Venerable Gangxiao: ECT Therapy for Difficult Illnesses — Chapter 8: The Medical Perspective of Freudianism

Chapter 8: The Medical Perspective of Freudianism

1. What Is the Unconscious?

We used to assume that all human behavior is governed by consciousness. I think about what clothes I need, and I go buy them — psychology was the study of consciousness. Dr. Freud argued that this view is wrong. Human behavior is shaped not only by consciousness but by the unconscious as well, and psychology must study both.

So what is the unconscious?

I won't quote a formal definition here. Instead, I'll describe some of its key features and functions, which should give you a general sense of what it is. Definitions are precise but abstract, and hard to grasp.

The human psyche includes at the very least both consciousness and the unconscious. Picture an iceberg: the unconscious lies beneath the waterline, consciousness above it. The portion below is unknown to us, yet it is far larger. We're generally unaware of the unconscious, yet it wields enormous power, constantly shaping our behavior. Its content is largely instinctual and can be immoral; consciousness, by contrast, is social and must heed moral demands. The unconscious runs on the pleasure principle; consciousness runs on the moral principle. Under normal conditions, consciousness can repress the unconscious, keeping its uglier aspects from surfacing so that our conduct meets society's moral standards. The whole function of education and culture is to strengthen that repressive grip. Yet social morality must also, to some degree, accommodate the unconscious — striking a compromise that satisfies instinctual demands within set limits. Sex within marriage, for instance, does not count as adultery. Most of the unconscious grows on its own in the dark, but part of it consists of material that has fallen in from the outside — traumatic or unpleasant experiences that have been forgotten, so to speak tossed into its abyss.

Freud accordingly divided the personality into three parts: the superego, the ego, and the id. The id is unconscious and can include a person's selfish side — the petty, small-minded aspect. The superego is conscious; it is the ideal self — the noble, virtuous aspect. In reality, though, we are neither purely petty nor purely noble, neither pure id nor pure superego, but ego — a compromise of both. We act petty sometimes and noble at other times; we've done good deeds and things we'd rather hide; we've had lofty thoughts and thoughts too shameful to speak.

Why do we do things we don't want others to know about? Why do we have thoughts too shameful to voice? The unconscious compels us — the id compels us. As the saying goes, each person is half beast, half angel. That's precisely the point.

2. The Existence of the Unconscious

Does the unconscious actually exist? Yes, it does. Freud gathered many convincing real-life examples to prove its existence. Ordinary people have all experienced slips and dreams, which is why Freud devoted entire works to hunting for evidence of the unconscious in slips and dreams. These examples aren't dramatic or eye-catching, but they're certainly plentiful. To make the case clearer, it's best to look at extreme examples — abnormal people, sick people. They may not be numerous, but they're typical.

Obsessive-Compulsive Disorder — Chinese Classification of Mental Disorders code 55.1.

Definition: A neurosis whose primary clinical picture consists of obsessive symptoms. Its defining feature is the coexistence of conscious compulsion and conscious resistance to it; the tension between the two leaves the patient deeply distressed. The patient knows the obsessions are abnormal but cannot escape them. In long-standing cases, the disorder may settle into mostly ritual actions that bring some relief from mental anguish, but by then social functioning is severely impaired.

Possible presentations include: ① Obsessive thoughts — obsessive memories and vivid mental images; ② Obsessive emotions — intense fear of losing self-control, of having a breakdown, or of committing a crime; ③ Obsessive impulses — frequent urges to act right now, or powerful inner drives, without actually acting on them, causing the patient great distress (for instance, a terror of throwing a baby out the window); ④ Compulsive acts — yielding to the obsessive thoughts through repeated hand-washing, checking, or asking for reassurance, or performing counter-rituals against the obsession.

Consciousness clearly knows the person shouldn't think or act this way, but they've become "neurotic" — consciousness can no longer steer their thoughts and behavior. The unconscious has grown too powerful; it's about to break the surface, already letting us glimpse a corner of itself. The unconscious drives the thinking and the doing; consciousness can neither manage it nor repress it.

Freud cited the following case:

A nineteen-year-old girl, desperate to get to sleep, declared that she needed absolute quiet at night and that every sound had to be eliminated. So she carried out a number of tasks — she stopped the large clock in her room and moved all the smaller clocks out of the room, including the wristwatch on her bedside table. Every flowerpot and vase had to be carefully placed on her writing desk so that nothing would fall and make a noise overnight. She herself knew these reasons were shaky — even if the little watch stayed on the table, its ticking would be inaudible; and even if it could be heard, a clock's steady rhythm actually helps one fall asleep. She admitted that the flowerpots and vases left where they were would certainly not fall, and that the fear was groundless. Yet other parts of her ritual didn't even serve the goal of quiet: she insisted that the door between her bedroom and her parents' bedroom be left half-open. To achieve this, she put various obstacles in the doorway — which only seemed to invite more noise. The most important rituals, though, centered on the bed. The long pillow at the head of the bed had to be kept from touching the wooden frame. The small pillow had to be laid across the long pillow in a diamond shape, and she would rest her head precisely on one corner of the diamond. Before pulling up the down quilt, she had to shake the feathers so they settled downward, then smooth them flat again. There were many more such details; I won't list them all. Don't imagine these little tasks went smoothly — at every step she worried she hadn't done it right and had to try again and again, going over each point, doubting this one, then that one. The result was that it always took several hours before she and her parents could rest.

