Psychiatric BY
SlLV\()
Controversy: \IIIETI.
Man’s
Ethical
Dimension
\I.l).
Although determinism maypermeate human existence, man’s moral values raise him above the level of an animal and enable him to direct his own life. The author suggests that psychiatrists should influence thepatient to exert his will, make conscious choices, and, above all, assume a sense ofresponsibilityfor his own actions. In order tofree the patientfrom whatever conditions hinder his will and to help him make choices, psychiatric treatment must consider man’s ethical dimension.
COMMITTED AS WE ARE to the scientific method, we psychiatnists divide, dissect, and examine the psyche of the human being piece by piece. This is a legitimate procedune, provided that after the analysis we reach a synthesis, give the proper consideration to those aspects of the personality that could not expand, and, most impontant, do not leave out any basic human dimension. We do not always follow this procedure. In our double allegiance to science and to man, who in his totality is not reducible to the accepted canons of science, we tend to adhere to traditional science exclusively and to minimize man’s ethical dimension. In what I call the “ethical dimension” I include such vast areas as moral values and the phenomena of will, conscious choice, and responsibility. I do not mean to suggest that the therapist should impose his values on the patient; I simply wish to stress that values always accompany and give a special psychological significance to facts and that when we deprive facts of their value, we fabricate artifacts which have no reality in human psychology. An individual may suspend his value judgment when he wants to examine a fact from a specific point of view, but then the ethical content has to be reestablished if the fact is to have human significance. If we remove the ethical dimension, we reduce man to a subhuman animal, an animal that is not beyond freedom and dignity, but whose organization precedes the expenience of freedom and dignity-a subhuman animal to whom Skinnenian psychology can be safely applied.
Read tion,
at the Detroit,
127th annual Mich., May
meeting of the American 6-10, 1974.
Dr. Arieti is Clinical Professor lege, New York, N.Y. Address St., New York, N.Y. 10028.
of Psychiatry, reprint requests
Psychiatric
Associa-
New York Medical to him at 125 East
Col84th
It is easy for many of us who practice psychodynamic psychiatry to understand how Skinner’s approach has only limited application to our work. The functions of the psyche that we study in our daily work-feelings, emotions, attitudes, introjection, guilt, expectation, purpose, goal, inner self, personality, determination, choice, will, etc.----are miraculous on imaginary entities for Skinncr ( 1 ). According to Skinner, ideas, dreams, images, insights, and conflicts cannot be seen or observed and, therefore, do not count, nor can the existence of an inner life be inferred from them. Skinner follows a procedure antithetical to the medical procedure, for a physician does not simply observe his patient’s behavior but also makes inquiries about what goes on inside ofthe patient. Although I have never gathered statistics on a large scale on this subject, I am inclined to believe that many psychiatrists are ready to reject Skinner’s position. But unfortunately, many of us are willing to accept other positions that do not consider adequately the ethical dimension. In contrast to the position of Rollo May (2), Leon Salzman (3), Leslie Farber (4), myself(S), and many othens, a large group of psychiatrists and psychologists do not believe that there is such a thing as human will. Certainly a normal voluntary action consists of many steps, some of which are not yet susceptible to scientific analysis. We do not know when neurology ends and psychology begins. We do not know the intimate neurological mechanism that initiates a voluntary movement. Perhaps what we call will is the synthesis on result of many neuropsychological mechanisms plus newly emerging elements that in a tentative way we call autonomy, individuality, originality, creativity, and indeterminacy.
PREEMINENCE
OF
DETERMINISM
Determinism reigned supreme in the era of hard-toimagine proportions that extended from the appearance ofthe atom to the development ofthe human cortex. The simplest entities (the subatomic particles) and the highest (some parts of the human cortex), respectively, opened and closed this vast era that unfolded over billions and billions of years. The most complex entity in our universe, the human cortex, again permits a certain independence from causality as it existed at the subatomic level studied by Heisenbeng. However, the freedom of man,
Am
J Psychiatry
132./January
1975
39
MAN’S
ETHICAl.
