I've been neglecting the blog a bit this year, partly because I'm trying to become a psychotherapist. Most of my time is absorbed in taking classes and writing papers. The last time I did an advanced degree, I eventually tried to revise my seminar papers for publication, and placed quite a few of them in academic journals over the years; I hope to do the same for some of these, too. Some of the material is about my own conflicts or limitations, which is writing I'm reluctant to disclose, lest it alienate anybody whom I might otherwise perhaps be able to help. But other recent papers seem to me appropriate, thoughtful enough, and maybe even interesting, so I am thinking of posting some. This is the first one I'll try here; please comment if you feel like it.
(Speculative) Mental Health Treatment Report
“…while the patient lives it through as something real and actual…”
--Freud, “Recollection, Repetition, and Working Through”
This MHTR assesses the protagonist of Shakespeare’s tragedy Hamlet, Prince of Denmark. Quotations from the play are cited with Roman numerals indicating act and scene, respectively (thus “II, iv” means Act Two, Scene Four). Temporality is a vexing issue here, since the character is killed in the drama’s ending, and since he experiences many marked changes of state as the action transpires. An MHTR is based on interviews; it’s an extrapolation from the patient’s own reporting, supplemented by the clinician’s observations and a handful of gross situational facts such as divorce, job loss, arrest, toxicology results, and so on. By contrast, our knowledge of Prince Hamlet is based on a text whose generic conventions include the theater’s “fourth wall,” an illusory barrier between the spectators (or the reader) and the delimited world internal to the text. For the purposes of this assignment, then, I am assuming a different play, identical to Shakespeare’s except that toward the end of Act Five, when Hamlet and Horatio are through talking with the Gravedigger but have not yet arrived at Elsinore for the duel with Laertes, the Prince excuses himself from Horatio’s company and enters a windowless shack by the side of the road, whose green weathervane wails on its hinges in the wind. Having heard this sound before in my dreams, I hear the creaking, squeaking swinging noise again now, as I wake to find myself apparently dwelling in this same shack, and practicing psychotherapy in it: beside my chair is a long couch, onto which a man of about 28 has just sat down, wringing his hands and rather fiercely staring at me.
Multiaxial Diagnosis Form
Diagnostic code DSM-IV-TR name
296.89 Bipolar II Disorder, With Rapid Cycling (Provisional Diagnosis)
296.64 Bipolar I Disorder, Most Recent Episode Mixed,
Severe With Psychotic Features (R/O)
Axis II: Personality Disorders and Mental Retardation
Diagnostic code DSM-IV-TR name
_________________ No diagnosis on Axis II
Axis III: General Medical Conditions
ICD-9-CM code ICD-9-CM name
_________________ No diagnosis on Axis III
Axis IV: Psychosocial and Environmental Problems
Problems with primary support group
The patient’s father died less than six months ago. Two months later, the patient’s widowed mother married the brother of her late husband. The patient is experiencing the grief of father-loss (which Freud called “the most important event, the most poignant loss, of a man’s life”), intensified by several factors involving his primary support group: an unusually strong identification with his late father (they share the same name), together with unresolved guilt over what seem like robust but unconscious Oedipal feelings of rivalry with his father, now dead; hatred of his uncle; and feelings of isolation and betrayal deriving from his mother’s “o’er hasty marriage” (her words) to this same uncle. Instead of joining Hamlet in his mourning, she apparently has thrown herself into a new life with her late husband’s younger brother, the new King. The patient was deeply hurt by the “wicked speed” with which she remarried: “But two months dead!” (I, ii). The patient’s firm belief that his uncle/stepfather murdered his father has made it impossible for him to adjust to his new family configuration (“A little more than kin, and less than kind.” I, ii).
Problems related to the social environment
Though the patient has one close friend (Horatio), most people at court perceive their career prospects and social lives as strongly dependent on a quick and thorough switch of allegiance, away from the dead man and onto his successor, regardless of any disparity in their relative merits as kings or human beings. But the patient, as the dead man’s loving son and heir apparent, finds himself incapable of any such adjustment. Perhaps this speaks for his integrity and self-knowledge; it also isolates and makes him vulnerable.
