Clinical Methods in Psychiatry Leston L. Havens Professor of Psychiatry, Massachusetts Mental Health Center, Harvard Medical School Modern psychiatry has developed distinct clinical methods correspond- ing to each of the major schools: the objective examination, free association, phenomenological reduction, and participant observation. Students and resi- dents seldom learn more than one or two, and the sharp differences between the methods make any eaxy or eclectic amalgam of them impossible. Never- theless, adequate training clearly requires mastery of all, just as sound practice requires our deciding when each is called for. Let us take up a problem in the teaching of clinical psychiatry. We can pretend we have a beginner—a medical student or a first-year resident starting clinical work; he is about to enter the general hospital wards, per- haps mental hospital wards. We want to decide what kind of teachers to give him, what written materials, and what type of clinical tasks to put before him, There are four major possibilities: descriptive-examinational, psycho- analytic, existential, and interpersonal. Each offers sharply different beginning experiences, which need distinguishing if the student is not to be confused and divided. DESCRIPTIVE-EXAMINATIONAL PSYCHIATRY Often we decide to teach the student first the examination of the patient —that is, how the patient appears and how to describe how he appears from the standpoint of a detached observer. We supply written materials detailing the various categories of description: appearance, behavior, mood, and the rest, These are analogous to what the student is already learning about the examination of the body, in which one also memorizes a long list of categories, so as not to omit anything, and then applies the individual items to the patient like a check-list. A patient who has sufficiently prominent signs to highlight an undisputable observation is selected—pethaps a patient with catatonic gestures, if such a patient can be found anymore, or someone CuinicaL METHops IN PSYCHIATRY ¢ 7plainly manic, incoherent, or distinctly obsessive. The goal is to indicate that there are definite psychopathological phenomena which one can learn to recognize and name—to increase one’s power of recognition. Perhaps even at this early stage of the work, attention is directed from isolated symptams to collections of symptoms and syndromes; an effort is made to teach recognition of several of the major features of the principal clinical entities, ‘There are a number of justifications for this widely used procedure. Tt has close parallels to general medical teaching: the emphasis on symptoms, signs, syndromes, diagnosis, and qualities such as orderliness and objectivity. The medical student, who is generally trained ta eschew subjective consider- ations, is not immediately asked to concern himself with his feelings about the patient, the patient's subjective responses, or the effects of the two on each other. Furthermore, in contrast to free-associative teaching, the student practicing descriptive psychiatry is given a great deal fo do; he does not have to endure long silences or keep his third ear cocked. Even if student and teachers feel a little superficial, there can be a businesslike, unanxious, objective air about these descriptive beginnings. Problems ‘spring up from several directions. In the United States today there are fewer and fewer teachers able to make more than the most rudimentary descriptive observations, Detailed knowledge of the distinc- tions developed in the first half of the century is unusual; the whole subject of diagnosis—its purposes, limitations, difficulties —has fallen into great confusion. Vague terms like borderline, latent, and reactive dominate clinical discussions. And even the patients fail us. Fewer and fewer have been locked up for decades, and perhaps for that reason they do not demonstrate so clearly the signs and syndromes of objective psychiatry. For every clear phobic complaint, there are ten patients who complain their “lives have gone wrong,” and more and more behavior problems fill the clinics, But even after we have decided that the problem is the patients, there remains the question: Could we teachers recognize any but the most blatant examples of classical signs and syndromes, if they did appear before us? ‘As a result, the initial teaching of descriptive psychiatry, although still widespread, becomes more and more perfunctory. Many instructors leave it entirely to the students. Manuals are handed out; no one reviews the writeups; there is a vestigial, ritual atmosphere, in striking contrast to the excitement and intimacy of supervisory teaching. There is one other major reason for this, the consideration of which will take us quickly to some different models for our initial psychiatric expo- sure. Observational methods comprise only part of modern psychiatry’s 8 ¢ INTERNATIONAL JOURNAL OF PSYCHIATRYI believe that the schools differ far less in their facts and theories (which can usually be translated back and forth) than they do in their methods. methods of data collection. The