties
Two illegitimate children; low morality; shared symptom of enuresis; no aims or purpose; conflict.
Dimension of External Communication:
Isolation; truanting from school; exploitation of welfare agencies; quarrels with neighbours; poor school performance; mother unemployable.
Dimension of Physical Properties:
Poor diet; squalor; debts.
The choice of indicators is a reflection of family dysfunctioning. The individual’s choice is dictated by his life experience in the family, e.g. an angry family evokes anger in a child. The choice of expression in a relationship is similarly determined, e.g. physical hostility may be taboo and verbal hostility alone possible. The material changes in the family can take place only within the limits set by its condition. Group manifestations are a family expression, e.g. sulking may be an expression of hostility in a particular family. The community interaction may determine the indicators, e.g. that fear be controlled by obsessional ritual or that sexual taboos be imposed. Again, gastric ulceration is a common indicator in Western civilisation, but not in primitive communities. No only do present events dictate choice of indicators, but so do events from the past. Every indicator has to be understood as a manifestation of past or present family dysfunction, or as a resultant of both.
It is fundamental to the doctrine of family psychiatry that psychopathology must always be thought of as an expression of dysfunction in a whole family group. A family can show manifestations, indicators, or dysfunction at any point in its system. Thus indicators appear in the five dimensions. Almost invariably they appear in all, although this may escape notice except on the closes examination. But the family group will not show manifestations of dysfunction to the same extent through all its aspects, e.g. the second child may show more manifestations than the first, or a girl more than a boy, or the family’s external relations may be more disturbed than its physical conditions.
In the dimension of the individuals, each family member usually shows symptomatology. Naturally, this will not be exposed if examination concentrates on one person alone and overlooks the remainder of the family. But each individual does not show psychopathology of the same kind, nor to the same degree.
In the dimension of internal communication, each relationship will usually show disharmony. Naturally, this will not be seen unless each relationship is examined. In practice, the mother/child relationship often comes under far greater scrutiny than the father/child relationship; the marital relationship also receives a fair degree of attention, but not always from the psychiatric service. Each relationship will not show psychopathology of the same kind, nor to the same degree.
A disturbed relationship may give rise to any indicator in the physical or psychic fields, in both individuals of the partnership, e.g. an obsession in the wife and a rash in the husband. Sometimes the symptomatology is shared by both partners, e.g. impotence in both (a psychosomatic reaction); joint depression, suicide of folie à deux (affective changes), or overt quarrelling. Furthermore, some indicators tend to be associated with a particular relationship, e.g. a mal-relationship between husband and wife is often responsible for premature ejaculation, dyspareunia, impotence and frigidity.
Hence, too, family patterns may dictate choice of indicators, e.g. in some families open quarrelling is forbidden and its members sulk instead. Cultural pressure may also influence choice of indicators, e.g. sexual taboos increase the incidence of sexual disharmony.
That a particular relationship comes to the attention of a referral agency may be fortuitous. Quarrels between husband and wife may evoke the attention of friends; the faulty relationship between mother and infant may be picked up by the regular surveillance of a community “mother and baby” clinic; the relationship most under stress may come to attention , e.g. a marriage, due to the intervention of a third party. That indicators of faulty relationships come to attention rather than individual indicators is equally fortuitous.
Symptomatology in the general psychic dimension manifests itself in a pattern common to the whole family. Families may be prone to particular types of physical disability, e.g. accident proneness, stomach disorders, or speech disturbances. They manifest affective changes as a group, e.g. panic may be the group reaction to stress. The family’s pattern of behaviour is shared by all its members, e.g. exploitation of neighbours. Choice of family group symptomatology may be influenced by cultural pressure; e.g. the culture may dictate that fear be controlled by obsessional ritual.
That group disharmony rather than individual or relationship disharmony comes to the attention of a referral agency is again fortuitous. Usually this is less likely to happen, as few agencies ascertain whole family patters of dysfunction. It is not inconceivable, however, that in time many more agencies will function as family agencies, e.g. in a number of countries the personal doctor operates more and more as a family physician.