DIMENSION
made possible by his cortex, is different from the socalled freedom ofthe subatomic particles. It is integrated with the essence of man. Although this freedom produces an interruption in the deterministic chain of causes and effects, it immediately rejoins determinism, thereby neestablishing continuity, for the will of man becomes a cause action. It is a causality compatible with free will. It is for future research to establish whether subatomic “freedom” becomes incorporated in some particles of neurons and changes ideas into free actions and thus reintegrates itselfinto the essence of man. For many psychiatrists, including myself, what we call will, that ability by virtue of which we conform our behavion to our determination, is the culmination of the psychological functions ofthe human being. Certainly we can bypass our will. We may meekly obey others, or we may behave in conformity with our conditioned reflexes. If we have some psychiatric disorder, our will is hindered in various ways. If we are hysterical, we lose control of some functions of our body. If we are phobic, the avoidance of the dreaded event rather than our determination will guide our actions. I f we are obsessive-compulsive, we feel obligated to obey internal injunctions even when they seem absurd. Ifwe are psychopathic, we cannot say no to ourselves; we are under the impulse to satisfy our urges immediately. If we are catatonic, we go through a stage in which even our smallest movement may be endowed with cosmic responsibility and guilt; consequently, we do not move at all. Those of us who have intensely studied the catatonic type ofschizophnenia consider the catatonic state to be the nadir of the human condition (6). Although the catatonic is not physiologically paralyzed, he cannot respond to people who touch him, bump into him,
of
smile
at
him,
on caress
him.
He
appears
to
be
a statue,
but unlike a statue he hurts in a most atrocious way, haying lost the most precious and human of his possessions -his will. By studying cases of catatonic schizophrenia of different degrees of severity, we can learn a great deal about the existence, unfolding, and impairment of the will (6). Psychiatric treatment attempts to liberate the patient from whatever condition limits his will, whether it is a mild neurosis or a severe catatonia. It should be understood, however, that total freedom and total self-causation are not available to any man. Even partial freedom is not something a human being is born with; it is a striving, a purpose-something to be attained. Being born free is a legal concept that, although valid in daily life, has philosophical limitations. Striving for freedom is an unceasing attempt to overcome the conditions of physicochemistry, biology, psychology, and society that affect human life. The psychiatric patient has the additional burden of ovencoming the conditions of his psychopathology, and the purpose of psychiatric treatment is to help him do so. It would be unrealistic to forget, however, that this self-ca usation is only a thin margin of a totality in which the majonity of facts and events are ruled detenministically. But I feel that this thin margin is sufficient to change the world, to make history, to cause the rise on fall of man (5).
40
A mJ
Psychiatry 132:1, January
1975
FREUDIAN
VIEW
OF
THE
CONCEPT
OF
WILL
Classical Freudian psychoanalysis has a controversial (and I would say ambivalent) attitude toward the concept of will. On one side, Freudian psychoanalysis adheres to a strict deterministic view of reality and life that leaves no room for human choice. According to Freud, most of our actions are caused by unconscious motivation, and as long as our actions are the result of unconscious motivations, we cannot call ourselves free or feel responsible for what we do. Like many other great thinkers, Freud contradicted himself on many issues, including the question of will. More than any of his predecessors on contemporaries he revealed the role of the unconscious wish as a detenminant of human behavior. But Freud’s great discovery does not imply that will has no role. Let us consider Freud’s famous statement, “Where id was, ego must be.” Freud meant that as a result of psychoanalysis, unconscious wishes, generally relegated to the id, must become pant of the ego; i.e., they must become conscious. But what is the purpose of this? To make the id pant of the ego does not mean unleashing the unconscious wishes or giving them free reign or unrestricted access to conscious behavior, although this is the way some people interpret Freud’s statement. I believe that Freud meant that once the unconscious wishes become conscious, they will be regulated by the functions of the ego. The individual will be in a better position to accept or reject them. In other words, Freud conceived psychoanalysis not as a libenation of the id but as a liberation of the ego from the unwanted, unconsciously determined oppression exerted by the id. Thus, psychoanalysis has the function not of restnicting but of enlarging the sphere of influence of the will. Its aim is to return a sense of responsibility to the human being for many actions that previously were beyond his control. In this respect, psychoanalysis enlarges the ethical dimension.