great bulk of clinical psychiatrists receive their long-term training in methods predominantly psychoanalytic, inter- personal, existential, or, very soon, behavioristic. Each of these schools, with the exception of the behavioristic, has made major attacks on the value of objective observations and descriptions; in fact, each established itself off the body of the first psychiatric establishment—descriptive psychiatry. Therefore, psychiatric instructors quickly take their students, no matter what else they have planned or are supposed to do, to the practice of those psychiatric methods they themselves have learned—be they free association, participant observation, phenomenological reduction, reinforcement, or re- ciprocal inhibition procedures. I think it is important to emphasize that the various psychiatric methods are sharply different. I believe that the schools differ far less in their facts and theories (which can usually be translated back and forth) than they do in their methods. Therefore knowledge of the various schools’ methods is not an academic or theoretical matter, but one of central importance to clinical practice. I appreciate that this is not what is usually said; we are ‘usually told that most psychiatrists do more or less the same thing and differ only in their vocabularies, theories, and major facts. Each of the major schools grew from observations of a certain kind, made on particular kinds of patients, using very special methods. Descrip- tive psychiatry used easily differentiated patients (because it was interested in the differences between patients) and attempted to establish fixed entities by describing objective signs that did not depend on the patient’s report, but could be validated by a number of observers standing off from the patient. The objective position and resulting method, so close to that of general medicine, emphasized the doctor's objectivity, his degree of detachment from , patients. Empathy, trust, and warmth were only tools with which to hold patient still, so as to be better observed, or to persuade him to give historical accounts of symptoms. The fruit of this was the psychological ‘or mental status examination and the host of possible observations included under it. Very quickly this objective psychiatric method came under attack. Some criticisms were, strictly speaking, not attacks, but efforts to extend objectivity (as with phenomenology). One, psychoanalysis, essentially took the objective ‘categories of Kraepelin’s and Janet’s psychiatry and worked within them— CuinicaL METHODS IN PSYCHIATRY * 9detailing the psychological processes leading to the classic entities. On the other hand, social psychiatry was an attack on objective psychiatry, certainly as it developed in the hands of Adolf Meyer and Harry S. Sullivan. In essence, these men said the symptoms and entities of German psychiatry were not fixed, but exquisitely sensitive to the social matrix. And, of course, existential psychiatry, leaving its phenomenological objectivity behind, attacked all ob- jective efforts. The psychoanalytic method shared objectivity and neutrality with the descriptive one, but in its passivity and the type of data produced it diverged very quickly. This is clear enough from the advice given medical students by psychoanalysts and descriptive psychiatrists. One says to ask questions; the other says not to. But of all the major schools, except bebaviorism, psy- choanalysis is undoubtedly closer to medical, descriptive psychiatry than any of the others (perhaps because Freud was so much the doctor and scientist), which makes the ill feeling common between the two ironical. PSYCHOANALYTIC PSYCHIATRY Rather than starting our beginner with the objective, descriptive method, we could start him with a free-associative procedure. Redlich’s book on the initial interview (1954) or perhaps the Deutsch and Murphy volumes (1955) could be used as reading. In this case most instructors would prefer out- patients as initial student experiences, and typically the student would be set to historical, rather than examinational, data-gathering. In fact, this is the procedure followed in a good many medical student and residency programs, whatever catalogs and brochures may state. Because they are often psychoanalytically trained, the instructors regard “unconscious material” as of the greatest relevance and sincerely believe the students need, first and foremost, to be taught to listen for and work toward the deeper layers. Therefore, these instructors’ comments in supervisory sessions—which today certainly constitute the chief and most sought-after psychiatric teaching instrument—quickly point the beginner toward a psychoanalytic stance. Although I discuss supervision here with the free-associative method, its place is not thus restricted. Existential and interpersonal psychiatrists also use supervision; only descriptive and perhaps behaviorist psychiatry are taught primarily through case presentations and at the bedside. We can, therefore, expect supervisory teaching to reflect much of modern psychiatry and some of its most recent trends. This it