THE PSYCHIATRIST AND POWER
Dr. Jean-Marc Mantel
This article was translated
from the French
by Jacques Stern & Simon Macnab
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"He who reaches the very
end of his run
knows the nature of man.
To know the nature of man
is then to know Heaven."
Mencius (Meng-Tseu)
Behind the medical student’s apparently innocent choice of psychiatry, there is a desire, and it’s mostly unconscious, to gain mastery over the mind: to put an end to being enslaved by mental agitation and the various impulses which make living chaotic. This inner quest does not appear immediately apparent, however it does reveal itself when we candidly examine the motivations behind our actions.
Consequently there is in each of us a need to no longer be a slave of our thoughts and their content. We can observe an example of such enslavement in the succession of states of pleasure and pain, which can be experienced during the unfolding of so-called “negative” or “positive” thoughts. This becomes even more obvious with our dreams, which are mental projections with a tremendous power of evocation that can generate intense feelings of fear or joy. Thus man is indeed the slave of his mental state.
Medicine and psychiatry’s long apprenticeship, the countless hours spent in the company of people in distress, the desire to understand the cause of sickness, pain and suffering, are a training in discrimination that teach the “trainee-healer” the art of profound insight. Depending on the maturity of each person, this vision can either come to rest on the causes and effects of the observed phenomena, or try to ascend to the very source of the mind of the one who makes the observations.
The habit of living disconnected from others is a protection against the overwhelming pain, which would be generated by the understanding that someone else’s suffering is no different from our own. Those desks, loaded with books and papers, which so often shield the psychiatrist from his patient, are in fact the symbol of our fear of too close a contact with ourselves, a contact with solitude, sadness, and other emotions. All these manifestations express the fear of losing control of our own mind. This control, so yearned for, channels the impulses like a dam tries to tame a wild river. The countless desires which assail a human being, some of which are satiated and others kept on a leash, are like a thousand-headed dragon whose heads at times suddenly surge forward unexpectedly, crushing the walls that were constructed with such perseverance.
In keeping his patient at a distance in this way, the psychiatrist thus attempts to distance himself from his own demons.
Putting the patient in a diagnostic box is one of the other ways that distance can be maintained. Diagnosing “depression”, “neurosis” or “psychosis”, gives the impression that the suffering’s origin has been grasped, and produces a sense of security. “I now know what I have.” But it is not enough to know what we have in order to know what we are.
The very diagnosis itself is the limitation on what it aspires to protect. It creates a concept on which the ego of both the patient of the psychiatrist will be able to settle, so producing a context for the distress that has been expressed.
There is the disadvantage, however, that the patient is now imprisoned in a new conceptual identity and the psychiatrist in a belief that he has understood.
The attachment to knowledge is another expression of the demonstration of power. Treating someone who is in need of help further bolsters the psychiatrist in the idea of being the one who knows. A barrier is thus established in his mind, strengthening the separation between him and the other. The attachment to knowledge is in fact a hidden form of ignorance, a new barrier buttressing the illusion of being the one who knows, and keeping the other locked in his belief system. Thus the patient is carefully nurtured in the idea that he is ill and the psychiatrist in the idea that he is sane. Yet any psychiatrist who analyses himself knows very well how filled he is with fear, doubt and all the emotions experienced by his patient. And yet only rarely will he admit to this. To think that the patient expresses everything that the psychiatrist represses!
The attachment to knowledge is also conveyed by the countless wars between the schools, in which all kinds of researchers argue over the pre-eminence of their knowledge, all the while omitting to mention their own residual ignorance. Not only does it make communication difficult between human beings, but also between disciplines. This attachment is a brake on the free exchange of understanding, an understanding that does not belong to anyone other than to life itself.
The prescription is another one of the manifestations of the demonstration of power. The drug or its derivative is intended to assert authority. Mostly it is prescribed without even really consulting the patient. No alternative is offered, and the medication is imposed, like a sword intended to cut off the dragon’s head. Any attentive doctor knows full well however, that in most cases, in the absence of being able to kill it, he is only putting it to sleep. So, the invisible enemy becomes even more difficult to defeat. To think that it was the dragon itself that invented the cure, so as to deviously veil itself from the purifying gaze of an astute and penetrating observation.
The manner in which the remedy is prescribed reveals all the psychology, expectations and illusions that imprison the physician. Has he tried the drugs he prescribes so well? Would he accept for himself the devastating effects of certain treatments, which, in seeking to eliminate what’s bad, end up by killing the patient one way or another. There are some refined ways of dying that destroy human beings’ sensitivity and their capacity to think for themselves. Should the well-known aphorism “don't do unto others what you would not have done unto you” not also be applied to those who write prescriptions?
Have you ever noticed how rare it is for a doctor to ask his patient for his opinion concerning his treatment plan? By depriving himself of such a dialogue, he deprives his patient of the opportunity to contact the “inner doctor” who lives in each of us. The outer physician is only there to reflect the patient back to the inner one. There is scope to discover something fresh when inviting without imposing. The invitation leaves the patient free from his choice and does not back him into a corner from where he can only find release through a violent reaction.
The issue of treating a patient without his consent is also worth exploring. Does it make sense to treat someone against his will? On the pretext of incapacity, should one substitute one’s own will for one that has been deemed deficient and then impose treatments that are have not been solicited? When you were a child, were you forced to eat food that you did not want, or did they take you to a place of worship against your will? You know very well that this is the best way to create disgust and indelible rejection.
