- Email: [email protected]
Psychobiologic resilience, psychotherapy, and the creative process
Psychobiologic Resilience, Psychotherapy, and the Creative Process Frederic
F. Flach
T
HE NATURE of the creative process has been extensively investigated in recent years. Although still rudimentary, the findings of such studies have serious implications for understanding psychiatric illness and effectively employing treatment, particularly psychotherapy. Kubie’ defined creativity, stating that it implies invention, the uncovering of new facts or new relationships among new and old data. “This is not the whole of creativity,” he commented, “but an essential part of the process without which there can be no such thing as creativity.” McKinnor? called the creative idea one that involves a response or an idea that is novel . (one which) . . must to some extent be adaptive to, or of reality. It must serve to solve a problem, fit a situation or accomplish some recognizable goal. And . . (creativity) . . involves a sustaining of the original insight, an evaluation and elaboration of it, a developing of it to the full.
Wertheimer, summarizing the Gestalt definition, referred to the process as the act of “destroying one whole in favor of a new and better one.“3 These definitions are in close agreement. Most important, they separate the process of creativity itself from any particular product of creative thought and action. Thus, the concept of creativity need not and should not be restricted to the field of science of artistic expression. Rather, it can be viewed as a human faculty, as central to the understanding of personality structure as affect or intelligence. STAGES
IN THE CREATIVE
PROCESS
Analysis of the creative process has more or less established four stages in which the creative act takes place. The importance and duration of each stage varies, of course, from individual to individual and from problem to problem. The first stage is called preparation. As Maddi stated,4 “A long period of purposeful, relentless, organized thought precedes creative insight.” One must acquire and possess a sufficient degree of knowledge of the subject and master those skills necessary to accomplish the creative event. The second stage is called incubation. Having once recognized that a particular problem has no obvious solution in spite of serious effort, one must often put the problem aside for an indefinite period of time-to let it “simmer’‘-so that the preconscious mind in its complex and rich manner, can rapidly mobilize large quantities of data and superimpose dissimilar ingredients into new percepFrom the Department
Cornell University Medicul College. NeKs York. Associate Professor, Department of Psychiatry, Cornell University Medical College. Nets York: Attending Psychiatrist, Payne Whitney Clinic, New York Hospital, New York: Attending Psychiatrist, St. Vincent’s Hospital and Medical Center, New York, N.Y. @ 1980 by Grane & Stratton, Inc. 0010-440X/80/2106-0013$02.00/0
Frederic
510
of Psychiatry,
F. Flach. M.D.: Clinical
Comprehensive
Psychiatry,
Vol. 21, No. 6 (November/December),
1980
PSYCHOBIOLOGIC
RESILIENCE
511
tual and conceptual patterns, “reshuffling experiences,” as Kubie’ stated, “to achieve those fantastic degrees of condensation without which creativity would be impossible.” Arthur KoestleIS called this activity bisociation, since the thought processes involved occur on more than one plane of consciousness. He described this activity as a relaxing of the controls that normally characterize logical thought processes and a “regression to modes of ideation indifferent to the rules of verbal logic.” His description is quite reminiscent of Kris’ well-known phrase. “regression in the service of the ego,” when the individual remains in control. yet can relinquish secondary process thinking enough to permit more primitive modes of thought and feeling to emerge in the course of traditional psychoanalysis. The third stage is called illumination. Here the new insight breaks into consciousness. Under conducive environmental conditions as well as in the presence of inner personal openness of mind, solutions, connections, and novel ideas may literally flash into awareness. Kekule’s description of his search for the nature of the benzene ring is a classic one. He had pursued his research as far as he could. Then, he put it aside. One evening as he dozed in front of the fire “the atoms were gambolling before my eyes . . . all twining and twisting in snakelike motion. But look! What was that? One of the snakes seized hold of its own tail. and the form whirled mockingly before my eyes. As if in a flash of lightning. I awoke.” At once he saw that here was the form and structure, in the ring created by the six carbon atoms, for which he had been looking all along. The fourth stage is verification. Stein” forcefully emphasized the importance of this step when he stated that, “No one ever wins a Nobel prize for an idea, but rather for carrying that idea to its completion.” At this point the individual must painstakingly explore the validity and effectiveness of his new insight and be willing, if wrong, to go back to the beginning and start again in his quest. It is apparent that movement from conscious thinking of a more logical type to preconscious thought processes of a more allegorical, figurative, and unbiased mode-and back again-requires the flexibility to transit the boundaries of consciousness in a relatively unthreatened manner. Thus, as Schubert’ pointed out, the person with severe psychoneurotic obsessive-compulsive traits employing repression, for example, usually lacks the required fluidity because he cannot relinquish secondary process thought, whereas the patient with a severely disorganizing illness, such as acute or chronic schizophrenia, is usually unable to organize secondary thought patterns so as to effectively understand and employ original ideas. Kubie’ particularly stressed that the preconscious and not the deeper unconscious was involved in the creative process. The latter he felt could not be the source of original responses, since it is made up of powerful stereotypes, unoriginal perceptions, and emotions dating back to the earliest years of life. often with enormous degrees of rage and fear, and in effect, serving to block free access to the preconscious if strong enough. In Jungian theory, the role of the unconscious in the creative process is formulated somewhat differently. As described by McC~lly,~ it is the collective or objective part of each person’s unconscious rather than the personal part established as a result of one‘s own
512
FREDERIC F. FLACH
life experience, that is the source of original insights. The so-called “archetypal sources” that are activated under appropriate conditions give rise to archetypal images that possess special characteristics containing the essence of human experiences repeated enough and formative over the centuries of man’s existence to make a permanent imprint on the neural structure. Such images concern themselves with things that are fundamental and universal to the human experience, such as fathering, mothering, femininity, masculinity, goodness, and evil. PERSONALITY