POSITION
OF
SOME
PSYCHODYNAMIC
SCHOOLS
In addition to Freudian psychoanalysis, some schools of psychodynamic psychiatry have also neglected the role of autonomy and individuality, which are prerequisites for free will. Whereas some geneticists believe that most or all of our life is predetermined by our genetic code, some psychodynamic psychiatrists believe that our present life is entirely determined by our past experiencesby what our parents, families, schools, and society have done to us. Thus, although the psychiatrists who focus only on the environment do not invoke heredity, their basic philosophy is similar to that of the geneticists: man’s destiny is shaped by forces external to the self.
WE
CREATE
Obviously
netic, familial, to the extreme
OUR
we
OWN
are
SELF-IMAGE
influenced
and social factors degree that many
by
external
forces.
Ge-
are important, but not psychiatric studies im-
SII.VANO
ply. Conceptions that view the individual only as a passive agent or tabula nasa, as a receiver, or as a puppet pulled by strings ofdiffenent kinds have prevailed in daily psychiatric practice. For instance, when we elicit a history from the patient’s family or (in most cases) from the patient himself, our aim is to establish how this history has made the patient what he is now. Some psychiatrists ignore completely the fact that the patient has always recreated that history. What he tells us is seldom what happened but more frequently what he perceived and interpreted, what he assimilated, and what his memory has constantly changed and given different meaning to. The child does not just reflect on absorb from the environment; he also tries to select what to absorb on what to give prominence to. The image that the child has of himself does not consist of reflected appraisals from parents or family members but of what the child did with those appraisals. In the same way, the image that he has of his parents and siblings, although related to the actual essences of these people, is not a mirror reproduction but rather a subjective interpretation. There is a definite discrepancy between the way reality and the significant people in one’s life were in the past and the way one has perceived
them.
nounced vidual
in the but also
individual
This
discrepancy
is
particularly
pro-
schizophrenic and pneschizophnenic exists (to a lesser degree) in the
and
in all
of us. This
discrepancy
mdineurotic
is one
mani-
festation of individuality. The image that the individual has of himself is particularly important because it is a major constituent of inner life on what is at times called the self. And, our self-image is not created exclusively by others but also by ourselves. We are among our own crcative forces. I must stress again that I do not mean that we are completely free. The self in whose creation we have cooperated is also the result of our specific biological endowment and a random mixture of’ external factors. The psychiatric patient has less possibility of contributing to the creation of’ his own self’ than the normal person because he was handicapped by external contingencies. However, the patient who has successfully progressed to an
advanced
mother
stage
on father,
of his
treatment
childhood,
will his
stop
spouse,
blaming or
the
his condi-
tions at work for all his troubles. The more he becomes conscious of his secret life (the more he understands his thoughts and motivation), the more he increases the area of his responsibility. He recognizes the role that other people played in his life, but he assumes some nesponsibility for what happened to him and especially for the way he will direct his life in the future. Ofcounse, it would be absurd for him to think that his destiny will be entirely in his own hands, hut he is aware that he too is a determining force in his life. Insofar as psychiatric treatment increases the ability to make choices, it is constantly involved with man’s ethical dimension. Any choice that affects others reveals our sense of responsibility, our concern or lack thereof not only for ourselves but for others. What we are responsible for is typically a product of our own self. Of course, when responsibility becomes one’s only concern, it is distorted
own
and assumes great decrease ety ofhuman
a tyrannical role; however, its absence, in it, produces in us the psychopathic life.