certainly does. Supervision allows attention to detail (whether of content, interaction, or shared feelings) in an ongoing relationship in which 10 * INTERNATIONAL JOURNAL OF PSYCHIATRYIn a classroom buttressed by classmates one can call the teacher a fool, but alone in his office, surrounded by the mementoes of a lifetime, how many have the heart or the nerve? little is expected right away or on the basis of a few observations. It allows attention to the doctor's problems—whether of countertransference, intimacy, spontaneity, perceptiveness, or the ability to be “where the patient is”); we have a treatment within a treatment. It permits adequate discussion of tech- nique. The student wants to know “how to do it,” and supervision is a kind of apprenticeship, usually to practitioners. Finally, supervision allows a very complete understanding of the patient. This ideal so deeply held during the 1930s and 1940s of American psychiatry—the ideal of grasping the patient's “whole personality”—has its best chance of fulfillment in the many-sided, prolonged acquaintance characteristic of supervision. The limitations of supervisory experience as a teaching technique are equally obvious, for attention to microscopic details must obscure the macro- scopic. Today’s students lack much sense of the shape of the great syndromes, ‘the ways in which patients differ, and the lifetime trajectory of different types. Close up many patients look very similar; we discover similar fantasies, con- flicts, and defenses—even patterns of interaction. Of course, the patients differ in the extent to which a fantasy is conflictual or the frequency with which a defense is used, but these quantitative considerations are hard to establish day to day, and the supervised patients tend to blur into one another. The intimacy of supervisory teaching tends to reinforce school loyalties —a second difficulty. In a classroom buttressed by classmates one can call the ‘teacher a fool, but alone in his office, surrounded by the mementoes of a lifetime, how many have the heart or the nerve? In addition, our own behavior and loyalty are so much the focus of the supervisory work: Have I done what his technical principles suggest I should? If I haven't, was it a matter of my misunderstanding, my disagreeing, my being “sick,” or is there that much ‘leeway in the technique? The student is on the spot in supervision rather than the teacher, as in the lecture situation. Worst of all, because psychotherapy is a scientifically unproved treatment, no one who makes his living by it can help but be defensive about the unproved status. And students’ questions must be very threatening. Oh yes, we have all been analyzed and may even have socked away enough to retire, but the defensiveness is obvious nonethe- less. Then there is the matter of the students’ fearing to be known. Psychiatric teaching is unique in the extent to which both knower and the amount known CuintcaL METHODS IN PsycHtaTRY * 11The supervisory process tends to reinforce the cult of silence into which ‘many of our people fell for so long. catch the attention of teachers, and this will remain the case as Jong as thera- pists are the principal instrument of therapy. We have a technology of people, in contrast to the rest of medicine. I remember in my first residency year one fellow resident in supervision with me, at the home of a noted teacher, who for several months could literally report nothing that the patient had said or done. The resident would lose his notes, remember nothing after an inter- view, or begin talking in the supervisory session only to go blank, Our tactful teacher waited, as he would have done in psychotherapy; he even resisted mentioning that this example of hysterical mutism sprang from a sexual conflict the resident had about the patient. Eventually the block passed, inter- view details were recalled, and the resident went on to receive a recommenda- tion from the teacher toward the next phase of his training. I am not suggest- ing that anything bad, or even unusual, happened. My purpose is to demon- strate the student’s tender, defensive position; he was so much on the spot. Is being in so tender, so defensive a spot compatible with free independent learning and investigation? Perhaps it is in medical school in which the students still have many options, but, once the great professionalizing and guild-building process has ‘begun in the residency years, J wonder. In short, supervisor and supervisee tend to condition, to reinforce, each other at the expense of more flexible, adaptable, changing knowledge and skills. I think, too, that the supervisory process tends to reinforce the cult of silence into which many of our people fell for so long. If he were to say something to the patient, the student might have to report it to the supervisor; at least it might leak out during the supervision. Now, we make a great mistake if we underestimate the extent of fear students have of instructors. A student may fear to report what a patient has told him, if he feels ashamed not to understand it; he will be a good deal more fearful to report