"When will you buy your new tires?"
"Sorry, I am unessential."
A few months prior to this writing this would have sounded completely incoherent
and senseless. However, experienced as determined by the present situation of the
tire rationing system the answer fits the question perfectly: "I cannot buy
any tires because my driving has been declared unessential."
In the case of the patient, the doctor's question had not been asked at random
but had occurred within, and had been determined by, a clearly structured field
situation. The doctor had asked the patient why he shivered, a question which clearly
fitted in with his role. He himself had suggested an answer which would have fitted
in with the concrete situation since the window happened to be open. However, the
patient's answer not only did not fit the question, it also fitted nowhere into
the field situation. It was flung into it like a foreign body, seemingly arbitrarily,
piecemeal, without any functional determination by anything in the field as the
doctor experienced it.
The solution of the enigma came some weeks later. It was learned that the patient
had written a good deal of poetry which dealt with problems of paramount importance
to him. In a discussion of these it developed that for many years he had been a
lonely timid sad fellow without any way of articulating his inner trends, but with
an intense desire to do so. He had wanted a full rich happy life, but had actually
had just the opposite. All his needs and hopes had remained hidden, no one knew
of them. This difficulty became so disturbing that he had gone to the library to
look at the psychological literature, and there he found a formulation for his problem:
he was an introvert and should be an extrovert. Here then was the psychological
situation which had determined his 'answer.'
To the doctor this situation was entirely new and unexpected. For
the patient it had existed for several years and had become increasingly urgent.
He had become more and more preoccupied with it, and finally, in the illness, devoted
all his time to its solution. Everything, every moment in his life was centered
around it.
For the sake of clarity the 'real' hospital situation is called
S1, and the patient's psychological situation S2. In relation to S2,
S1 was external and peripheral. For the patient, the demands made of him by
S1, the 'reality,' were just annoying, essentially constituting a disturbing
intrusion into S2. At the beginning of the physical examination he had responded
to the S1 requirements and had let himself be annoyed. But when the disturbance
became too strong the S2 forces dealt with it abruptly and sharply, and the
patient resumed his preoccupation with his problern. His sarcastic grin indicated
that he knew quite well that the doctor could not know anything of this problem
and of the second situation, and would be unable to understand the 'answer.'
There are two possible ways of understanding this answer. One could
assume that the patient wanted to improve the doctor's question in the direction
of what should be most essential in the doctor-patient situation: "Don't ask
me why I shiver. lt does not matter. Tell me rather whether an introvert can ever
be an extrovert. This is my central problem." The other possibility is that
he wanted to reduce all S1 interference to a minimum so that he would not
be disturbed in his preoccupation with S2.
The doctor's question may be called q. The doctor asks it
as a fitting part of, and functionally determined by S1. [6]
The patient experiences it essentially in its functional relation to his S2,
where it has the totally different psychological quality of a disturbance. [7] One sees that psychologically the two are unequal. lt is therefore
not permissible simply to assume the validity of q = q. The piecemeal identity
of the isolated question is not what matters functionally. It has to be seen in
its field dynamics. It is also clear that the fitting answer to the question in
its S1 meaning is by no means necessarily identical with a fitting answer
to it in its S2 meaning. Within the framework of S2 the patient's
answer and behavior are understandable; not so within S1. The innocent doctor,
not knowing at this time of the existence of S2 naturally experienced the
answer within S1, and was baffled. To him it appeared 'irrelevant.'
This type of case must be clearly differentiated from another type,
illustrated by the following example. A mother asks her child, "Did you brush
your teeth?" The child answers, "I want to go to the movies." The
question arises out of the mother's situation with regard to the care of the child.
The answer arises out of the child's preoccupation with the Saturday afternoon serial
picture. But in this case both S1 and S2 are parts of a common situation
in which both live. Question and answer are mutually understandable at once, although
they do not fit each other directly. In the case of the patient S1 and S2
were not part of any encompassing common situation.
The following paragraph deals with apparently good and simple cases
which may, however, be shown to be cases of schizophrenic thinking if analyzed carefully.
"How are you?"
"Fine. I want to go home."
This answer was given regularly by another patient on morning rounds.
It deals with the same topic as the question, the patient's health. It continues
the question's direction. It seems a good answer. There are three possible ways
of understanding it. It could be sound, simple, sincere. The patient might not have
realized that he was ill, and, subjectively might have felt well enough. Or, it
could be a normal lie. Knowing that he was not well he might have wanted to leave,
just as a patient with a physical disorder might want to leave a hospital prematurely.