SELF-REALIZATION
AND
THE
ROLE
OF
ARIETI
or a van-
PSYCHIATRIC
TREATMENT
A misinterpretation and a misapplication of some psychiatnic and psychoanalytic concepts stand out among the many causes of the permissiveness and hedonism of our days. I refer particularly to the concept of self-realization that has persuaded many to strive for self-fulfillment, even ifthis means disregarding the rights of others. This misunderstanding derives not only from the already mentioned concept of id liberation, misconstrued from Freudian theory, but also from a broad generalization of some concepts of the neo-Freudian schools of psychoanalysis and humanistic psychology. Maslow, Homey, and Fromm believe that the highest ethic, as well as the aim of psychotherapy, is the one that leads to self-realization. This point of view is controversial on many grounds. First, there is no preordained, specifiable potential in man that has to be realized. Man is indefinite and capable of unpredictable growth because of the multitude of possible encounters with different systems of symbols and concepts (7). Man must aim at continuous growth or selfexpansion, but not at a mythical realization of an assumed potential. Man is not an acorn that may become an oak. For man, there is no question of potentiality but of infinite possibilities. Second, “self-realization” is very deceptive as a subjective experience. Reading the writings of Mussolini and Hitler, and even ofsome politicians of our own times, one is forced to conclude that these people were sure of realizing themselves and their “own destiny” by following a mission or mandate given them by the people. Third, and most important, self-realization ignones the actual problem of ethics, one’s moral relation to others. Self-fulfillment is not necessarily an ethical aim; it may be a form of hedonism and narcissism, again easily recognized in the lives of some politicians. What some authors mean by self-fulfillment is a legitimate aspination.
However,
not on ethical remain ethically ical principles. logical growth fringe
upon
the
when
self-fulfillment
is pursued,
it is
grounds but for personal gratification. To justifiable, it must not interfere with ethWe certainly should aspire to our psychoand happiness, provided we do not innights
of others.
Ultimately, we must ask the question of whether psychiatnic treatment itselfconditions the patient by making him choose accepted behavior and reject what is considered socially unacceptable behavior. To the extent that treatment has this effect, it is not psychodynamic; it does not enlarge the freedom of man. We must be able to make a fine distinction. Influencing the patient (as psychodynamic treatment does) does not mean conditioning the patient; it means increasing the patient’s vistas and his range of choices. The patient then does the
A mJ
Psi chiatri
132.1, January
1975
41
MAN’S
ETHICAL.
DIMENSION
choosing. As a matter of fact, as Halleck (8) has recently stated, the patient should have a voice even in the choice of his own treatment.
if we
have
added
responsibility rection to our
CONCLUSIONS
Am
will,
our
choice,
that
and
give
our
sense
of
meaning
and
di-
Alfred
A
REFERENCES
Often a defeatist philosophy of life, in which everything is presumed to be fallacious or illusionary, penmeates psychotherapy. According to this view there is no escape from the determinism that regulates human life (9); human life is a part of a deterministic cosmos in which everything is caused by something else. Obviously a large part of our existence is determined by outside forces. Certainly we must agree with Freud that the part of the iceberg which is submerged is much larger than that above the surface. But from that pant which is above water we can see the polar star and a large part of the firmament. Even though the deterministic forces prevail and ultimately overcome us, we should not feel defeated
42
our
to the conditions existence.
I Psychiatry
132:!, January
/975
I. Skinner
Knopf,
BF:
Beyond
Freedom
and
Dignity.
New
York.
1971
2. May R: Love and Will. New York, WW Norton, 1969 3. Salzman L: Personal communication, 1972 4. Farber L: The Ways of the Will: Toward a Psychology and Psychopathology ofthe Will. New York, Basic Books, 1966 5. Arieti 5: The Will To Be Human. New York, Quadrangle/New York Times Book Co. 1972 6. Arieti 5: Interpretation of Schizophrenia, 2nd ed. New York, Basic Books, 1974 7. Arieti 5: The Intrapsychic Self: Feeling, Cognition and Creativity in Health and Mental Illness. New York, Basic Books, 1969 8. Halleck SL: Legal and ethical aspects of behavior control. Am J Psychiatry 13 1:381 --385, 1974 9. Knight RP: Determinism, freedom and psychotherapy. Psychiatry 9:251-262, 1946
SlLV\()
Controversy: \IIIETI.