Consequently is it not possible to treat someone without violence, and accompany without manipulation?
The question of mental manipulation is very much the order of the day, as seen in the many reported accounts of cults and other quasi-religious organisations. But, as psychiatrists, aren't we prone to manipulate the other, to impose upon him our belief systems and our opinions, under the cover of an acquired learning? This is also a question any psychiatrist aspiring to become conscious should ask himself.
Whenever an opinion is imposed, it conflicts with the opinion of the other. This friction, you could say, might perhaps be necessary to inject some “good sense” into a “disturbed” mind. But we should be very careful not to turn the “good sense” into an indirect form of power taking, seeking domination under the cover of good intentions.
These thoughts on the practice of psychiatry bring us to question the true nature of power. Is power of a personal nature, lying in the hands of the physician, or does its origins lie beyond the person?
Let us imagine a situation where we are meeting with someone in need of help for the first time. Let us see straight away that from the very first contact, whether it is over the phone for an appointment or when the person enters the room, a feeling arises in us. It can be one of empathy or even familiarity as if we were meeting someone we have always known, or one of rejection and antipathy. This first contact is important, since it already contains within it the events that will follow. A current of confidence and empathy between the two parties is essential if a therapeutic relationship is to succeed.
Next comes the question of inner clarity. We can only help people who are more confused than ourselves. And we will only be able to guide them to where we are, in our own maturity and self-understanding. Therefore, reactions of rejection or antipathy often relate to incompatibilities and invite us to orientate the prospective client towards another therapist, whose sensitivity will better match their need. When this observation arises, it is a good idea not to let the needs of our ego - needs for recognition and superiority - interfere, and acknowledge in the moment that it is better to “pass the baton”. On the other hand, to hold on to a prospective patient is often a reflection that we are attached to an image of ourselves that we are unable to relinquish.
The magic of an encounter lies in its power of awakening and understanding. It is not through our acquired learning that these magical moments arise, but just the opposite, through an innocence, which enables the other to express himself freely, without fear of being judged. Thus our inner attitude has a determining effect on the other's attitude. Here we find ourselves far removed from the doctoral scholarship of the scientist attached to what he believes he has.
When we feel that we are completely welcomed and listened to, just as we are, then we relax. This also applies in a therapeutic relationship. Whenever the patient feels that he is completely welcomed just as he is, he also lets go and relaxes. This relaxation is a prerequisite for understanding. If a patient leaves the room more agitated and upset than he was before he came in, we must ask ourselves the question what within us triggered that defensive response. And we will always find an impulse towards rejection, a rejection of the other as he is. Thus the other sends us back to ourselves. He is a mirror. We believe that we “cure” him, but he cures us as much as we cure him. He teaches us to be simple, clear and authentic. Consequently he grants us the possibility to develop qualities which are essential for us to function harmoniously. So actually we could say that we are two patients who meet with each other, united in a search for an authenticity which is to be found in both of us.
The notion of personal power disappears here, giving way to the natural power of presence and love, as perceived in its impersonal dimension of welcoming and listening.
One can speak of impersonal power, in the sense that the transformational magic of an encounter points to what is essential, and does not belong to the physician who is only a channel to express a dimension that surpasses him. When the ego and its demands disappears, the true “person” can emerge. But this “person” is not a new arrogant character. It has the qualities of openness and transparency appropriate to the subtle dimension of our being.
We can equally take the example of the decision. Is a decision ours or is it imposed upon us?
If we are attentive to the way a decision takes shape in our mind, we are going to notice that the decision is a sort of gestation which forms in a subtle way, takes a variable amount of time to ripen in our mind, and then expresses itself when the time is right. Only then does it imposes itself upon us, and can trigger an action. If we do not project upon all of this movement, the idea of an individual self with power over this manifestation process, we will be able to discover that it has its own rhythm, and there is little scope to intervene or interfere. It is the decision that imposes itself upon us and not the other way round.
Here the very notion of free choice is thrown into doubt. If decisions are imposed upon us, then it follows that choices are as well. This would imply that there is no choice, but only a succession of decisions that trigger action. Of course the will may obstruct a decision, but this exercise in will is also part of those forces of decision-making, and will influence the way things unfold.
Are we master of the will, or does this will impose itself upon us? Here again, we are led to question the individual self and the illusion of power that imprisons it. Is the birth of the body, its maturation and destruction, the expression of personal power or is it the manifestation of an impersonal intelligence in which we are the actor and the contemplator?
It is through the intimate observation of our functioning that our understanding matures. We cannot see in our patients any more than what is given to us to see in ourselves. The very mechanisms of suffering are no different in one from the other. It is only in discovering them in ourselves that it will be possible to discover them in the other. Without this clarifying vision, it is really difficult to guide someone with a confused understanding. Instead, we often find dogmatic attitudes, which are the reflection of a misunderstanding of the profound realities that govern our being. They reflect fear and lead to authoritarian deviations all too common in the changing world of mental health.
Therefore, we need first to get to know ourselves better if we want to offer patients a new understanding of themselves. Such an understanding would not be founded in alienation, rooted in a new belief system, but in an awakening to a dimension of tranquillity. This would be a sign of inner achievement that finds its flowering, not in the “elsewhere and later”, but in the here and now.