"You Can't Feel Your Thoughts":
A CLINICAL NOTE ON THE EXPERIENCE OF SCHIZOPHRENIA*
Ferdinand van der Veen
(This paper was originally published in Voices: The Art And Science of Psychotherapy. Spring, 1974. This is the journal of the American Academy of Psychotherapists. The paper has been slightly revised for this venue.)
In this paper I want to present and discuss a verbatim account of a portion of a group therapy session with hospitalized mental patients, during which two patients commented with unusual depth and clarity on their experience of themselves in relation to their illness. The central theme of their comments concerns the cessation of a mental process; a stopping or blocking of the mind that results in an inability to know one's own experience--to feel one's thoughts or think about one's feelings. This process seems relevant to many of the difficulties encountered in psychotherapy especially with schizophrenic persons.
A Therapeutic Problem
Psychotherapy with the hospitalized schizophrenic person is commonly accepted as a difficult, problematical undertaking. In contrast to the therapist's experience with non-hospitalized, less disturbed persons-persons more like himself-here he is faced with an unfamiliar and unpromising therapy situation and one that is difficult to understand. The hospital patient may or may not be acutely upset at the time the therapist sees him, but in either case he is often unable to talk about feelings, to engage in self-exploration, to recognize or try to understand his personal problems, to develop trust in the therapist; or, in general, to engage in the kind of activities found to be helpful for less disturbed persons. Also, the patient may often interrupt, misunderstand, or simply not attend to the therapist. The task facing the therapist, to help this person achieve some stable sense of personal integrity and adequacy, is therefore both puzzling and uncertain.
One obstacle to this task is the difficulty in accounting for the behavior of the schizophrenic person in terms of his own experience of himself. In part this can be attributed to the inability of the schizophrenic person to communicate his experience.
But it also appears to be due to a general lack of knowledge about the inner experiences of the schizophrenic person.* What is it in his experience that makes self-exploration, attending to feelings, and listening to others so difficult and unlikely? What is the schizophrenic person's own sense of what is amiss in his inner world?
*This paper was first drafted while the author was at the Wisconsin Psychiatric Institute, and was partially supported by USPHS Grant No. 3496 to Carl R. Rogers. Appreciation is extended to Norton Stoler and Eugene Gendlin for their helpful criticisms.
The Experience of Two Schizophrenic Patients
The purpose of this paper is to provide a partial answer to these questions in the words of two schizophrenic patients, as they talk about their experience during a session of group therapy. The following quarter-hour of a group therapy meeting (the tenth such, with a group of eleven patients) is presented verbatim to give as accurate a picture as possible of the way in which the patients viewed their own experience.
One patient, Joe, is in his middle twenties and comes from a rural background and has had little education. Roy, the other patient, is in his middle thirties, and considerably more educated.** Both Joe and Roy have been severely troubled by schizophrenic experiences and episodes for a number of years. The author served as therapist for the group. No attempt is made here to analyze the therapist's statements; they are included to provide the original context for what the patients said. Generally, the tone of the therapist expressions is consistent with an attempt to understand in a tentative fashion the present experience of the patients and to encourage self-exploration and personal identity. The excerpt begins with the therapist asking a question of one of the patients:
Therapist: (To Roy) . . . I think it has something to do with, well here's somebody who really cares enough, somehow, that he wants you to get well. I was wondering, what do you think of that? What do you think of Jack feeling this way (toward you)?
Roy: (Rejecting Jack’s caring about him) Well, what is well? I'm comparatively well today! At least I'm not depressed. At least I'm not a ... I don't have these constant thoughts going through my mind. I'm not overly anxious today.
Therapist: (Wanting to understand) That you're actually feeling pretty good already, today.
Roy: I suppose the mind takes just so much and then it can't take any more and it just blocks out all this terrible, terrible thing that's gone on for the last two or three months.
Therapist: Hm ... Your mind, somehow, inside you, said, "Well, that's enough. This, this is as much as I can handle, and I'm just not going to think about all these things."
Roy: Well, (sigh) I, I know there is something terribly wrong with me and I know I'm sick. And I guess once you try to, to accept, try to accept this thing, that's a step.
*Shlien (4) has discussed the genesis and the results of the psychotic state: "Once experienced, this is indescribably frightening, and the acute state leaves (the person) deeply shakenand unsure of himself now he knows what psychosis is, even though we do not (1961, p.293).
**Assumed names are used for the patients and identifying material in the transcript has been slightly altered to avoid recognition.