Man’s
Ethical
Dimension
\I.l).
Although determinism maypermeate human existence, man’s moral values raise him above the level of an animal and enable him to direct his own life. The author suggests that psychiatrists should influence thepatient to exert his will, make conscious choices, and, above all, assume a sense ofresponsibilityfor his own actions. In order tofree the patientfrom whatever conditions hinder his will and to help him make choices, psychiatric treatment must consider man’s ethical dimension.
COMMITTED AS WE ARE to the scientific method, we psychiatnists divide, dissect, and examine the psyche of the human being piece by piece. This is a legitimate procedune, provided that after the analysis we reach a synthesis, give the proper consideration to those aspects of the personality that could not expand, and, most impontant, do not leave out any basic human dimension. We do not always follow this procedure. In our double allegiance to science and to man, who in his totality is not reducible to the accepted canons of science, we tend to adhere to traditional science exclusively and to minimize man’s ethical dimension. In what I call the “ethical dimension” I include such vast areas as moral values and the phenomena of will, conscious choice, and responsibility. I do not mean to suggest that the therapist should impose his values on the patient; I simply wish to stress that values always accompany and give a special psychological significance to facts and that when we deprive facts of their value, we fabricate artifacts which have no reality in human psychology. An individual may suspend his value judgment when he wants to examine a fact from a specific point of view, but then the ethical content has to be reestablished if the fact is to have human significance. If we remove the ethical dimension, we reduce man to a subhuman animal, an animal that is not beyond freedom and dignity, but whose organization precedes the expenience of freedom and dignity-a subhuman animal to whom Skinnenian psychology can be safely applied.
Read tion,
at the Detroit,
127th annual Mich., May
meeting of the American 6-10, 1974.
Dr. Arieti is Clinical Professor lege, New York, N.Y. Address St., New York, N.Y. 10028.
of Psychiatry, reprint requests
Psychiatric
Associa-
New York Medical to him at 125 East
Col84th
It is easy for many of us who practice psychodynamic psychiatry to understand how Skinner’s approach has only limited application to our work. The functions of the psyche that we study in our daily work-feelings, emotions, attitudes, introjection, guilt, expectation, purpose, goal, inner self, personality, determination, choice, will, etc.----are miraculous on imaginary entities for Skinncr ( 1 ). According to Skinner, ideas, dreams, images, insights, and conflicts cannot be seen or observed and, therefore, do not count, nor can the existence of an inner life be inferred from them. Skinner follows a procedure antithetical to the medical procedure, for a physician does not simply observe his patient’s behavior but also makes inquiries about what goes on inside ofthe patient. Although I have never gathered statistics on a large scale on this subject, I am inclined to believe that many psychiatrists are ready to reject Skinner’s position. But unfortunately, many of us are willing to accept other positions that do not consider adequately the ethical dimension. In contrast to the position of Rollo May (2), Leon Salzman (3), Leslie Farber (4), myself(S), and many othens, a large group of psychiatrists and psychologists do not believe that there is such a thing as human will. Certainly a normal voluntary action consists of many steps, some of which are not yet susceptible to scientific analysis. We do not know when neurology ends and psychology begins. We do not know the intimate neurological mechanism that initiates a voluntary movement. Perhaps what we call will is the synthesis on result of many neuropsychological mechanisms plus newly emerging elements that in a tentative way we call autonomy, individuality, originality, creativity, and indeterminacy.
PREEMINENCE
OF
DETERMINISM
Determinism reigned supreme in the era of hard-toimagine proportions that extended from the appearance ofthe atom to the development ofthe human cortex. The simplest entities (the subatomic particles) and the highest (some parts of the human cortex), respectively, opened and closed this vast era that unfolded over billions and billions of years. The most complex entity in our universe, the human cortex, again permits a certain independence from causality as it existed at the subatomic level studied by Heisenbeng. However, the freedom of man,
Am
J Psychiatry
132./January
1975
39
MAN’S
ETHICAl.