Already a very learned man, Hamlet hopes to continue his studies. But his uncle, who has recently become the focus of intense feelings of rage, helplessness, and resentment, has prevented this: “For your intent / In going back to school in Wittenberg, / It is most retrograde to our desire…” (I, ii). Lately he derides both his reading (“words, words, words…” II, ii) and his writing (“I have not art to reckon my groans” II, ii).
The patient is a prince, raised to expect that he would succeed his royal father to the throne of Denmark. In recent months, however, his uncle has been crowned in his stead. Somewhat naïve about other vocations, the patient cannot seem to imagine himself as anything but the Prince he was, or the King he had expected to become. Though briefly exiled to England, he returned to Denmark in an effort to carry out what he regards as the will of his father’s spirit. Like Shakespeare’s Coriolanus, he may say “There is a world elsewhere,” but unfinished business calls him back home.
The patient reports disgust with his uncle on a broad range of issues which include the latter’s alcoholism, often manifest in boisterous late-night drinking binges held in the large residence they share (I, iv). Though the castle of Elsinore is capacious, Hamlet does live under the same roof as the King and Queen, which may be exacerbating his horror at the thought of their sexual relationship. He became visibly distraught as he vividly speculated on the subject with somewhat eroticized disgust: “Nay, but to live / In the rank sweat of an enseamèd bed, / Stewed in corruption, honeying and making love / Over the nasty sty…” (III, iv).
Problems with access to health care services
Although the patient has inherited considerable wealth and social position (“to the manor born”), the healthcare available to him is severely constrained by his temporal position in the continuum of history. Wilfred Bion once cited the moment in Shakespeare’s Macbeth when the Scottish King learns that the Doctor cannot help his mad Queen, and responds in disappointment: “Canst thou not minister to a mind diseased?” Bion supplied a fitting answer: “Well, not at the moment, but in four hundred years, come along again and we’ll see what we can do.”[i]
Problems related to interaction with the legal system/crime
Rather like a corporate whistleblower or a political dissident (Alford, 2001), Hamlet is caught between the law of the organization to which he belongs, and a higher ethical imperative which that law has apparently compromised. The patient reports overhearing his uncle remarking on this very matter: “In the corrupted currents of this world / Offence’s gilded hand may shove by justice, / And oft ‘tis seen the wicked prize itself / Buys out the law…” (III, iii). Hamlet has no “problems related to interaction with the legal system” because Elizabethan law (see III, i; IV, iii; V, i) was still a fluid thing, not really a “system,” nor has he the benefit of legal recourse against his royal uncle, for the same reason that a successful revenge would likely go unpunished: at the top of any society, successful violence tends to remain above the law. In the words of Shakespeare’s contemporary, John Harrington: “Treason doth never prosper… for if it prosper, none dare call it treason.” A person of the 21st Century could not be in Hamlet’s situation, which presupposes a hereditary monarchy in Northern Europe; but anyone who felt Hamlet’s rage for a new stepfather and believed that the Ghost of his father was demanding that he murder him would, of course, be a danger to himself and to others, a homicide risk and a likely candidate for 51/50 involuntary hospitalization.[ii]
Other psychosocial and environmental problems
The patient’s girlfriend was enlisted by her father to spy on the patient. He found out about this, took it quite personally, and abruptly ended their relationship, directing a tirade of verbal abuse at her and at himself (III, i).
Axis V: Global Assessment of Functioning Scale Score: 20 Time Frame: recent weeks, since the Coronation of King Claudius. The GAFS is difficult to apply here, for reasons explained above and below. In general, the patient maintains meaningful relationships and shows keen intellect, but he also shows signs of being a danger to himself and to others.
II. PATIENT’S INITIAL REASON FOR SEEKING TREATMENT.
The patient reports several depressive symptoms, including anhedonia: “I have of late—but wherefore I know not—lost all my mirth, forgone all custom of exercises” (II, ii); suicidal ideation: “O that this too too solid flesh would melt… Or that the Everlasting had not fix'd / His canon 'gainst self-slaughter!” (I, ii), “To be, or not to be” (I, iii); as well as anxiety-related insomnia: “Sir, in my heart there was a kind of fighting / That would not let me sleep.” (V, ii). He also reports a highly disturbing command hallucination: “Revenge his foul and most unnatural murder.” (I, v).
