The Importance of Caring

The importance of caring: Laing, Mosher, Podvoll and the 'genuine nursing of the mind'

Three men are commonly seen to dominate the history of 20th century psychiatry: Freud, Jung and Ronnie (R.D.) Laing. All were visionaries with loyal followings. Sadly, history also reveals how each had feet of clay. Although much has often been made of their moral frailties, this should not detract from a careful appraisal of the value of their work. We were reminded of this last fact when we listened again to Anthony Clare’s interview with Ronnie Laing in his radio series, In the Psychiatrist’s Chair. Laing talked candidly about his isolate childhood, the development of his introspective nature, and the mother who unwittingly nurtured, without doubt, the most controversial psychiatric voice of the past fifty years, at least within the UK. Who would have forecast that a solitary child, from a middle class Scots home, would have so rocked the foundations of 20^th century psychiatry? The very mention of his name, more than a decade after his death, is sufficient to trigger vituperative debate. This may, of itself, be sufficient evidence for the endurance of his influence.

Whether Ronnie Laing’s mother was mad, or just another example of the cold and distant creatures not uncommon in Presbyterian Scotland, was a question left unanswered in that interview. However the experience of loveless, childhood isolation clearly sensitised the young Ronnie to others who appeared similarly cut off from the world and ultimately themselves. Although he eventually fell victim to the carefully blended misery of alcohol abuse and melancholy, his key interest was in people in psychosis. What might be the meaning of their exaggerated experiences and extreme behaviour and how did they come by them? Perhaps these alienated souls reminded him of his own alienation – providing a mirror for his own soul, which appeared tortured in a quite different way. In the Clare interview Laing challenged the common view that he had romanticised madness, especially in its ‘schizophrenic’ form. Such disordered mental states made Laing feel acutely uncomfortable. He saw such people as at risk of drowning in their own distress, and he never had any desire to get in the water, and risk drowning with them. There was more than touch of irony in that comment, since the details of the Dionysian downfall of the most famous psychiatrist of the love generation are well known. At 61 he died of a heart attack playing tennis - too competitively as was his wont – in the South of France. In the interview, recorded five years earlier, Laing laughed nervously as he recalled how his mother had told his daughter how she had once fashioned a voodoo doll, intent on creating a heart attack in her only son. His weary, but still good-humoured voice, suggested that Laing was all too aware of Death closing in on him. Perhaps also he was aware that his mother would have the last laugh.

In this reprise of the original recording, Anthony Clare noted that every living psychiatrist owed something to Laing, although the details of his debt were never explored. Instead Clare tried to establish himself as a heavyweight Laingian critic, rather than as celebrity shrink. It seems self-evident to us that the legacy of R. D. Laing cannot – indeed should not – be restricted to the institution of psychiatric medicine, not least because it did so much to damn what it saw as the heresy inherent in Laing’s recorded thought. Indeed, the General Medical Council revoked Laing’s right to practice, on apparently petty grounds, offering further evidence of medicine’s desire to rid itself of its most famous ‘turbulent priest’.

Laing’s influence extended far beyond psychiatry, psychotherapy and medicine. However, the practical application of Laing’s thought – by the man himself and some of his most famous allies and former pupils – was largely non-medical. Indeed, we might interpret the application of his philosophy – especially through his frequently revised views on psychotherapy – as a nursing approach, focused on nurturing the conditions – social and interpersonal – under which people might finally seize their own power and use this, constructively, to define themselves, rather then be subjugated, if not actually driven to madness, by others.

Given Laing’s focus on the experience of madness, the radio interview reminds us of the inherent value in hearing him talk in the rough Glaswegian brogue, which can be refreshing to the ear. At times he articulates certain words carefully – as when he talks of the denigration of the experience of madness – giving emphasis to the word’s root in denial. Ironically this careful attention to language eludes Professor Clare who, throughout refers to his subject as ‘Laang’ despite both Laing and his son, Adrian – who offers a concluding commentary – calling themselves Layng. It might be stretching Clare’s lapses too far to suggest that they betray a failure to listen – or even a refusal to hear what is being said. However, it seemed like a significant lapse. Such failings - or resistances - are common among psychiatric professionals, not just psychiatrists. In the view of many who have been patients, such carelessness often signals the professional’s capacity for rapport, and its progeny, empathy. Perhaps one of the obvious differences between Laing and his critic and inquisitor, Clare, is that whereas the latter became famous for chatting, in an intimate yet cosy fashion, to celebrities who were, by and large, comfortable in themselves and their identities, Laing made his name as a counter-culture figure, largely by dint of his close, but risky, contact with people who were as dispossessed as they were mad.

Indeed, in the eyes of many Laing let himself get too close – empathically speaking – to his patients, and risked burning himself in the process. Empathy is almost de rigeur in psychiatric circles. Sympathy is invariably frowned upon.