DIMENSION
made possible by his cortex, is different from the socalled freedom ofthe subatomic particles. It is integrated with the essence of man. Although this freedom produces an interruption in the deterministic chain of causes and effects, it immediately rejoins determinism, thereby neestablishing continuity, for the will of man becomes a cause action. It is a causality compatible with free will. It is for future research to establish whether subatomic “freedom” becomes incorporated in some particles of neurons and changes ideas into free actions and thus reintegrates itselfinto the essence of man. For many psychiatrists, including myself, what we call will, that ability by virtue of which we conform our behavion to our determination, is the culmination of the psychological functions ofthe human being. Certainly we can bypass our will. We may meekly obey others, or we may behave in conformity with our conditioned reflexes. If we have some psychiatric disorder, our will is hindered in various ways. If we are hysterical, we lose control of some functions of our body. If we are phobic, the avoidance of the dreaded event rather than our determination will guide our actions. I f we are obsessive-compulsive, we feel obligated to obey internal injunctions even when they seem absurd. Ifwe are psychopathic, we cannot say no to ourselves; we are under the impulse to satisfy our urges immediately. If we are catatonic, we go through a stage in which even our smallest movement may be endowed with cosmic responsibility and guilt; consequently, we do not move at all. Those of us who have intensely studied the catatonic type ofschizophnenia consider the catatonic state to be the nadir of the human condition (6). Although the catatonic is not physiologically paralyzed, he cannot respond to people who touch him, bump into him,
of
smile
at
him,
on caress
him.
He
appears
to
be
a statue,
but unlike a statue he hurts in a most atrocious way, haying lost the most precious and human of his possessions -his will. By studying cases of catatonic schizophrenia of different degrees of severity, we can learn a great deal about the existence, unfolding, and impairment of the will (6). Psychiatric treatment attempts to liberate the patient from whatever condition limits his will, whether it is a mild neurosis or a severe catatonia. It should be understood, however, that total freedom and total self-causation are not available to any man. Even partial freedom is not something a human being is born with; it is a striving, a purpose-something to be attained. Being born free is a legal concept that, although valid in daily life, has philosophical limitations. Striving for freedom is an unceasing attempt to overcome the conditions of physicochemistry, biology, psychology, and society that affect human life. The psychiatric patient has the additional burden of ovencoming the conditions of his psychopathology, and the purpose of psychiatric treatment is to help him do so. It would be unrealistic to forget, however, that this self-ca usation is only a thin margin of a totality in which the majonity of facts and events are ruled detenministically. But I feel that this thin margin is sufficient to change the world, to make history, to cause the rise on fall of man (5).
40
A mJ
Psychiatry 132:1, January
1975
FREUDIAN
VIEW
OF
THE
CONCEPT
OF
WILL
Classical Freudian psychoanalysis has a controversial (and I would say ambivalent) attitude toward the concept of will. On one side, Freudian psychoanalysis adheres to a strict deterministic view of reality and life that leaves no room for human choice. According to Freud, most of our actions are caused by unconscious motivation, and as long as our actions are the result of unconscious motivations, we cannot call ourselves free or feel responsible for what we do. Like many other great thinkers, Freud contradicted himself on many issues, including the question of will. More than any of his predecessors on contemporaries he revealed the role of the unconscious wish as a detenminant of human behavior. But Freud’s great discovery does not imply that will has no role. Let us consider Freud’s famous statement, “Where id was, ego must be.” Freud meant that as a result of psychoanalysis, unconscious wishes, generally relegated to the id, must become pant of the ego; i.e., they must become conscious. But what is the purpose of this? To make the id pant of the ego does not mean unleashing the unconscious wishes or giving them free reign or unrestricted access to conscious behavior, although this is the way some people interpret Freud’s statement. I believe that Freud meant that once the unconscious wishes become conscious, they will be regulated by the functions of the ego. The individual will be in a better position to accept or reject them. In other words, Freud conceived psychoanalysis not as a libenation of the id but as a liberation of the ego from the unwanted, unconsciously determined oppression exerted by the id. Thus, psychoanalysis has the function not of restnicting but of enlarging the sphere of influence of the will. Its aim is to return a sense of responsibility to the human being for many actions that previously were beyond his control. In this respect, psychoanalysis enlarges the ethical dimension.