III. PATIENT’S HISTORY AND CURRENT CONDITION.
The patient explains that he has recently had experiences whose ethos he associates with madness—“an antic disposition”—and that although he initiated most of these as deliberate performances of a feigned madness, as each episode progressed, it became impossible for him to distinguish with full confidence between this mere malingering and a real insanity that deeply frightened him. Factitious disorder (300) is ruled out, since there is an environmental reason “to put an antic disposition on” (I, v), namely to frustrate his uncle’s efforts to control his response to the crisis at court.
His girlfriend reports an instance of Hamlet’s crazy behavior: “Lord Hamlet, with his doublet all unbraced, / No hat upon his head, his stockings fouled, / Ungartered, and down-gyvèd to his ankle; / Pale as his shirt, his knees knocking each other, / And with a look so piteous in purport / As if he had been loosed out of hell / To speak of horrors…” (II, i). This was malingering. Yet perhaps its form expresses elements of the patient’s experience, as if his outer clothing were expressive (albeit inadequately) of his inner spirit, just as it is seen to be in the earlier “inky cloak” scene (I, ii). There, the element of the clothes that matched the spirit was their mourning blackness; here, it is their disarray. Like the acting of the Player who weeps for Hecuba (II, ii), but unlike the lies of a killer (one who might say something like “The harlot's cheek, beautied with plastering art, / Is not more ugly to the thing that helps it / Than is my deed to my most painted word.” III, i), Hamlet’s antic disposition is a dissembling in the service of the truth.
IV. MENTAL STATUS EXAMINATION
The patient is unsure of his precise age but presents as about 28, a Danish male of royal background who currently has no employment, gainful or otherwise. He did not seem unkempt, as he had in Ophelia’s description above (“his doublet all unbraced…”), but seemed reinvested in his appearance, with buttons and laces all done up correctly, and, perhaps importantly, a white shirt among black garments instead of all black. He began the interview seeking advice about his girlfriend’s recent symptoms of acute mental distress. When we turned to the patient’s own experience, he was extremely guarded at first. Unsatisfied with the confidentiality clauses in the intake forms he had signed, he made me swear by his sword, “Never to speak of this that you have heard.” (I, v). That done, the patient disclosed his suspicions that his father may have been killed by the younger brother who survives him—the patient’s uncle, who now enjoys his mother’s bed as well as the throne. These suspicions were, in the patient’s view, confirmed (“O, my prophetic soul!”) by a recent encounter with a speaking apparition that claimed to be his father’s spirit, and which proceeded to elaborate a vivid account of exactly how the uncle murdered the father (I, v). The patient commands an impressive interpersonal sensitivity. He noted my silent skepticism about the Ghost and responded: “There are more things in heaven and earth… Than are dreamt of in your philosophy.” (I, v). For good or ill, our “philosophy,” broadly construed, is the only tool we have in hand, and it militates very strongly for the proposition that there is no Ghost outside the patient’s mind. In a separate interview, the patient’s mother reports an episode in which Hamlet, in her own presence, claimed to hear and see this same Ghost, while she had no such experience (III, iv). Yet this is complicated by the reports of others in the patient’s circle: Bernardo, Marcellus, and Horatio (I, i; I, iv; I, v), each reported seeing the same apparition, watching it together, first without Hamlet and then with him. Shared Psychotic Disorder (297.3) is ruled out, since four people saw the Ghost simultaneously, three of whom show no other mental disturbance.
The patient has recently become obsessed with the hypothesis that his uncle murdered his father. He is overwhelmed by the feeling that he is personally obligated to avenge that murder by murdering his uncle in turn. As a mandated reporter I reached for a telephone, intending to alert the police, but the voice on the other end was Dogberry, the clownish constable from Much Ado About Nothing, who seemed to gape and sputter at the sheer enormity of the situation as I described it. He let me know, in his idiom full of fake verbal sophistication and earnest virtue, that his scope of competence and scope of licensure (“office” was his word for it) could by no means extend to the restraint of a Prince, much less the arrest of a King, and he hung up on me.