This is the unconscious at work: it makes the patient behave and think this way, and consciousness's protests count for nothing. In the case Professor Yang Desen wrote for the OCD entry in the Chinese Classification and Diagnostic Criteria of Mental Disorders, the patient was tormented half to death by pointless thoughts.

In some cases of schizophrenia, meanwhile, evil wins out over good — the unconscious actually overpowers consciousness. The person is wholly under the unconscious's control; the force of consciousness (the social, moral self) seems to vanish, and no trace of reason is left. He may even hear commanding voices (auditory hallucinations) and kill someone or slash his own wrist, insisting that someone ordered him to do it. Who gave the order? The unconscious.

In patients with affective disorders, the demons of the unconscious rise up against consciousness, and the two forces are roughly matched. One moment the unconscious wins: the patient is elated, talkative, hyperactive, euphoric, even grandiose. The next moment it's defeated: the patient is despondent, listless, and may feel death would be preferable.

The struggle between consciousness and the unconscious is in fact continuous. In normal people, consciousness holds the upper hand and keeps the unconscious in check. Once that grip slips, it's as if a caged tiger has broken loose — it manipulates and controls the person, and the person goes mad.

So yes, the unconscious is real.

3. The Unconscious and Illness

The unconscious wants to express itself, but consciousness doesn't always allow it to surface. Sometimes the unconscious disguises itself to slip past consciousness's censorship and emerges in distorted form. This is especially clear in hysteria.

Take Dora again, mentioned earlier. Unconsciously, she was drawn to the handsome, accomplished Mr. K — a man of mature masculine appeal who loved her. Consciously, she knew this was forbidden: the age gap was large, Mr. K was a married man, her father's friend. So when Mr. K took her out, she went gladly and enjoyed herself — the unconscious at work. But when he kissed her, she slapped him, and afterward she was tormented into illness — again, the unconscious at work.

Nervous cough: to avoid pregnancy, she could perform oral sex, but that was somewhat disgusting — so it became a cough.

Abdominal pain: if Mr. K had had his way, she would already have given birth — so her belly ached.

Lameness: if Mr. K had had his way, she would have fallen — so she limped.

In consciousness, illness is always unpleasant, but in the unconscious it needn't be. The unconscious may see advantages in being sick, and so an unconscious motive for illness takes hold. With such illnesses, even what looks like a minor ailment that should yield to the right medicine can be hard for the doctor to cure. The reason: being ill has its benefits. A factory director with muddled finances who knows he can't account for himself may fall ill — even become laden with complaints, losing his voice, going partially paralyzed, running a fever of unknown origin. Symptomatic treatment may do little good. Dr. Jung went so far as to argue that for some illnesses doctors shouldn't cure them at all, but let the patient hide within the illness to escape responsibilities he can't bear — social, economic, or legal. Freud said that although such patients go from doctor to doctor, their motivation to get well isn't as strong as they themselves believe. A small child, wanting extra attention from its mother, may cry until it vomits, or run a fever. Adults do the same: using illness to dodge responsibility, or to draw concerned attention from others — both strategies work. Such illnesses are the patient's masterwork. A college-entrance-exam candidate who's unsure of passing but can't face telling his parents is especially prone to falling ill. Mr. K and his wife don't get along — when he goes on a business trip, she recovers and is full of life; when he comes home, she wilts and is especially prone to gynecological problems, all because she doesn't want to fulfill her wifely duties. When life's burdens grow too heavy, back and shoulder pain set in; only when the load lightens does the pain go away.

Telling patients these things, doing "ideological work" on them, doesn't work — it falls short of the therapeutic goal, because persuasion usually reaches only consciousness. It's as useless as telling someone not to grieve over a lost child. You urge a depressed patient to pull themselves together, but they can't, and the physical symptoms clinging to the depression won't lift either. Only when the patient, deep in the psyche at the level of the unconscious, truly feels that "it's no big deal, forget it, no need to take it so seriously" can they lighten up, rally, and let the illness go.

As for recovery, circumstances have to change. Once a political campaign has passed, or a financial audit has ended without problems being uncovered, patients who were on the wrong side of the campaign, or directors whose finances were in disarray, will recover. A small dose of medicine — even one that had been useless before — now works, burnishing the doctor's reputation as a miracle worker. In fact, recovery would have happened anyway, with no medicine at all.