But, but, ah, you're sick that's all (gently spoken), and when I'm, I feel pretty good today, I'm still probably even more sick right now than I was months ago. I don't know.
Therapist: You really have no way of telling how sick you are.
Therapist: But you feel pretty sure that you are, that you are not well, the way Jack would like you to be.
Roy: Well, I know that, what I went through, was, was a sickness, and, ah, complete mental collapse and, I have written down things in the notebook that I have, my reactions, reactions of myself towards people and the reactions of people towards me, and most of the reactions are reactions (quietly explaining) of ah, of ah, (sigh), well, (more quickly and with more emphasis) that lead me to believe that, that there is something very obviously wrong with me, that, that everyone, can see it. Because when I talk to people I, ah, going on in my mind all the time are things that, ah, I'm sure they are thinking (T: Hm.) And which I'm sure they are thinking.
Therapist: Right now?
Therapist: Right now?
Roy: Right at this moment?
Therapist: While you are talking to us.
Roy: No, because yesterday and today have been sort of good days. If they are good days, they are good days in the fact that I’m fairly calm. But as I said, perhaps I'm sicker than I was even when I was upset.
Therapist: Why is that?
Roy: Why? Because when I do feel like this, when I do feel the way I do today, it's a feeling of ah, that I’m rejecting everything that I wrote down in this notebook, of my feelings, and so forth.
Therapist: You're saying that never happened or something?
Roy: (Quietly, but emphatically) No, no, the feelings happened, but I must go back to this, to try to figure out what's wrong with me. (More emphatically) I must go back to this to find out what happ-- what, what's wrong with me, so that I don't get upset again like I did before. There is this constant fear that I'm going to get upset again; and go through what I went through last August and September.
Therapist: Hm. And that was so frightening and terrible, you somehow want to feel very sure you don't have to ever...
Roy: If I have to, I, I don't want to forget that because that's most important. Before, I always forgot this. I managed to go along, and (sigh) and drag myself around, even though I was depressed many days, and everything. But, then what happened? Bingo! I up, I got, I went to pieces again. That has happened now twice in the last two years. And I don't want to go through that again, I'd rather be dead . . . I, I just can't think of how hard it was for me.
Therapist: Hm (softly).
Roy: . . . And I just hope that it doesn't, I just hope. You see, I can't be sure, it may be even more severe than it was last year, and, if it's more severe, it will be even worse, it will be, and I can't comprehend this, I'm so, in such a terrible state ....
Roy: That I just . . . I just can't comprehend this. 1, it's like trying to comprehend infinity.
Therapist: Can't even think of something worse than the way you felt, last September. Somehow that's really there now in you, that, "by God, I can feel this way. That can happen to me. And that is so horrible, I don't, I don't ever want to forget that, I don't, I want to somehow find out about it. In some way feel reassured or assured that it won't happen again, and, not to be afraid of that, of it happening again" . . . And that's why you feel a little suspicious when you, when you're like you are today, because you realize, "Well, when I feel this way for very long I'm very likely to forget how upset I was, or something. And I don't, I don't want to forget that, that's too important." ... Is that right, or...?
Roy: Yes, that's right. (Pause)
Therapist: Do some of the rest of you, who've been kind of quiet today, have some thoughts on this?
Joe: It seems like I went through the same thing, ah, last spring, cause my mind was taking so much of, what he was talking about and then, and towards last May, towards summer, ah, my mind just couldn't take no more, it just, stopped like that, and, ah, (Therapist: Hm-Hm) I've been going along like that ever since.
Therapist: That you, too, had a kind of episode of just feeling ....
Joe: (Interrupts) Feelings, feelings that of hearing, kind of like, remember--trying to think that what everybody else is thinking and, ah, and hearing, kind of imagining voices and that and, got so, it got so your mind couldn't take it no more, then it stopped.
Therapist: Hm-hm. I see. It was the same quality of this getting worse and worse and worse until you just, you reached your limit and ah, shut it off, in a way.
Therapist: And there's somehow also the feeling, like Roy has, that this is still part of you, in a way, it's just kind of, shut off, but ....
Joe: It, it's still part of me, it, for all I know I could be sicker (now) than I really was, but ah, it's just that it's calmed down so that it don't, don't seem that way right now.
Therapist: Um-hm. I see. Right now you don't feel that way.
Joe : That's right.
Therapist: Hm-hm. I was just wondering because you, you've asked for EST (electroshock therapy) and so on. So I, I thought it might still be, might be there for you, something like, still be upsetting you in some way.