V. COURSE OF TREATMENT
Under Axis V “educational problems” were discussed. Despite his love of learning, the patient reports a new contempt for his studies, which seem trivial compared with the crisis of his father’s murder and its consequences—especially the patient’s obsessive but ambivalent yearning for revenge: “Yea, from the table of my memory / I’ll wipe away all trivial fond records, / All saws of books, all forms, all pressures past / That youth and observation copied there…” (I, v). Yet this image of erasing false knowledge from his mental notebook is followed immediately by a counter-image of writing down something new, in a painful moment of what Bion might call “learning from experience”: “My tables! Meet it is I set it down / That one may smile, and smile, and be a villain.” This is just one recent iteration of an ever-repeated discovery, that human beings are capable of amazing levels of evil which they seek to cover with equally amazing levels of deceit. Treatment should honor the painful learning in that lesson, while pointing up its incompleteness: secret betrayals, false shows of love, and deeply personal loss are not the whole story of human life, and need not be the whole story of Hamlet’s life, if he can learn more.
VI. COLLATERAL CONTACTS
VII. CURRENT TREATMENT GOALS
The patient is a strange man with a high degree of achieved individuality. Since he often remarks on the perceived emptiness and consequent interchangeability of the people around him (especially courtiers, e.g., Rosencrantz, Guildenstern, Osrick), treatment will have to include respect for individuation and idiosyncrasy. Prince Hamlet also finds himself at or near the uttermost pinnacle of the society to which he belongs—a rare state of affairs which would frustrate any effort to pathologize his grandiosity as mania or even hypomania (this complicates the distinction between Bipolar I and Bipolar II in Hamlet’s case, as does his command hallucination, which speaks for Bipolar I, whereas the rest of the patient’s functioning seems much less mentally disturbed than the hallucination would suggest). In rank he is a prince; in nature and achievement he’s what Shakespeare elsewhere (Henry the Fifth, II, ii) called “the full-fraught man.” Envisioning a good therapy outcome for him is challenging, because he has come to associate change with loss, and grief with integrity. His uncle and his mother have already made bad-faith efforts to rush his mourning (I, ii), so he will need plenty of time to grieve for his father.
The main obstacle to the patient’s happiness seems to be his hateful feelings for his uncle. Yet these feelings are rooted in very real deeds. It would be crazy-making for a therapist to go after Hamlet’s symptoms—the anhedonia, suicidal ideation, and the intermittent psychotic breaks including visual-auditory homicidal command hallucinations—without respecting the concrete facts to whose vexing presence they represent a partly effective, partly self-destructive response.
This uncle represents to the patient his own defeat, and his father’s murder—but also, the victory of a worldview so deeply cynical as to cast the value of existence into doubt. In our interview, Hamlet quoted the Chorus from Sophocles’ Oedipus the Tyrant as they comment on a successful regicide: “if such acts are respected, why should I join in the dance and worship”?
One possible outcome is that the patient will accept the duel proposed to him recently by Laertes, and then allow the violence of the duel to break out of its conventional confines and kill King Claudius. But this uncontained violence might well destroy the patient, his mother, Laertes—in short, all concerned (as in fact happens in V, ii, the final scene of the play). In such a case, treatment goals are alternative futures in which violence is successfully contained, sublimated, or diverted onto objects deemed appropriate for its absorption. If Hamlet can gain the throne without killing his uncle, he can lawfully dispose of him. Treatment might direct the patient’s attention to the practical means at his disposal, in ways conducive to reality-testing. As Jones (1910/1949) has shown, Laertes turns the Danish people against Claudius quite easily, and “Where Laertes succeeded, it is not likely that Hamlet, the darling of the people, would have failed.” Yet this has not occurred to him, so far.