what he himself has said, especially if he does not understand that either. One solution is to say nothing, or, as one student told me cheerfully, to invent afterwards what you've said. John Holt has taught us how often these “adaptive” maneu- vers occur in Classrooms. Supervision is not exempt. Supervision also favors the intellectual cast of psychoanalytic teaching. Some teaching methods, such as seeing a patient together with the teacher, favor observational skills; others favor empathic skills or other special inter- viewing techniques. But supervision focuses on explaining. This has always 12 © INTERNATIONAL JOURNAL OF PSYCHIATRYPsychoanalysis asks that masks be dropped, not to embarrass their wearers, but because the need for some of them is long since gone, because the closely guarded private self is a product of misconceptions, narcissism, and fears. been the glory of psychoanalysis—its explanatory power over extraordinary ranges of data: psychic, social, literary, anthropological, religious. The result for the student is a dramatic increase of his own explanatory power. Again, Tam not calling attention to this because it is bad. It is obviously very good; for example, analytic students gain special keenness in understanding the Jarge number of possible meanings any human event can have. What I am suggesting is that supervision has serious limitations when it is the only, or even the major, teaching device. Then there is the psychoanalyst’s interest in unmasking. Like the rest of modern medicine, psychoanalysis moves us behind the first-given, sympto- matic phenomena to the processes concealed. It is always ready to believe that things are not what they seem—that behind the skin is the tumor. Recall ‘how in Freud’s Dora case suspicion fell on first one family member, then another; the very reproaches Dora made toward her father Freud brought back on her own head. In the end everyone was involved, like the characters ‘in an Albee play. I do not need to emphasize that this skeptical, worldly atti- ‘tude—physician as detective—accords well not only with many tempera- “ments but, more important, with reality. Disease is partly a defensive process; ‘the hard issues are hidden ones. Superficiality, denial, naiveté—against which psychoanalysis sets itself so splendidly—must lead us astray. At the same time this unmasking can become a formula and a game. In Jung's theories, for example, we ate asked to accept a psychology of oppo- ‘sites: if the masculine element is outer and conscious, an equally powerful feminine element must be inner and unconscious. One gains symmetry at ‘the expense of nature’s not-so-neat reality. Or in psychoanalysis, we come to “suspect that love means hate, masculinity homosexuality, and so on. Experi- enced practitioners know better, but the student's first impulse is in this “direction, resulting in a great rise in his suspiciousness of others and himself. ‘One fears “giving one’s self away.” Slips are watched for. The student grows "guarded, even spooky, like some of the doctors. Worst of all, one tends to _ approach the patient district-attorney fashion—out to prove the worst. Patients sense this quickly and grow guarded in their turn. In short, the medical tendency to unmask may lead to more masks and an escalating, quiet quarrel between patient and physician. Later the psychoanalytic student will say to his patient, “Yes, T want Cunicat METHops IN PsycHIATRY * 13to unmask you, but not because what you have masked is bad. Quite the con- trary, your mask is unnecessary and only costs you energy better spent clse- where.” There is Hilarie Belloc’s poem about the English courtier Godolphin: Today I heard Godolphin say He never gave himself away. Come, came, Godolphin, scion of Kings, Be generous in little things. That is bitterer than I mean, but the point is there. Psychoanalysis asks that masks be dropped, not to embarrass their wearers, but because the need for some of them is long since gone, because the closely guarded private self is a product of misconceptions, narcissism, and fears. Our teaching problem, then, is to take the student beyond unmasking as a personal motive to some larger view of face and mask. That we are not always successful is obvious from the way some even experienced analysts use analysis as a weapon, not so much against disease as in defense of their own egos. But as much could be said against the scalpel and some surgeons. These last two emphases of analysis, intellectuality and unmasking, make up a large part of the existential criticism of Freud (Jaspers, 1963). I think it will help move forward this paper’s effort, in order to show the limitations as well as some of the advantages of all the schools, to now con- trast psychoanalytic methods with existential ones. I will start by contrasting phenomenological methods (out of which existential psychiatry grew in part) with analytic ones; then I will discuss existential psychiatry directly, as an introduction to our third beginners’ model. First, there is one familiar difference in the data of phenomenology and psychoanalysis. Phenomenological data are “conscious”; indeed, they are the very stuff of consciousness, The investigator directs the patient’s attention to his feelings about time and space and colors; he asks him to report what he experiences under these categories. He seeks an alert, aware, cooperative, hopefully articulate, even eloquent patient who can render his inner experi- ences. In direct contrast, psychoanalysis seeks a dreamy state. Everything alert, directive, self-consciously descriptive should be thrust aside; one wants to let deeper levels of the nervous system speak, The deepest unconscious stuft will take time to emerge; the psychoanalyst needs great patience, plus the ability to detect resistances to emergence and what is required to remove them. Further, he must expect the unconscious formations to emerge in rela- tion to him, almost as if, because he lay closest, when they did emerge they 14 * INTERNATIONAL JOURNAL OF PSYCHIATRYThe phenomenological investigator ... wants to enter the patient's world— to be taken into his mental life, his eigenwelt, and to experience with the patient his umwelt and mitwelt, his surroundings. attached themselves to him; but, of course, his neutral presence attracted the neurosis. The neurotic capacity for extraordinary hopes and expectations found in the neutral, passive doctor fresh opportunities for exercise and rose to the bait. All this is a kind of turning the inside out, luring the inside out, so that the neurotic formation can be examined and worked over as it occupies the relationship between doctor and patient. Something very different is required of the phenomenological investi- gator. He wants to enter the patient's world—to be taken into his mental life, his eigenwelt, and to experience with the patient his umwelt and mitwelt, his surroundings. So Minkowski literally moved into the schizophrenic’s life space and, by living there with the patient, caught glimpses of how the world must look to his companion. This sort of home visit, carried to the highest power, represents the almost final breakdown of the enormous initial barriers between patient and doctor. The phenomenological doctor must be active, literally active, moving his place of business. This, too, is in contrast to the activity of the psychoanalyst, who is verbally incisive. Emphasis falls in one method on the person of the patient, in the other on the material. Verbal incisiveness is the last thing the existentialist would want to have, lest the patient see it as critical and distant, while the phenomenologist is bent on being “taken in.” Similarly, even if the existential doctor wants to be “where the patient is” (only in an emotional sense, without the actual move), he must actively put himself in the patient’s mood. He must abandon all objec- tivity or surveillance of the patient’s situation and accept the patient’s exper- ience of his situation on his, the patent’s, terms. Later there may need to be corrections, but at first the existential doctor will have to take the patient's view of mother and father and live in that felt relationship with the patient. The existentialist is “taken in,” and the risks of being “taken in,” in the other sense, make the existential method frightening or foolish to many. At first in the development of phenomenological and then existential analysis, it was necessary for the doctor to be “taken in,” in either sense. ‘As Jaspers (1963) said, everything depended on finding communicative patients and then taking down what they said. But the investigators grew tired of these anecdotal reports, these fragments of experience, and wanted a more inclusive view—of umwelts, mitwelts, and eigenwelts. Furthermore, how was one to know what the uncommunicative patients were experiencing? (CLINICAL METHODS IN PsYCHIATRY * 15By placing himself as much as possible in the patient’s world, the existential psychiatrist finds feelings like the patient's generated in himself; he is readiest of all psychiatrists to share the patient's feelings. Specialized methods thus had to be developed. It was likely, too, that not even the communicative patients were telling much; many of the patients’ accounts in the phenomenological literature have an official feeling that sug- gests diplomatic bulletins. Similar to this is the experience, of anthropologists studying foreign cultures. They wander into the tribal area, encounter a few natives (who are probably communicative largely because they have no one else to talk to), and hence are not part of the center of things. Later, if they behave themselves, less eccentric informants appear. They discover that the first spokesmen were either part-outcastes or, even less helpful, official types, meant to dispose diplomatically of strangers. Later serious anthropologists learn the language, sit around for long periods letting themselves be known, perhaps dress and eat and sleep as the natives do, until they are all but natives themselves. Then everything seems quite different—for example, much less “primitive.” The existential method developed in just this way, with more and mote reduction of the foreign elements. The examinational and