Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
What Is Pathos?
While Canguilhem’s (1966) work stresses the importance of pathos in clinical diagnosis, he never fully operationalizes this concept. Indeed, Canguilhem is not focused on psychopathology and deals with the question of pathology in a generic way. Yet, in order to make pathos operational, which is crucial from a clinical point of view, the work of French philosopher Paul Ricoeur, who combined phenomenology and hermeneutics, is noteworthy. In 1992 Ricoeur presented a paper entitled La souffrance nest pas la douleur—Suffering is not the same as pain, which provides a framework on how suffering and distress are expressed. While Ricoeur explicitly indicates that his analysis is not based on clinical practice, his reflections may well be applied to psychiatric problems (see also Vanheule and Devisch 2014).
The first distinction Ricoeur makes concerns the difference between somatic pain and mental suffering. What both have in common is that they are affective experiences. Yet, whereas pain manifests as distress in the body, suffering is a mental experience that is related to the language-based reflections we make about ourselves and about others. Both are distressing events we all live through at one time or another. For example, when we lose a longed-for job, or when a loved one dies we suffer, which gives rise to mourning. In such a context, Freud (1917) argues that mourning consumes the one who is left behind and is faced with the work of revising her representations of reality: raw sorrow ravages the soul. If applied to psychiatric diagnosis it could be argued that in a number of psychiatric conditions, like in severe panic, somatization, and hypochondria, pain and mental suffering are not clearly separated. Yet, what Ricoeur’s analysis suggests is that logically speaking, they can be discerned, while experientially pain and suffering might present as enmeshed phenomena. Frequently, patients experience psychic pain as more severe and less tolerable than somatic pain (Yager 2015).
Ricoeur stresses that a key characteristic of suffering qua mental experience is that it cannot be measured in a standardized way. Whereas a thermometer can assist us in discerning fever in the body and medical imaging can allow us to observe brain damage, pathos cannot be measured via precise technical devices. Ricoeur indicates that we must “read” people’s distress by paying attention to “signs of suffering.” Suffering is neither self-evident nor open to empirical observation: It can only be discerned when people express what they live through, whether through words, somatic phenomena, or behavior, indicating a certain despair that overwhelms them.
It could be argued that since Ricoeur, instruments to assess mental suffering have been developed (Yager 2015). Indeed, a number of self-report questionnaires to assess psychic pain, like the Mental Pain Scale (Orbach et al. 2003), have been created. Next to such direct measures of mental suffering, instruments that assess disability due to mental health problems, like the Whodas 2.0 (World Health Organization 2010) which offers self-administered, proxy-administered an interviewer-administered versions, could also be seen as indicators for mental suffering. However, these instruments are all questionnaires, that don’t immediately tap into the experience of suffering, but aim to grasp expressions of mental suffering in fixed formats. Such instruments provide a standardized language through which people can express themselves, assuming that in making the move from private experience to shared communication (through set
Fig. 4.1 Two orthogonal axes on which Ricoeur situates mental suffering
response categories) the essence of their experience is captured. Clinically speaking, such instruments are limited in that they don’t allow a complaint to be expressed in terms of the patient’s own discursive repertoire, meaning that they make the patient dependent on the discourse of the professional. As already discussed in Chap. 2, such a practice exposes the patient to power dynamics in which the professional dominates.
In his conceptual model, Ricoeur discerns two orthogonal axes on which he situates mental suffering, which we represent in Fig. 4.1. There we see that pathos can be thought of in terms of the relationship between self and other, and in terms of a continuum between languishing (patir) and acting (agir).
In terms of the self-other relationship, Ricoeur suggests that suffering consists of withdrawing from the bond with the other. Those who suffer detach from others, and thus feel isolated and personally overwhelmed by the misery they endure. Such isolation renders the individual ensnared by an intolerable experience: life starts being a living hell; “the world no longer comes across as liveable, but as emptied” (Ricoeur 1992, p. 17).
In some clinical contexts withdrawal alternates with attempts to affiliate. In that case, the patient still addresses others in an attempt to express her struggle to cope. In other patients, by contrast, trust in the support of others is minimal. Indeed, in clinical problems like acute psychosis with delusions of reference or in cases of chronic abuse, disconnection from others is often more radical: the belief that the other could possibly understand what one is living through is simply missing. Sometimes the other is seen as the aggressor from which nothing positive can come, which only heightens the experience of psychological isolation and, thus, intensifies psychological suffering.
In terms of the dimension between languishing and acting, Ricoeur argues that pathos implies an experience of impossibility at the level of performing an act that could transform one’s self-experience. He situates this impossibility at four levels.
First, suffering is often marked by impossibility at the level of speech. This is characterized by something of a fracture between two tendencies: while the patient would like to speak about what she lives through, she cannot find the right words or the courage to speak, thus ending up in silence. When speech fails in a radical way, mental suffering finds expression in crude and rudimentary (non-verbal) manifestations, like inconsolable weeping, restlessness, agonized crying, or self-harm. Here the individual is overwhelmed by destructive inner tension, which from a Lacanian point of view comes down to a jouissance she cannot articulate. If speech is possible, this kind of distress can prompt a minimal appeal for “help” or can be expressed in verbal complaints (“I can’t live like this anymore”). Such expressions open up the possibility of a dialog and can be the impetus for integrating the painful experience into a broader narrative. Dialogical interventions, which are often successful for patients in severe distress (e.g., Seikkula et al. 2006), build on the continued effort of trying to integrate baffling experiences of distress in conversations that aim at getting hold of distress-provoking circumstances.
