Saturday, August 4, 2012

The Disease of Abnormal Integrity

For B&J

The disease of abnormal integrity is an expression coined (I believe) by my mentor, Carl Whitaker, M.D.

Carl was part physician, part psychiatrist, part obstetrician and gynecologist, part philosopher and part dairy farmer. Being a grandfather taught him to be tender and playful. Being a farmer taught him to be ruthless.

Carl was raised on a dairy farm and he never seemed far from the no-nonsense, plain-spoken and unapologetic manner one might expect of an earthy farmer. As a young man, he was encouraged by the town doctor to go to medical school – and not knowing any better, he did. After medical school, he continued his residency to become an obstetrician/gynecologist, but with the outbreak of the Second World War, there was a demand for psychiatrists – and so, he was deemed a psychiatrist.

The majority of Carl’s clinical work was with psychotic patients. In that era, schizophrenia was understood VERY differently than it is today. When Carl practiced, there were only the most basic anti-psychotic medicines that invariably had terrible side-effects and so whether patients had schizophrenia (as we understand it today – a brain disease) or their behavior was, for reasons not understood, bizarre or psychotic, psychotherapy was the treatment. 

Psycho-dynamics (unconscious influences) were typically thought to explain a patient’s bizarre language and behavior. Today, most clinician’s would agree that schizophrenia (the brain disease) should be primarily treated with medications, but there are still many patients who do not have a brain disease – and their behavior is judged bizarre or inappropriate by the so-called “normal” culture.

Carl developed an unusually keen understanding of his patients’ psychotic language and behavior. Just as one takes on a regional speech accent after years of living in the region; Carl lived in the neighborhood of psychosis for decades – and his language and theories reflected that. I vividly remember how difficult it was for me, initially, to understand his arcane and seeming idiosyncratic expressions and descriptions of an individual’s or family’s problems. His language often sounded bizarre and frequently was laced with Freudian theory and obstetric and gynecological metaphors. Frankly, it was shocking.

I suppose I became enamored of Carl partly because he was famous but also I secretly enjoyed his outrageous comments. Carl had another quality that really enchanted me; he was one of the only people I’d ever meet who had no pretenses – or none that I discerned. He had nothing to prove, was unconcerned with others’ opinion of him and was thoroughly unimpressed with himself.

The concept of a disease of abnormal integrity is one of Carl’s often puzzling expressions. Carl believed in what he described as dialectics. At one end of a continuum, some people are so direct, unvarnished and/or unaware of social convention that their behavior and language seems “crazy” or bizarre - it violates societal norms – leading to the individual being excluded from the culture – a culturally instinctive shunning. At the other end of the spectrum are individuals who apparently have no sense of integrity with an abiding inner sense of core values. Carl would describe such people as “sociopaths”.

According to Carl’s reasoning, if a person with schizophrenia “hears voices” – because they have abnormal integrity, they answer the voices - even if they’re in the middle of a supermarket. Bystanders will likely describe this person as “crazy”. While many of us may freely admit we hear voices, we normally believe that the thoughts, really, are our own. Most importantly, WE DO NOT ANSWER OR ARGUE WITH THE VOICES AS WE STAND IN THE MARKET. This is an extreme example but more subtle examples are all around us. A person who naively makes a comment that is entirely unacceptable in polite society might be one such example. The majority of people may rightly wonder, “What’s wrong with that person? Don’t they KNOW how unacceptable their comment is?”

Carl urged us to have the flexibility to be unusually honest (he would probably call it, “crazy”) when called for but also know when to “play the game” that society expects (he’d probably call it, psychopathy). He’d argue that being too one-sided either way would be problematic. If we’re too honest, the culture (which is inherently duplicitous) will punish us – by social shunning, being arrested or psychiatrically hospitalized. If we’re too much of a game-player then we have no soul – no core integrity. (Actually, Carl would have said it in a more seemingly vulgar way – he’d say then you’re just a “mechanical f**ker” – a “crazy” way of saying you’re like someone that has sex the way animals do, mechanically – with no heart, with no soul.

Carl told the story (I’m assuming it’s true.) of when he was appointed chairman of psychiatry at Emory University. For Carl, it was an undreamt achievement. One of his first decisions was that all medical students would be required, for their first two years, to participate in weekly group-psychotherapy. Probably a great idea – but he succeeded in alienating the rest of the faculty which led to his dismissal. It was a crushing professional and personal blow to Carl. He had acted with abnormal integrity either unaware or unimpressed that his behavior violated the established “norm”. It didn’t matter that it was probably a good idea – because it was intolerable to the dominant culture. He was pushed out the same way the human body will produce antibodies that attack a virus or bacteria that is experienced as “foreign”.

How often do we see that the culture, (whether it’s the culture in a family, the workplace, the legal or political system) is dishonest and we rail that, “it shouldn’t be like that”. If we “speak truth to power” (as some like to say) we will assuredly be eliminated. But, if we are “tricky”, if we know how to work within the system, so as not to alert the “normative obedience-dogs”; perhaps we can bring a change. 

Of course, some find some smug sense of self-righteousness as they enact the role of martyr. This is often the tact of the immature or otherwise uncontrolled-impulsive. (Those aspiring to martyrdom should carefully contemplate the first criteria for being a martyr.)

I often think that one’s reasonable expectation of integrity can be thought of as a set of concentric circles. (Like a bulls-eye target.) In the center, one might have one or two extremely close individuals – you can most likely expect integrity from them. In the next circle are very close friends – but capable of betraying your trust. The further we go to the outer circles the less we can reasonably expect integrity. When we function in the outer circles we need to be “tricky”, we need to “play the game” for the sake of self- preservation.

Carl’s cautionary admonition: “Learn to be as tricky as you are crazy.”

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