free-associative methods also developed slowly into their sophisticated forms (contrast Benjamin Rush’s examination with those of the contemporary Maudsley, or Freud’s technique in the Katherina or even Dora case with the modern analyst’s). So existential psychiatry went from a dependence on reports of willing patients to phenomenological reduc- tion—the name for the existential method of shedding ideas, expectations, prejudices, and formulations, in the interest of getting closer to the patient. We are to approach the patient naked, openhearted; the goal is to be utterly unbiased, to “put the world between brackets.” Of course, we are no more able to be successful at this all the time than the analyst is to get all free associations, or the Sullivanian is to “participate” steadily. But the existential analyst means to achieve, as far as possible, this putting aside of preconcep- tions, ideas, expectations, and diagnoses—hence the wooly-minded, far-out reputation of existential psychiatry among doctors. In contrast, the whole business of medical education is to equip the doc- tor, load him down with facts, concepts, instruments, and injectables. The medical students and interns on the general hospital services come to resemble the White Knight in Alice in Wonderland: the thick notebook in one pocket, stethoscope or ophthalmoscope falling out of another; the forehead tense with knowledge, facts almost held there in the frown, so freshly learned they feel 16 * INTERNATIONAL JOURNAL OF PSYCHIATRYeasy to lose. The student might yearn to be phenomenologically reduced, or reduced in any way, but the whole, stubborn drift of medicine is against it. What existential psychiatry gains by its method is power of feeling. By placing himself as much as possible in the patient’s world, the existential psychiatrist finds feelings like the patient’s generated in himself; he is readiest of all psychiatrists to share the patient's feelings. We can also contrast existential’ psychiatry and psychoanalysis in the physical positions taken by patient and doctor. The existential eagerness to be “taken in” means the doctor places himself in front of the patient; he does everything not to conceal himself. On the other hand, psychoanalysts literally disappear; they do not want to be “taken in” or to intrude themselves. A space is being cleared between doctor and patient into which mental content can flow. In contrast to both psychoanalysis and existential psychiatry, interper- sonal or Sullivanian psychiatry will sometimes place the patient beside or at an angle to the doctor; the two can see each other, but not directly. The Sulli- vanian does not want to confront the sensitive patient too directly, but he also does not want to go out of sight completely; that would allow the patient's projections too complete a dominion of the clinical situation. Finally, the descriptive psychiatrist sits or stands before the patient, like an existentialist, but he places something between himself and the patient—desk, instrument, folder. The willingness, even eagerness, of existential therapists to be “taken in” allies these methods with religious practices and healing, as does the existen- tial concern with values and meaning. Typically, religious people throw down their arms before the world. They choose not to be defensive or shrewd, or perhaps temperamentally cannot be; great emphasis falls on the wisdom of naive folk and children. It is not so important to win on the world’s terms as to “preserve oneself by losing oneself” (entering the world of the other, in existential language). The good religious and the good existentialist relish disaster as an occasion to show oneself before the world. Contrast this with the psychoanalytic concern with drive discharge, the compromising of pleasure and reality, the unmasking of religion—indeed, the psychoanalytic unmasking of everything conscious, secondary, or defensive, which is the farthest thing from the existential “acceptance of life.” It is partly the difference between naive, enthusiastic natures and cunning, penetrating people, so that, as usual, we will see different temperaments drawn toward specific psychiatric methods and schools. Similarly, existentialism seeks meaning, emphasizes the clinical impor- tance of values, while psychoanalysis aims to reduce values to wishes and counterwishes: on the one hand, a reductionist emphasis of analysis; on the (CLINICAL METHODS IN PSYCHIATRY © 17other, existential reaching for wholes. So again there will be important tem- peramental differences to help decide school allegiances. Those who want to grasp the elements at work in any process—to separate out, to gain clarity and predictive power—will be drawn to psychoanalytic thought. Those seek- ing a general openness to the world, making an effort to experience things as they immediately are, will avoid reductionism and intellectualism and thus be closest to existentialism. Certainly, patients must experience the two approaches very differently. Those patients most likely to “take us in’—that is, psychopathic people —offer a nice example of the difficulties