In this particular case a third possibility seemed to exist. The
patient was a young, acutely ill, paranoid schizophrenic, He stated that prior to
his hospitalization he had been unjustly fired from his job, that he had been singled
out and persecuted by his foreman. [8] Subsequently
he felt that people watched him in the street and followed him. It fitted perfectly
into his paranoid picture of the world that in the hospital he found himself in
a place with locked doors, confined, deprived of his freedom, unable to make decisions.
This was his S2. The thing to do was, of course, to get out. He knew that
the people in charge of the place claimed that it was a hospital, and that he was
a mentally ill man who needed doctors. He had been told that he could not be discharged
as long as he was sick. He was far from certain that all this was true; it could
be pretense on their part. They probably fooled him for some hidden reason. However,
theirs was the power, and he had to play their game. In order to get out he had
to convince them that he was well. This seemed to be the reason for the answer.
One sees that the answer is only apparently simple. lt is simple only as long as
one looks at it without realization of its meaning in S2. The simplicity
is deceptive. The question is not simply q but fq(S1), the answer
not simply a, but fa(S2). [9] The two
are logically and psychologically not an innocent good whole, but conceal a cunning
bit of trickery. Such instances are usually overlooked in the textbook chapters
and investigations dealing with the formal disturbance of thought because the usual
approaches do not take into account the fact that they are field determined.
Echolalia and echopraxia, two other very puzzling forms of psychotic
speech and behavior, may sometimes be similarly understood. A patient who was a
very nice and friendly young furrier suffering from an acute paranoid episode, was
convinced that he was being persecuted by his union. He was hallucinated, and very
busy listening to the names which his enemies called him. He was constantly preoccupied
with his psychotic experiences, and repeated attempts to talk to him were very difficult
because of his marked echolalia. On one occasion when his physician had taken him
into his office and with a friendly smile asked, "How do you do?" the
patient with an equally friendly grin had vigorously nodded his head and eagerly
answered, "How do you do?" The doctor now said, "Good morning."
The patient repeated, "Good morning." The doctor put his finger to his
nose. The patient, nodding and smiling did the same. And this went on. It was, however,
noticeable that when the doctor asked no questions and let him alone the patient
watched him out of the corner of his eye, and yet at the same time seemed again
intensely preoccupied with his psychotic experiences. This observation gave the
clue to a possible understanding of what was going on.
The doctor was really forcing the patient into a very complicated
situation. On the one hand the patient had to attend to the dangerous events in
S2 which demanded constant concentration and alertness. On the other hand
there was the friendly doctor trying to get the patient into a nice social situation
within S1. [10] Now to the patient, and
with regard to his S2, the hospital situation was something peripheral, implying
a neutral routine which, most of the time, he could follow more or less passively
and automatically. But when it demanded more of his attention it constituted an
interference in his concentrated functioning within S2. This was also true
of the doctor's attempt to draw him into a conversation. But since he was peripherally
aware that the doctor was a well-meaning fellow, and since he himself was exceedingly
friendly and good-natured, it did not occur to him just to give the doctor the cold
shoulder.
This was a dilemma. He had to satisfy the requirements of both
S1 and S2 although the two situations seemed to be mutually exclusive.
Under the pressure of these two conflicting situational needs he hit upon a way
out. While he could not rid himself of the urging S2 forces to meet adequately
the S1 requirements, he could at least enter into a peripheral halfautomatic
social relationship with the doctor by repeating whatever the latter did and said,
while still being able to be preoccupied with S2. While this was not very
adequate and certainly strange it served to indicate his good will towards the doctor.
In this case, echolalia and echopraxia were in all probability determined as the
resultant of the clashing requirements of two heterogeneous simultaneous situations.
Echolalia was recently observed in a case of presenile dementia
with moderate brain atrophy as shown by air studies. As far as could be observed,
the dynamics here were somewhat different. In this case there was no S2.
The difficulty was created by the organic handicap. This patient also felt the need
to respond to the questioning physician, and to establish some sort of relationship;
apparently he very much wanted to do so. But he was too dull, too slow, too much
handicapped to grasp and respond quickly and adequately. In this case prolonged
handshaking and repetition of the questions or greetings were the best possible
way, a stop-gap. At least he did not have to stand mute while he felt the need to
respond somehow. Echolalia saved the social situation.
Back to 1st part of this paper
Footnotes:
[6] q = fq(S1) (read q
= function q of S1). [-> back to text]
[7] q = fq(S2). It follows
that fq(S1) # fq(S2). [-> back to text]
[8] Actually he had been dismissed
because of a general slow-down of business.
[-> back to text]
[9] Read a = function a of S2.
[-> back to text]
[10] The patient's delusions
had not spread to the hospital environment. [-> back to text]
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