POSITION
OF
SOME
PSYCHODYNAMIC
SCHOOLS
In addition to Freudian psychoanalysis, some schools of psychodynamic psychiatry have also neglected the role of autonomy and individuality, which are prerequisites for free will. Whereas some geneticists believe that most or all of our life is predetermined by our genetic code, some psychodynamic psychiatrists believe that our present life is entirely determined by our past experiencesby what our parents, families, schools, and society have done to us. Thus, although the psychiatrists who focus only on the environment do not invoke heredity, their basic philosophy is similar to that of the geneticists: man’s destiny is shaped by forces external to the self.
WE
CREATE
Obviously
netic, familial, to the extreme
OUR
we
OWN
are
SELF-IMAGE
influenced
and social factors degree that many
by
external
forces.
Ge-
are important, but not psychiatric studies im-
SII.VANO
ply. Conceptions that view the individual only as a passive agent or tabula nasa, as a receiver, or as a puppet pulled by strings ofdiffenent kinds have prevailed in daily psychiatric practice. For instance, when we elicit a history from the patient’s family or (in most cases) from the patient himself, our aim is to establish how this history has made the patient what he is now. Some psychiatrists ignore completely the fact that the patient has always recreated that history. What he tells us is seldom what happened but more frequently what he perceived and interpreted, what he assimilated, and what his memory has constantly changed and given different meaning to. The child does not just reflect on absorb from the environment; he also tries to select what to absorb on what to give prominence to. The image that the child has of himself does not consist of reflected appraisals from parents or family members but of what the child did with those appraisals. In the same way, the image that he has of his parents and siblings, although related to the actual essences of these people, is not a mirror reproduction but rather a subjective interpretation. There is a definite discrepancy between the way reality and the significant people in one’s life were in the past and the way one has perceived
them.
nounced vidual
in the but also
individual
This
discrepancy
is
particularly
pro-
schizophrenic and pneschizophnenic exists (to a lesser degree) in the
and
in all
of us. This
discrepancy
mdineurotic
is one
mani-
festation of individuality. The image that the individual has of himself is particularly important because it is a major constituent of inner life on what is at times called the self. And, our self-image is not created exclusively by others but also by ourselves. We are among our own crcative forces. I must stress again that I do not mean that we are completely free. The self in whose creation we have cooperated is also the result of our specific biological endowment and a random mixture of’ external factors. The psychiatric patient has less possibility of contributing to the creation of’ his own self’ than the normal person because he was handicapped by external contingencies. However, the patient who has successfully progressed to an
advanced
mother
stage
on father,
of his
treatment
childhood,
will his
stop
spouse,
blaming or
the
his condi-
tions at work for all his troubles. The more he becomes conscious of his secret life (the more he understands his thoughts and motivation), the more he increases the area of his responsibility. He recognizes the role that other people played in his life, but he assumes some nesponsibility for what happened to him and especially for the way he will direct his life in the future. Ofcounse, it would be absurd for him to think that his destiny will be entirely in his own hands, hut he is aware that he too is a determining force in his life. Insofar as psychiatric treatment increases the ability to make choices, it is constantly involved with man’s ethical dimension. Any choice that affects others reveals our sense of responsibility, our concern or lack thereof not only for ourselves but for others. What we are responsible for is typically a product of our own self. Of course, when responsibility becomes one’s only concern, it is distorted
own
and assumes great decrease ety ofhuman
a tyrannical role; however, its absence, in it, produces in us the psychopathic life.