Family dysfunction frequently manifests itself in the dimension of physical properties, e.g. poverty despite an adequate income; sloth resulting from apathy and disinterest; low income due to lack of application; loss of employment as a reaction to family emotional crises. Yet again it is fortuitous that adverse material circumstances are the manifestations that arouse attention in referral agencies, rather than individual, internal communication, or general disharmony. Most often these manifestations come to the attention of social agencies. But selection factors operate, as an agency may have a special function, e.g. a housing agency may ascertain sloth but overlook employment failure, or an agency may serve lower income groups only and overlook child neglect in a higher income group.
In the dimension of external communication, signs of dysfunction may arise at the three points of contact: individual-community interaction, e.g. stealing outside the home by a child; partnership-community interaction, e.g. parents’ refusal to send a child to school; or family group-community interaction, e.g. quarrelling with the neighbours. The community influences the family by informal and formal means. Enforcement of the latter is entrusted to agencies with statutory powers, e.g. police, courts, health inspectors, child-care agencies, etc, and these, in addition to enforcement functions, may accept responsibility for ascertainment of dysfunction. Usually agencies with statutory powers are likely to observe signs of dysfunction in this dimension of family-community interaction.
Indicators in Society
Society, too, reacts as a somato-psychic entity with psychic and somatic indicators. Not only may there be high incidence of psychosomatic disorders, but also signs of psychic disruption, like social unrest, low morale, apathy, strife, war, corruption and fragmented incohesive public action. The indicators may follow a common pattern through a large population, e.g. the panic reactions common in the Middle Ages. Mass suggestion can affect the choice of indicators, e.g. the increase in drug addiction in adolescents forced by massive propaganda to display their adulthood in this fashion.
There may be an interplay of family and social factors in indicator production, e.g. alcoholism may be the accepted expression in a given population, but only those in disturbed families manifest it to a severe degree.
Some indicators are termed “social” problems, e.g. high divorce rate, high suicide rate, alcoholism, drug addiction, promiscuity, child neglect, etc. Some of these are “social” only in the sense that a large number of people are involved, like tuberculosis 50 years ago. Like tuberculosis, however, the eradication of these problems involves not only large scale preventive action, but also curative procedures at individual and family level. The preventive actions must be devised and guided by knowledge acquired through curative procedures.
A Note on Nosology
Nosology (nosis – disease, logy – word) in psychiatry and psychology can be confusing and variously employed in different countries. Part of the difficulty is due to an inability to establish agreed criteria for clinical categories.
Two main divisions are the fields of : 1. Neurosis; 2. Psychosis. Here the nomenclature is unsatisfactory. ‘Neurosis’ means ‘disorder of neurone’ implying a physical origin. But it is used to cover psychological states, emotional disorder, personality disorder. These states could strictly come under the term ‘psychonosis’, disorder of the psyche. The term ‘psychosis’ means ‘disorder of psyche’ implying a psychological origin. But it is used to cover states such as toxic psychosis, alcoholic psychosis, drug psychosis and schizophrenia. These states have a cerebral basis and could better come under the term ‘encephalonosis’, disorder of the encephalon.
The term ‘insanity’ is also not useful. It is derived from ‘insanus’, not sound in mind.
Sometimes strength of the disorder is used to determine nosology. Severe conditions are termed ‘psychotic’; less severe conditions are termed ‘neurotic’. This is contrary to clinical experience. Neurotic states can be very severe, ending in the death of an individual.
There are also mixed states, e.g. a personality disorder (neurosis) can be aggravated by a drug psychosis, sometimes making a very serious condition.
The term ‘schizophrenia’ – ‘split mind’, first used by Bleuler lacks proper descriptive value. Kraepelin’s original term, dementia praecox, early dementia, is nearer the mark. When its cerebral origin is finally proved it may merit a term such as enchaloataxia.