Second, Ricoeur situates the impossibility of acting at the level of general passivity and a basic inability to take action. Often, she who suffers would like to do something, but believes that nothing can be done, thus giving rise to a position in which one has to endure one’s state of agony. Indeed, often patients suffering from mental pain have the feeling that they are caught in a vicious cycle, where nothing can alleviate their experience. This might drive the individual to despair. When an individual has the impression that she can link concrete actions as potential solutions to her experiences, a shift along this dimension (i.e., toward taking action) occurs. For example, a man who indicates that dark thoughts disappear for a while when playing the piano, or a mother who indicates that her baby stops crying when she lets him rest on her body, bears witness to basic steps toward overcoming the position of passivity with respect to an otherwise overwhelming psychological experience.
The third point in which Ricoeur situates the impossibility of performing an act is in failing narration. In line with many other scholars (e.g., Bruner 1990; Damasio 2010) Ricoeur (1992, p. 21) believes that the way in which we experience ourselves and the world is largely narratively based: “a life is nothing but the story of this life, and a quest of narration. Understanding oneself comes down to being capable of telling stories about oneself that are both intelligible and acceptable.” The underlying idea is that our experiences are not inherently organized; such organization is inaugurated precisely by speaking about oneself and about the world. In the experience of pathos, such organization is missing: “suffering is expressed as a rupture in the narrative thread” (Ricoeur 1992, p. 22). Indeed, often patients who suffer can hardly speak about the things happening to them. Speaking might be too threatening, too painful or experienced as an impossible or shameful endeavor. This confronts the patient with a chaotic gap in the midst of self-experience, which some psychiatric patients fail to overcome, resulting in a continuous struggle (O’Loughlin et al. 2014). Moreover, if this narrative thread is broken, the experience of time becomes seriously altered: the future and the past lose sense, and what one is left with is the burden of the actual moment. This viewpoint tallies with Eric Cassell’s (2004) idea of suffering. He stresses that events that threaten the intactness of a person, and consequently imply a perceived impending destruction or dissolution, result in suffering.
The fourth, and final, point Ricoeur refers to is the impossibility of valuing oneself. People only make the step toward performing an act if they think of themselves as agents that are capable of making accurate judgments. In Ricoeur’s view, suffering individuals break down at this level. They no longer know if they can really trust their own opinions and appreciations of what goes on in their life, and are unsure about what they want and what they don’t want. At the level of self-experience, this might lead to the conclusion of being stuck in a dead-end situation (“I’m incapable of overcoming this”), followed by inevitable feelings of guilt and shame concerning their sense of impotence in overcoming their despair. In some patients, negative self-appraisal can obtain an interpersonal quality as well, giving rise to the sense that others cannot be trusted: others cannot possibly comprehend what they are living through; they have malignant intentions in relation to which one is nothing but an object.
Next to these four aspects of impossibility in performing an act that could transform one’s self-experience, Ricoeur indicates that pathos not only comes down to an experience of impossibility, but also coheres with a sense of being overwhelmed by excess. A person who suffers is devastated by a surplus of affective stimuli that cannot be contained by means of words and actions. Inner tension, which, in clinical contexts, is frequently felt through bodily sensations that do not spontaneously resolve, hence suffering individuals’ tendencies to act upon the body (e.g., through self-harm or substance abuse), or to externalize overwhelming strain (e.g., through aggressive acts).
Finally, suffering usually gives rise to a plethora of questions that simply cannot be answered in straightforward ways; answers are incessantly sought nevertheless: “Indeed, questioning is related to plaints: Until when? Why me? Why my child?” (Ricoeur 1992, p. 30). Suffering not only has a perplexing effect, it provokes a perpetual search for sense and reason concerning the why and wherefore of one’s experience.
Considered from Lacan’s theory, suffering not only confronts the human being with a senseless element of jouissance, which is felt as a strain, but also confronts her with the question of her own existence. As we suffer, we face an unintelligible component that disturbs our common inner world. It actualizes a “something-else” or an “Other-thing” that concerns us, yet, cognizing efforts fail to get hold of such a disturbing experience. In terms of Lacanian terminology, suffering presents us with a so-called extimate element: a strange component in the interiority of our intimate experience. Lacan (1959, p. 459) suggests that given human self- reflexivity, which coheres with our use of signifiers, such an experience confronts us with a basic question: “Who am I?” Suffering challenges what, and how we habitually think of ourselves and of others, which gives rise to self-directed epistemic questions (“What/who am I?”) and to questions concerning the opinions and intentions of others in relation to us (“What does he/she want?).” Thus considered, mental suffering entails much more than the experience of debilitating symptoms. It coheres with a painful intimate interrogation, which, quite characteristically, crystal- izes around the identity-related topics humans usually struggle with, like gender identity, parenthood, or the meaning of life. From a Lacanian point of view such a link between mental suffering and identity-related questions are not surprising. Lacanian theory presumes that confrontations with identity-related issues might give rise to inner conflict, or have a maddening traumatic impact, which makes up the breeding ground for symptoms and suffering.
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