SELF-REALIZATION
AND
THE
ROLE
OF
ARIETI
or a van-
PSYCHIATRIC
TREATMENT
A misinterpretation and a misapplication of some psychiatnic and psychoanalytic concepts stand out among the many causes of the permissiveness and hedonism of our days. I refer particularly to the concept of self-realization that has persuaded many to strive for self-fulfillment, even ifthis means disregarding the rights of others. This misunderstanding derives not only from the already mentioned concept of id liberation, misconstrued from Freudian theory, but also from a broad generalization of some concepts of the neo-Freudian schools of psychoanalysis and humanistic psychology. Maslow, Homey, and Fromm believe that the highest ethic, as well as the aim of psychotherapy, is the one that leads to self-realization. This point of view is controversial on many grounds. First, there is no preordained, specifiable potential in man that has to be realized. Man is indefinite and capable of unpredictable growth because of the multitude of possible encounters with different systems of symbols and concepts (7). Man must aim at continuous growth or selfexpansion, but not at a mythical realization of an assumed potential. Man is not an acorn that may become an oak. For man, there is no question of potentiality but of infinite possibilities. Second, “self-realization” is very deceptive as a subjective experience. Reading the writings of Mussolini and Hitler, and even ofsome politicians of our own times, one is forced to conclude that these people were sure of realizing themselves and their “own destiny” by following a mission or mandate given them by the people. Third, and most important, self-realization ignones the actual problem of ethics, one’s moral relation to others. Self-fulfillment is not necessarily an ethical aim; it may be a form of hedonism and narcissism, again easily recognized in the lives of some politicians. What some authors mean by self-fulfillment is a legitimate aspination.
However,
not on ethical remain ethically ical principles. logical growth fringe
upon
the
when
self-fulfillment
is pursued,
it is
grounds but for personal gratification. To justifiable, it must not interfere with ethWe certainly should aspire to our psychoand happiness, provided we do not innights
of others.
Ultimately, we must ask the question of whether psychiatnic treatment itselfconditions the patient by making him choose accepted behavior and reject what is considered socially unacceptable behavior. To the extent that treatment has this effect, it is not psychodynamic; it does not enlarge the freedom of man. We must be able to make a fine distinction. Influencing the patient (as psychodynamic treatment does) does not mean conditioning the patient; it means increasing the patient’s vistas and his range of choices. The patient then does the
A mJ
Psi chiatri
132.1, January
1975
41
MAN’S
ETHICAL.
DIMENSION
choosing. As a matter of fact, as Halleck (8) has recently stated, the patient should have a voice even in the choice of his own treatment.
if we
have
added
responsibility rection to our
CONCLUSIONS
Am
will,
our
choice,
that
and
give
our
sense
of
meaning
and
di-
Alfred
A
REFERENCES
Often a defeatist philosophy of life, in which everything is presumed to be fallacious or illusionary, penmeates psychotherapy. According to this view there is no escape from the determinism that regulates human life (9); human life is a part of a deterministic cosmos in which everything is caused by something else. Obviously a large part of our existence is determined by outside forces. Certainly we must agree with Freud that the part of the iceberg which is submerged is much larger than that above the surface. But from that pant which is above water we can see the polar star and a large part of the firmament. Even though the deterministic forces prevail and ultimately overcome us, we should not feel defeated
42
our
to the conditions existence.
I Psychiatry
132:!, January
/975
I. Skinner
Knopf,
BF:
Beyond
Freedom
and
Dignity.
New
York.
1971
2. May R: Love and Will. New York, WW Norton, 1969 3. Salzman L: Personal communication, 1972 4. Farber L: The Ways of the Will: Toward a Psychology and Psychopathology ofthe Will. New York, Basic Books, 1966 5. Arieti 5: The Will To Be Human. New York, Quadrangle/New York Times Book Co. 1972 6. Arieti 5: Interpretation of Schizophrenia, 2nd ed. New York, Basic Books, 1974 7. Arieti 5: The Intrapsychic Self: Feeling, Cognition and Creativity in Health and Mental Illness. New York, Basic Books, 1969 8. Halleck SL: Legal and ethical aspects of behavior control. Am J Psychiatry 13 1:381 --385, 1974 9. Knight RP: Determinism, freedom and psychotherapy. Psychiatry 9:251-262, 1946