Joe: (Explaining) Oh, ah, it's hard for me to get a thought in my head that, that I can feel, you know. It's hard for me to think, I, so I can feel. I can think in a calm way but I can't remem-- think, ah, think so that, so I can ah, feel it in my head much. I thought, that's why, I say I might be, ah more sicker than I really was, but I'm just in a calm way. I know that ah, when I first came, the University doctor, when I was up in the ward there, checked me over and he said ah, "Your head must be like a radio, I mean, you can't get a," I don't know why he said it, why he referred to it like a radio, but he said "You can't get a thought in your head, ah seems like you're scared to think, get a thought in your head."
Therapist: Hm-hm. That somehow, well, I guess my way of understanding that is that, shutting down this way, like you did last summer, somehow, let you close your mind to thinking, in a way.
Therapist: And, ah, even though you can be calm now, it's kind of costing you, paying the price of not really,
Joe : Being able, being able, being able to think.
Therapist: Or at least feel like you're thinking. Guess that's more it, because you are obviously thinking, you're doing,
Joe: In a calm way. You can't feel it though, feel your thoughts or thinking.
Therapist: Hm-hm. It's the feeling of, "I'm really thinking this," That's not there. (Joe: Yeah). And that makes you wonder (Joe: Yeah) "Aren't I still sick, or a feeling like that, if I can't really feel my thinking?" . . . It's interesting that both of you two should feel this way. Here both of you are feeling kind of calm today, but both of you are wondering if you're not sicker now than, than you were before.
Therapist: I think I understand it better now.
Roy: (Aggressively) Do you think we are?
The Meaning of Their Experience
A central theme in the many ideas and feelings the two patients expressed during this excerpt is the occurrence of what might be termed the loss of the ability to know their experience. Amid much tentativeness, confusion and hesitation, they expressed this loss in a number of ways:
Roy said that his mind blocked in response to great turmoil, that he is unable to know whether he is sicker now than before, that he needs to reestablish contact with an essential part of his experience to guard against a recurrence of the turmoil and terrible suffering.
Joe expressed much the same uncertainty as Roy about being sicker now than when he was upset, and that his mind stopped when his experience became intolerable. He also said that now it is hard for him to get a thought in his head which he can feel. He almost said it is hard for him to think while remembering feelings. It is as if he can think, but not about or with feelings. The effect of this is that he is not really able to think, or, stated in a more precise way, that while he might be able to think, he cannot feel it, he cannot feel his thoughts. At the end of the excerpt, in response to the therapist’s somewhat impersonal statement, Roy reasserted both the importance of knowing and his own inability to know, by aggressively demanding that the therapist tell him whether he is sicker now than before.
Three elements in what Joe and Roy said seem especially difficult to account for in our present understanding of personality and personality change. They are (1) the stopping of one's mind, (2) a profound pervasive uncertainty about oneself, and (3) an inability to feel one's thinking. A possible connection between these elements in the patients’ descriptions may be outlined as follows:
1. Chronically stressful mental conditions lead to a cataclysmic upset in the person’s inner experience involving both thoughts and feelings.
2. This terribly painful upset is halted by the cessation of a fundamental mental process, experienced as a stopping or blocking of the mind, which quiets the upset.
3. As a consequence of this mental cessation a profound connection between the person’s thoughts and feelings is no longer intact. While it is again possible for them to think rationally, they no longer have a direct sense of their inner experience, including the experience of their own thoughts. They cannot think about their feelings nor feel their thoughts. And they can not judge their own state of well-being.*
Implications for the Patients' Lives and for Therapy
The loss of the ability to know themselves, to think about their feelings and feel their thoughts, to be in touch with and use their own experience, has a profound effect on many aspects of the lives of the patients. It means that a pervasive uncertainty attends many of the simple day-to-day decisions they need to make regarding their lives; it means that such elementary personal knowledge as whether they felt a particular way, angry for example, is mostly beyond their understanding;
it means that the effects of future events are largely unpredictable. These and other consequences of this loss helps us understand their sometimes overwhelming inadequacy in functioning, as well as their adequate and essentially normal behavior in certain impersonal situations where reliance on a knowledge of their own experience is unimportant.