It is worth noting that, despite an unspoken acknowledgement of his failing powers, Laing resisted either apology to his many critics, or any formal acknowledgement of his huge, and many might say, enduring influence. Perhaps he was aware that his status as the only psychiatrist to have been interviewed in this radio series was, in itself, sufficient evidence of his cultural significance.

Regrettably, the great fuss over his many alcohol-fuelled appearances on television, and his willingness to let his views be politicised recklessly in the late 60s, has obscured the Laingian legacy – much of it not part of his original ambition. Very early in his career, in Glasgow in the 1950s, he created a ‘rumpus room’ for disturbed patients. This was to become a model of the ‘safe space’ that acutely disturbed people needed, and where they might give free rein to their disturbed and disturbing emotions. The very name suggests the presence of the maternal in Laing. Without patronising the people who were nominally in his care, he recognised that – like children – mentally distressed people needed a space within their temporary home (hospital) where they might be in their madness. A couple of years later he wallpapered and furnished another of the bleak rooms at Gartnavel Hospital to create a real ‘living-room’ for four ‘back-ward’ women patients, who eventually were discharged, much to everyone’s surprise. That the women eventually found their way back into institutional care merely attested to the lack of support for them in the so-called ‘natural community’. The ultimate failure of this project may well have turned Laing’s vision from attempting to re-model hospital care, in favour of the establishment of more genuine community based alternatives – through the Philadelphia Association.

These early projects did, however, signal the possibilities of ‘nurturing’ people into recovery. Later, his experimental community at Kingsley Hall inspired many of his followers and former students, to develop the potential of therapeutic households. Arguably the most famous of these – Loren Mosher – who developed the Soteria House project in the USA, demonstrated over many years the possibility of nurturing recovery in people with schizophrenia, within an ordinary living environment, largely without any overt medical treatment.

Another North American disciple, Edward Podvoll, developed Laing’s emphasis on the importance of being fully present, carefully blending Buddhist concepts of the mind, with Laing’s more traditional Western phenomenological approach. From Podvoll’s original work has emerged the important Windhorse project, within which people are helped to emerge from severe psychotic states, through intensive support provided within ‘therapeutic households’.

These experimental projects, which emphasised the value of nurturing emergence from psychosis, through often extraordinarily ‘ordinary’ forms of human support, represent the nursing legacy of Laing’s original work in the 50s and 60s. Indeed, Podvoll – a psychiatrist - described people in psychosis as needing a ‘genuine nursing of the mind’. It is perhaps ironic that male psychiatrists should have discovered the human virtue - and therapeutic value - of organising a sustainable and sustaining caring environment. These, often quite extraordinary projects are, however, arguably only the tip of the iceberg of Laingian influence. The contemporary concepts of ‘safe houses’, supported accommodation, therapeutic households and, especially, the virtue of validating the distress of acutely mad people, owe much to his often-eccentric example. Little wonder that he became an icon for the emerging survivor groups like Survivors Speak Out, and indirectly inspired developments like the Hearing Voices Network, which discovered almost thirty years later that experiences dismissed as meaningless symptoms of a hypothetical brain dysfunction, could be understood and, often, represented a coded form of the distress the person had experienced earlier in life.

Talking of his own chronic melancholy, Laing suggested to Clare that, were he to descend deeply into the slough of despond, to the extent that he could no longer function, he would hope that a psychiatrist would offer him some medication that might relieve his distress. Perhaps significantly, he added that he would like to be removed to a nursing home where he might be suitably cared for. This is hardly surprising, since it reflects little more than what he had long believed was appropriate for the people in his own care. Whilst he knew the value of medication, he knew its limits. As researchers like Alanen and his colleagues in Finland have shown, it is possible for as many as 40% of people with a diagnosis of schizophrenia to recover without any psychotropic medication. Others may, in Alanen’s view, only need small doses of medication to help put them in the right state to benefit from the kind of nursing and psychotherapeutic care that Laing had espoused a generation earlier.

Clare appeared distinctly uncomfortable with Laing’s sensitivity, suggesting that he might have been ‘too sensitive to be a doctor’. As we have noted, much of Laing’s work can be read more as a ‘nursing of the mind’ than medical practice. Listening to Clare’s espousal of the need for medical distance, one appreciates why Laing’s huge compassion disturbed so many psychiatrists, especially those who had presided for so long over often abusive and dehumanising conditions of treatment.

Ultimately, however, Laing could not sustain the wild trajectory of his own personal growth. The caring emphasis of his work – often focused on severely disturbed women – suggests that he had spent his professional life trying to rehabilitate, metaphorically, the mother who had treated him with such callous, if not pathological, disregard. Finally the pins that his mother inserted in that voodoo doll found their spot and the light went out on young Ronald. Fortunately, his ideas have inspired a succession of voices, eager to develop his alternative vision of humanitarian psychiatry. The Laingian legacy remains in light.