Art of Psychiatry Society

Reading the Mind. The Maudsley Book Group.

R D Laing – The Divided Self

I have long had it in mind to start a book group dedicated to reading seminal works in, and related to, the field of psychiatry. After a chance meeting with Simon Harrison and Carol Kan, I finally decided to do something about it! Thus Reading the Mind was born, as was our small committee. The premise was simple really; psychiatry is a complex discipline, firmly a branch of medicine but interwoven with psychology, neuroscience, psychoanalysis, philosophy, sociology, anthropology and many more. The culture of reading widely around these subjects has somehow become more difficult for trainees to access. With so many areas to cover, where do you start? Well that’s exactly the sort of itch the book group aims to scratch.

The first meeting of Reading the Mind was held on Tuesday 29th March at the Institute of Psychiatry in seminar room 2. Our first book was R D Laing – The Divided Self. Seminal certainly but, admittedly, a difficult read. Professor Tony David kindly came along to help us make sense of it. The Divided Self was Laing’s first book, written at the tender age of 28, setting out his theory of schizophrenia in three parts. The result is a concise direct work, at times dense and convoluted but always interesting and, for the most part, clinically relevant. His goal was a re-telling of psychosis as an understandable reaction towards intolerable pressures placed upon the patient by those around him. The first part sets out his basic concept of ontological insecurity. Taking in existential philosophy and phenomenology, he placed a key focus on what it’s like for the patient. He wanted to demonstrate meaning in psychosis or, to paraphrase Karl Jaspers, to render understandable the, by definition, ‘un-understandable’. He vividly described this ontological insecurity as an indefinable feeling of something lacking and a primary disturbance of the self. According to Laing, this is the root of the schizoid and schizophrenic disorders. He went on to elaborate this with his theory of the false self/real self system. Those who have their ‘real self’ undermined repeatedly in childhood will develop a false self to interact with the world. These people are then at risk of developing psychosis when, under pressure, the real self shrinks and dies and the false self becomes overwhelmed and can no longer cope. Laing trained at the Tavistock and his false self concept is closely related to Winnicott’s ideas, who was his supervisor at the time. In the third part, he demonstrates his theory with clinical vignettes and patient histories.

The Divided Self generated much lively discussion and a range of opinions, both positive and negative. As a general overview, the group felt that the book had a positive historical role in repositioning the patient’s lived experience right back at the heart of discussions about what it is to have schizophrenia. To seek meaning in psychotic experiences and attempt to understand them and, crucially, make the patient feel understood, is undoubtedly of great importance and Laing consistently stressed this. There were some ways in which his theory supported our collective clinical experience such as the close relationship between ontological insecurity and the self-disturbance symptoms seen in prodromal schizophrenia. However, the group struggled with his theory, particularly the difficulty it seems to have in generalising to the kinds of cases we see daily in our practice. There were also criticisms about the overall project that R D Laing undertook. On the one hand, he outlined a theory for schizophrenia, marking it as a disease and something that occurred only in those vulnerable to certain stresses e.g. those who are ontologically insecure with a friable false self. But then on the other, he seemed to push for a sociological explanation for madness making it a potential outcome for anyone in the right (or rather wrong) circumstances, and later, took it further to say that madness was purely a social construction. There is then his legacy of the ‘schizophrenogenic family’, particularly the mother and the unnecessary criticism and stress this has placed on many families of patients with schizophrenia.

A famous cult figure in his lifetime, it was inevitable that discussion would turn to the large divide between the man and the psychiatrist. Laing struggled with alcoholism and clinical depression throughout his life, was given to emotional and aggressive outbursts and fathered ten children by four different women. Despite his emphasis on the importance of parenting, he wasn’t a consistent figure for any of his children. That said, he had a reputation as a very caring clinician who often went to great lengths to engage and understand his patients.

There is no doubt that The Divided Self is a seminal work and over the course of the group, it became clear that it has important implications that resonate still today.  R D Laing refocused psychiatry and placed the experiential component of our patient’s symptoms and the importance of active patient listening and engagement right back at the heart of the work we do.

Reading the Mind is open to any London psychiatry trainee.  The next meeting will be on Tuesday 24th May and we will be reading The case of the Rat man by Sigmund Freud.

Dr Lisa Conlan, ST5 psychiatry trainee.

R D Laing Wikipedia entry