In psychosomatic medicine there's a notion called the "pathological habitual pathway." Once a symptom appears and gets taken up by the unconscious motive for illness, the next time the person runs into trouble and wants to escape into sickness, what sickness do they slip into? The easiest is the one they've already had. So a single illness gets exploited at different times by different psychological causes. Freud therefore believed that the bodily factors in hysteria are fairly stable while the psychological ones are variable — which is what makes it such a deeply rooted illness.

The unconscious, then, is one cause in the formation of illness.

This conclusion applies not only to hysteria but to organic illnesses as well. As Freud himself put it: "Whenever they have a pathological organic condition — perhaps an inflammation or an injury — this is often enough to allow symptoms to form from then on, and the actual symptoms are immediately taken up as tools by the unconscious fantasies seeking expression." So it seems to cover organic conditions like inflammation and injury too.

4. How Can the Unconscious Be Influenced?

As mentioned earlier, the unconscious lives in darkness, and consciousness's sunlight doesn't easily reach it. But in some cases, the contents of consciousness can enter the unconscious — as with forgetting, when something from consciousness drops into the darkness and becomes part of it. One day Dora was terribly irritable without knowing why. Through Freud's analytic treatment it turned out that this day was Mr. K's birthday. In previous years, on this day, Mr. K would have invited her out for a pleasant outing and celebration; since the slap, she'd lost that chance, Mr. K no longer invited her, and she had pushed his birthday into the unconscious. But pushing it into the unconscious isn't the same as it disappearing. It still existed, still had its effect — when no invitation came, she was as distressed as if she were in reality waiting for a lover who never showed up.

The most famous example of deliberately influencing the unconscious is the post-hypnotic suggestion.

In 1889 the renowned hypnosis expert Bernheim carried out an experiment. A woman under hypnosis was told that after waking, at a certain time, she would open an umbrella sitting in the corner of the room. After being brought out of hypnosis, she carried out the instruction exactly. At first she didn't know why she had suddenly wanted to open the umbrella. When asked, she said she seemed to want to check whether the umbrella was hers. The motive was obviously at odds with reality — there was no need to open it; setting it in the middle of the room would have been enough to see it wasn't her umbrella. Clearly this was a rationalization she'd come up with on the spot. She offered her explanation in good faith and was certain her action was voluntary. Then Bernheim questioned and prompted her repeatedly, and at last the patient recalled the real reason: she remembered someone had told her to perform the strange act of opening the umbrella and placing it in the middle of the room at a set time.

This is the hypnotist functioning as an external force on unconscious motivation.

As noted earlier, Freud also pointed out that traumatic experiences can enter the unconscious.

For therapeutic ends it is sometimes necessary to deliberately influence and reshape the unconscious, steering it in a positive direction. Psychoanalysis is one technique that acts on the unconscious and can bring it into consciousness — but the course of treatment is unfortunately very long.

Shock can be viewed as a trauma that enters the unconscious and acts upon it. If the timing and intensity are properly calibrated — carrying the shock and ordeal just far enough, letting the patient undergo a kind of death — the notion "What is there left to fuss over? Just live well" can be delivered into the unconscious, where it begins to shape behavior as an unconscious motive.

Calibration matters here. As in the near-death experiences described earlier, the sequence is first fear and anger, and only at the end do positive emotions emerge; stopping at the fear stage would be disastrous. Ordeal carried to a certain point and then lifted can cure — but if it doesn't go far enough, or goes on too long, it causes illness instead. Best if the ordeal comes quickly and lifts quickly. ECT fairly well meets this requirement, and the degree of ordeal reaches the necessary level.

References:

1. Psychiatry, by Shen Yucun, People's Medical Publishing House, 3rd edition.
2. Behavioral Medicine, by Yang Desen, Hunan Normal University Press, 1st edition.
3. The Nature and Treatment of Neurasthenia, by Morita Shoma (Japan), trans. Zang Xiuzhi, People's Medical Publishing House, 1st edition.
4. Introductory Lectures on Psychoanalysis, by Sigmund Freud (Austria), trans. Gao Juefu, Commercial Press, 1st edition.
5. Analytical Psychology: Its Theory and Practice, by Carl Jung (Switzerland), trans. Cheng Qiong, SDX Joint Publishing Company, 1st edition.
6. Prevention and Treatment of Mental Illness, by He Ji and Zhang Xiyuan, Tianjin Science and Technology Press, 1st edition.
7. Diagnostic Criteria and Cases for Mental Illnesses in China, by Yang Desen, Hunan University Press, 1st edition.
8. "The Research Status of Near-Death Experiences," by Feng Zhiying and Liu Jianxun, Foreign Medicine: Psychiatry Section, 1986, no. 2.