Professional ethics precludes any recommendation to proceed with the revenge-command of the Ghost, yet the patient is implacably haunted by this same command. Treatment avenues that depend solely upon renunciation of ambition are therefore not likely to succeed, since their exemplars—e.g., Gilgamesh, Buddha, Pope Celestine V—were not, like Hamlet, haunted by guilt over unperformed vengeance. Instead it may be best either to help the patient to reassess his options for a putsch on the rabble-rousing model of Laertes (rather than on the assassination model of Claudius); or to marshal a legal proceeding, perhaps backed by foreign assistance from Fortinbras of Norway (who also has reason to want Claudius exposed and deposed). Whatever road the patient chooses through his practical problems, treatment goals should include a fortifying of the patient’s self-love, again through reality-testing, this time focused on the love tendered to him by Ophelia, by Horatio, and by the people.
As for his mother, it makes plenty of sense for the patient to be angry about the speed of her remarriage as well as her choice of second husband. Hamlet wrote the lines he gave to the Player-Queen: “Both here and hence pursue me lasting strife, / If, once a widow, ever I be wife.” But this ideal of postmortem monogamy is a recipe for despair, and there are well precedented alternatives available to the family. The work of mourning for his father will have to include a mourning for the marriage that was ended by his death; a new emotional life for Hamlet is linked with his eventual allowance of a new erotic life for his mother. It will also be essential to attenuate or reframe the patient’s identification with his late father, a difficult prospect which time may help bring about.
VIII. SUMMATION, PROGNOSIS, AND RECOMMENDATIONS.
Aspects of the patient’s typical mental functioning suggest intermittent hypomania, including non-pathological flight of ideas and insomnia. But his killing of Polonius—which I knew about from the text, not any disclosure by the patient—proves that he is a real danger to Claudius at the least, and perhaps even to others besides him. The deaths of Rosencrantz and Guildenstern (like that of Polonius, arguably) seem more like casualties of that distasteful “craft of intelligence” which defines so much of life at Court, than a personal act of violence. Hamlet did them no direct violence, and they were about the business of having him executed when he surreptitiously made unofficial but legitimate use of his late father’s signet ring to switch their instructions. The risk of suicide seems low, especially now that the lessons of the graveyard have been learned: that life ends soon enough anyhow, and that the vanity of human wishes frees us to live more playfully than we might otherwise dare.
Hamlet’s royal station is a source of both meaning and danger, opportunity and onus. He cannot, as some Americans have been known to do, reinvent himself as some other kind of man, lighting out for the territory to spin a new identity out of nothing. What he has inherited is too big for that. Yet there may be a way of making it smaller; in fact (as I’ve written elsewhere), this shrinkage may be what Hamlet has achieved in his recent observations: of the actor who weeps “for nothing,” of Fortinbras who fights “even for an eggshell,” and of the graveyard, where Emperors and peasants are alike turned into mulch. A personal dilemma that had seemed to great to master is gradually reduced to “the fall of a sparrow” by comparison to the cosmos at large. That is easily said, but Hamlet seems to be doing it: “learning from experience,” as they cannot whose lives are already scripted.
Alford, C.F. (2001) Whistleblowers: Broken Lives and Organizational Power. Ithaca: Cornell U.P.
Hecht, J. “Tragedy, Hamlet, and Luther,” Forschungen zur Frühen Neuzeit, Goethe University, Frankfurt-am-
Weber, M. (1904-05/1992). The Protestant Ethic and the Spirit of Capitalism. trans. Parsons. London: Routledge.
[ii] As a highly specialized rhetorical genre, the MHTR serves the well-being of the patient (since it represents an earnest effort to come to grips with the nature of his or her pain and predicament, the better to formulate a course of treatment) and the convenience of a surrounding world of highly regulated professionals. Whatever its merits and limitations, the MHTR (and the DSM which it aims to apply) epitomize the “rationalization” process whose eventual result Max Weber described as an “iron cage” for the human spirit. Yet this cage of modernity is simply “where” we live, and adaptation to it is a never-ending project. I suppose the patient’s experience of his or her life gets connected to the clinician, who is connected to the DSM-IV (TR), which connects him or her to the profession and to the legal system, and so on. To use a metaphor from the body, most of these links are the connective tissue of rationalized procedure; some are perhaps more nutritive, striving to supply personal human interaction as an artery supplies oxygen or a vein takes away carbon dioxide.