From the most ordinary and average state of normality to the strangest or most out-of-control situations, the brain is unable to see itself.
We do not experience our lives, our existence as people who feel, think, and take initiatives, as the expression of the activity of a part of our own body. Rather, it feels as though it comes from a different level, from something that exists “around” the head rather than inside it.
When we judge ourselves, our connection with the “self” that we see acting and feeling (and suffering) prevents us from correctly examining the mechanisms at work, even though it allows us to describe the symptoms of our distress without knowing their technical name.
When our overall balance is sufficiently preserved, we do not place too much weight on our own interpretations and instead regulate ourselves according to the evidence of what actually happens.
Because the brain cannot automatically correct its own tendencies or persist in directions that are not suited to it, when these tendencies become rigid as an expression of a disorder, we tend to become trapped within beliefs or impressions that lead us astray or keep us off course.
Insight
In mental disorders, even relatively mild ones, the person as a whole tends to become more rigid—not in the sense of being “static,” but in the sense that their mental position becomes more predictable and one-directional.
At the same time, the person loses even more of the ability to judge themselves. Under ordinary circumstances, they may occasionally be able to assess themselves objectively, “from the outside,” but under these conditions they tend not to understand where the disorder is taking them.
As a result, they tend not to question the mechanisms of the disorder, but rather to follow them.
Technically, this is referred to as “insight,” meaning the ability to look within oneself without having to detach from oneself, as occurs in dissociation—in other words, to be aware of the mechanisms that move us “from within.”
Insight therefore corresponds to having some doubt about the impression we are experiencing. This allows us to observe our own behavior and judge ourselves on the basis of that behavior, rather than according to whichever interpretation seems most pleasant or intuitive.
It is this capacity that provides a way out of our blindness to our own brain. It is what allows us to be educated, trained, and to persist in directions that may seem absurd or even wrong, thereby saving us from the rigidities and one-way paths that the brain has established.
Observer and observed: the psychiatrist-patient relationship
Every personality has its own one-way paths and dead ends, and disorders generally start from these tendencies and intensify them.
There is a type of exchange between psychiatrist and patient in which, in addition to treating the disorder, the patient is guided toward adapting to the treatment, its goals, and recognizing its effects even before those effects become obvious or satisfactory.
In general, the patient complains of symptoms and asks for them to be resolved, preferably in a stable or definitive way.
However, the process that leads to these results does not proceed in the way the patient would consider logical, and doubts, resistance, and misunderstandings often arise.
It is as though, for example, the patient were a traveler who gets into a taxi, gives the driver an address, but then gets the impression that the driver is going in the wrong direction, completely outside the expected area.
At that point, the passenger may ask to get out, insist on telling the driver which way to go, or at the very least become anxious.
Some very common forms of mistaken self-analysis include:
Denying one’s diagnosis while searching for very unusual or alternative diagnoses.
Believing that effectively accommodating one’s symptoms—for example, one’s worries—will resolve the situation.
Believing that one’s level of intelligence will make it easier to manage the illness and eventually find a solution.
Believing that the illness is caused or maintained by external agents, including events or factors that may have occurred years earlier.
Let us consider some examples.
A person with obsessions, for example, will ask to be freed from them. At the same time, however, they may experience treatment negatively because they believe that without their obsessions they will no longer have control over their life.
In other words, resistance develops based on the viewpoint of a person with obsessions: the idea that the solution is to control them as effectively as possible.
Quite simply, a hypochondriacal person will demand reassurance about their health or about medications and will react badly to answers that deny them this reassurance.
They may believe that treatment must first satisfy this need for clarity and reassurance, even when the need itself is obsessive, and only then somehow proceed toward the actual goal.
The psychiatrist, however, will try to teach the patient to bear in mind that the mechanism of obsessions should not be accommodated, simply because doing so is not only useless but can also interfere with decisions that need to be made and with the continuation of treatment itself.
A depressed person will ask to be treated but may simultaneously express distrust of the treatment, almost as though trying to discourage the doctor from treating them.
Even after being told that they need to be patient for several weeks, after the first few days they will repeat that they are still feeling unwell, simply because depression forces them into this repetitive pattern and pessimism.
If the doctor were to interpret this as distrust or lack of engagement with treatment, no genuinely depressed person could ever be treated.
Instead, the doctor must separate the patient’s declared perspective from their own, reinforcing in the patient the idea that the doctor knows of another route to a solution, however difficult to understand or initially “mysterious” that route may seem.
A person with bipolar disorder will complain about the effects of mood instability. They may rationally understand that resolving the situation requires at least several weeks, if not months, but then, after only a few days, they will report mood changes identical to those they had before and insist on drawing conclusions from them.
If they feel better, they will congratulate themselves or be pleased about it.
If they feel the same as before, they will declare that the treatment “doesn’t work.”
If they feel worse, they will think that the doctor made a mistake because they were supposed to feel better, whereas the opposite is happening.
Inevitably, the perspective imposed by the disorder will lead them to believe that they need someone to “lift them up,” and they will say that they can tell “immediately” whether the medication is working.
In this way, they may insist on using an unstable parameter—their current mood—to judge whether the treatment is moving in the right direction, risking being wrong in both directions: positively, if they feel better immediately, and negatively, if they are not yet feeling well.
A person with bipolar disorder may deny having bipolar disorder because euphoria is seen as the way out, or at least as a preferable condition, while non-euphoric excited phases—those in which mood is not actually good—are not regarded as evidence of bipolarity.
This creates a sterile opposition in which the doctor seems to be telling the patient, “If you are bipolar, then you must also be euphoric,” while the patient insists, “My mood is never as good as I would like it to be, so I am depressed.”
Psychoeducation: understanding one’s disorders
Finally, the same disorder—for example, depression—can be experienced differently depending on the person’s personality.
As a result, certain personality types may sometimes worsen particular aspects of the underlying disorder, such as the ability to ask for help, the ability to allow other people to manage the problem, or the tendency to blame oneself or take excessive responsibility.
In summary, psychiatric treatments often work gradually, correcting the disorder’s own perspective and allowing the person to discover a new point of view that they had neither imagined nor remembered was possible.
The solution is not where the obsessive patient insists it is, believing that they are being underestimated or treated disrespectfully if they are contradicted.
The solution exists despite the “nothingness” that fills the depressed patient’s perspective.
And it does not coincide with the intuition that the bipolar patient prides themselves on having and believes in every time, without realizing that they are oscillating between confidence and distrust like a swing.
Psychoeducation is a way of interacting with the patient that teaches them—not so much beforehand, in theory, but during treatment—to recognize the direction in which they are moving.
Usually, during the initial phase, there will be resistance or tendencies that need to be rejected or discussed, and the patient may have the unpleasant impression that they are not the one “in charge,” or that they are not contributing to decisions through their own intuition or reasoning.
All of this serves to safeguard the success of a treatment that could not be based on mistaken beliefs induced by a particular mental state.
If there is one thing that mental disorders generally deprive a person of awareness of, it is precisely…