of either method when used largely alone. A central part of the syndrome psychopathy is this tendency to “take people in.” Indeed, I teach that, if the doctor realizes very quickly that the patient is psychopathic, then either the patient is not so or at least not very much so; the helping person should be won over. At first glance this looks like the worst possible case for the existential methods. We can imagine psychopathic people looking up with a grin at the thought of “encountering” existentially oriented doctors. There is truth in that and in the greater safety of psychoanalytic efforts to reach behind this first-given, psychopathic charm for the various destructive and manipulative interests concealed. But at the next stage of the relationship, it is almost as if the relative appropriateness of the two schools’ methods were reversed. What happens is characteristically this. The psychopathic person does “take us in,” on the basis, say, of a hard-luck story; he has never had a break, and we should be the ones to provide it. The patient leaves; our wallet dis- appears with him and perhaps the morphine from the medicine chest. We were certainly “taken in,” as well as from, and psychoanalytic colleagues can gleefully remind us that certain countertransference rescue fantasies or other great expectations of our own were lit up by the patient, blinded us, and then abruptly turned off. But let us say the patient returns for a second visit, or third and fourth visits, presumably because the court insists on it or he wants more morphine or even perhaps he has some distant perception of being helped. If (and this is a large if) we can recover from our disillusionment, which was really proof only of our having had illusions—if by any chance we should regain our professional equilibrium, we discover that the patient's hard-luck story was exactly that. He really had a miserable upbringing and unreliable parents; his world was, if anything, worse than he had described it. For this is, in fact, the fully established early history of the psychopathic syndrome. If we persist in our psychoanalytic skepticism, we may not believe these truths; we may ascribe them to fantasy formation. The patient interprets this as disbelief and therefore distances himself from us. It turns out, in fact, that we are 18 * INTERNATIONAL JOURNAL OF PSYCHIATRYrefusing to believe the truth and so cannot help the patient with any reality- testing problems he has. As a result, this detachment and effort to unmask grossly mislead us. On the other side, while the existential doctor was initially misled and more easily robbed, at this later stage he proves sounder. He is now able to stay in contact with the reality of the patient. Thus we can see that the psychiatric schools lead to real achievements, but that each achieve- ment is limited; the schools need each other. Even this tolerant, ecumenical statement is misleading, however, for it suggests some easy commerce between the isolated points: inward feeling versus intellectual content, active pursuit versus passive waiting. And last: exisential partnership stands so starkly opposed to the psychoanalytic neu- trality and objectivity that we have to ask ourselves how any one clinical per- son can put together elements so diverse. EXISTENTIAL PSYCHIATRY In the existential mode the student is to enter and share the patient's world. He can attempt this psychologically or socially or both. He can share the patient’s feelings and ideas in an act of empathy. Or he can literally enter the patient’s world by visiting his home, moving with the clinic closer to the patient’s world, and working with the patients when their problems arise, as in emergency psychiatry, rather than waiting, scheduling, and setting in motion the elaborate apparatus of doctor-centered medicine. Both these exis- tential modes—empathy and social sharing—have great appeal today. There is much contemporary talk about equal rights, perhaps more than ever before: equal rights for men and women, black and white, children and adults, rich and poor. It is largely talk, and the old hierarchical arrangements persist. But out of such egalitarian efforts in the past have come spinoffs for that very large minority group—patients. It was the revolutionary communes roaming through the Parisian hospitals, rather than Pinel, who struck off the chains of the insane. And our own psychopathic hospital and community health movements in the United States began during the Progressive Era at the start of this century. Today, again, consideration is being asked for under- privileged people, including patients. For our contemporary beginner in psychiatry the egalitarian, existential approach has one further appeal. The student is already “reduced.” He has less knowledge, fewer diagnostic ideas, and less technical apparatus to discard than the well-trained professional. He also has a more natural upwelling of sym- pathy for the patient; there is a greater eagerness to help, less of the slightly jaun- diced, or even cynical, matter-of-factness characteristic of the seasoned ‘CLINICAL METHODS IN PsyCHIATRY * 19