The loss of the ability to know themselves may also help to account for a number of the puzzling aspects of the behavior of such patients in therapy. It has many consequences in terms of what they would then not be able to do. It means that they would be unable to communicate their feelings or attitudes accurately, or to explore their own part in their difficulties and problems, or to form a close trusting relationship, or to use their own judgment in evaluating their experiences, or to achieve a sense of their own personal identity. To the degree, therefore, that, as in the case of the patients, intellectual functioning can not be included in an experience, knowledge is not possible.
|*In an article on the goals of psychotherapy, Malone, et al., (2) mention the following anonymous quotation: "The poet straggles to make the reader 'think about his feelings, but even more importantly, feel about his thinkings,'" which illustrates the especially human and central quality of the interplay between our thoughts and our feelings.
Gendlin, in Experiencing and the Creation of Meaning (1) has presented a theoretical formulation of therapy which holds that meaning comes from and depends upon feelings, or more exactly, on the ability of the individual to refer directly to his inner experiencing.
A similar viewpoint, arrived at from a completely non-clinical frame of reference, is presented in the philosophy of Whitehead (5), which refutes the primacy of strictly sensory data in arriving at knowledge. "The philosophy of organism . . . explains the process (whereby there is the experience) as proceeding from objectivity to subjectivity, namely, from the objectivity, whereby the external world is a datum, to the subjectivity, whereby there is one individual experience. Thus, according to the philosophy of organism, in every act of experience there are objects for knowledge; but, apart from the inclusion of intellectual functioning in that act of experience, there is no knowledge (1929, p. 256)." (Italics added).
In addition to the implications for the lives of the patients and for their behavior in therapy, the patients' descriptions are also relevant to the experienced continuity on the part of the therapist between more and less disturbed persons, and between them and the therapist. It has often been said that schizophrenia or psychosis is a matter of degree, not of kind; also, that all persons have experiences similar to those of the schizophrenic, but not to the same extent. This similarity in kind between the various degrees of disturbance is supported by the occurrence of the kinds of problems described above for most therapy relationships, though to a lesser degree.*
On the other hand, if we consider the similarity and continuity between degrees of disturbance and between all human experience in the light of the descriptions of the patients, one salient fact emerges. It is that these persons have directly experienced the cessation of a mental process, a stopping of the mind, followed by an inability to know their experience, to judge their own well-being and to feel their thinking. While it is likely that at one time or another most of us have been unable to feel our thoughts or to know how we are, we have probably not directly experienced the actual interruption of the process that makes this possible nor, of course, the cataclysmic pain that appears to lead to such an interruption. We still have a strong sense of the possibility of feeling our thoughts, of being able to come to know about our experience, of, in a word, our potential for personal growth. In schizophrenia, on the other hand, the person may have directly experienced the loss of this potential. It would follow that a central problem in the treatment of schizophrenia concerns the patient’s inner struggle regarding if and how to re-establish this potential for personal, intuitive knowledge. How will it be possible for the schizophrenic person to again know about, make sense of, and attribute meaning to his feelings, so that he may again "feel his thoughts" and "know how he is"?
|*Otto Will, for instance, in a paper on Psychotherapy in Reference to the Schizophrenic Reaction (6), quotes Sullivan's remark that "We are all more human than otherwise." Further on in the same paper he writes that "In the course of therapy, we will discover that he who seemed crazy and incomprehensible to us appears so, in part, because his behavior is a reflection of those aspects of living common to all of us, but rejected and forgotten . . . (1961, p. 156). Rogers (8) has proposed an inclusive continuum of personality change, from a closed rigidity at one end to flow and openness at the other. He describes this as "... a continuum which (seems) to apply to the whole spectrum of personality change and development, and not to psychotherapy alone (Rogers, 1961, p. 114)."|
REFERENCES: 1. Gendlin, E. T. Experiencing and the Creation of Meaning. New York: Glencoe Free Press, 1962. 2. Malone, T. P., Whitaker, G. A., Warkentin, J., & Felder, R. Rational and Nonrational Psychotherapy. A Reply. Amer. J. Psychotherapy, Vol. XV, No. 9., 1961, pp. 212-220. 3. Rogers, C. R. A Tentative Scale for the Measurement of Process in Psychotherapy. In Stein, M. I., (Ed.) Contemporary Psychotherapies. New York: Glencoe Free Press, 1961. 4. Shlien, J. M. A Client-Centered Approach to Schizophrenia: First Approximation. Ch. XI, in Burton, A., (Ed.) Psychotherapy of the Psychoses. New York: Basic Books, 1961. 5. Whitehead, A. N. Process and Reality. New York: MacMillan, 1929. 6. Will, O. A., Jr. Psychotherapy in Reference to the Schizophrenic Reaction. In Stein, M. I., (Ed.) Contemporary Psychotherapies. New York: Glencoe Free Press, 1961.