TRAITS AND CREATIVE ABILITY
A number of studies have identified certain personality characteristics that seem to be strongly correlated with the ability to engage in creative problem solving. Dallas and Gaier,O for example, point out the following: independence; intuitiveness; dominance; flexibility; introversion; social presence and poise; openness to stimuli; unconcern for social norms; wide span of interests; and self-acceptance. These findings are in agreement with those of other investigators. Taylor,lofor instance, observed a higher degree of intellectual precocity, strong curiosity, and outstanding talent in many creative persons; he stated that these traits were often evident very early in life. Rosner and Abt” noted a special confidence and boldness in such persons, as well as an open-mindedness and freedom from preconceptions, the ability to tolerate the uncertainty of not knowing exactly where one’s work and life might be going at any given moment, yet with a definite sense of personal destiny and purpose. MacKinnon12 used psychometric tests to study creativity among a group of architects and found the following traits significantly related to creative ability: intellectual competence; originality; curiosity; sense of responsibility; cognitive flexibility; stability; good judgment; and sense of destiny. These characteristics seem to be similar to those which, by common experience, the psychiatrist associates with the ability to successfully weather stressful life experiences and, among patients, to foster a more rapid and complete recovery from states of decompensation. For many patients, their cultivation represents a major goal of therapy. STIMULATING
CREATIVITY
The research of Stein6 and Parnes13 has focused heavily on the development of methods that can be systematically used to stimulate creative thinking. Synectics, a method developed by Gordon14 and employs the use of analogies is considered by some the most effective way to achieve such stimulation, but it is far too complex for review here. Stein emphasized that to become more creative, it is critical to value the process of creativity and to actively think of oneself as actually or potentially creative. He also stressed the importance of identifying those circumstances and conditions-unique to each individual-under which one is more likely to discover new insights. Something as simple as changing one’s manner of dress can represent a strategy to let go of stereotypes attached to one’s self-image and role model in order to free up the imagination.
PSYCHOBlOLOGlC
513
RESILIENCE
Parnes emphasized two rules to stimulate creative deferred judgment; and (2) quantity leading to quality.
problem
solving: ( I)
Deferred Judgment Withholding evaluation while searching for new ideas is more than restraining one’s critical faculties to avoid premature closure of the flow of ideas. It appears to be intimately related to the process of perception. Parnes quotes McKim: l9 Since all perception involves some degree of imagination we all see imaginatively-in the broad sense of the word. We do not all see creatively. however. The key concept is flexibility. The person who can flexibly use his imagination to recenter his viewpoint sees creatively. ‘The person who cannot budge his imagination to see alternative viewpoints, by contrast, experiences only a one-sided. stereotyped vision of reality.
is this stereotyped vision that Parnes calls prejudgment. seems to facilitate perceptual restructuring.
It
Deferring judgment
Quantity Leads to Quality Parnes’ second rule is called the principle of extended effort. He has demonstrated experimentally that the more ideas one comes up with in search of any solution, the more likely one is to shake loose obstructive perceptions and to arrive at ideas that are indeed both original and ultimately effective. Interestingly, this procedure closely resembles the technique of free association used in traditional psychoanalytic psychotherapy. Parnes has also shown that the ability to use this method can be learned by practice. More is involved, however. than the elucidation of ideas. The individual must also be able to synthesize his thinking as he goes along or at least toward the final phases of the exercise; such synthesis is akin to what Arieti has describedI as the additional factor required to draw from the material at hand that new form that makes it truly creative. IMPLICATIONS
FOR PSYCHIATRY
Current knowledge about the nature of the creative process has important implications for the practice of psychiatry. I5 I would like to highlight three areas in particular: (1) reconceptualizing the nature of certain psychopathological states, in particular depression; (2) recognition of creativity as a critical element in successful therapy, regardless of the theoretical position of the therapist; and (3) prevention of mental illness at all levels. primary. secondary, and tertiary. RECONSIDERATION
OF THE NATURE
OF DEPRESSION
A major step forward in understanding the nature of affective disorders was made when Kraepelin offered his important distinction between those illnesses in which a disorder of mood seemed of primary importance and those in which it did not. Over the years, different types of affective disorders have been classified, ranging from the cyclical manic-depressive or bipolar disorder to the simple, reactive, unipolar depression often triggered by significant personal
514
FREDERIC
F. FLACH
stress. Necessarily, considerable thought has also been given to contrasting normal grief with illness in which depressive affect is the prominent component. Traditionally, the diagnosis of depression is made on the basis of the patient’s history and the presence of certain key symptoms. An alteration of mood is central. Lowered spirits, sadness, hopelessness, sleep difficulties, loss of sexual drive, appetite and weight loss, retardation or agitation, and at times delusions and other severe manifestations are included. In some patients socalled endogenous factors seem most evident; in others, environmental and psychological factors. Psychodynamic issues are also considered: the loss of something or someone valued, internalized rage, guilt, excessive superego formation. This information not only deepens the understanding of a particular patient but also guides the therapist toward his therapeutic choices, both biological and psychological. However, the existence of such theory and classification, while serving eminently practical purposes, may well prevent one from seeing the real nature of the disorder in depressed patients. For instance, it is widely assumed that normal grief and depressive disorders are two fundamentally different responses. But what if they are not? What if the depression of a patient with a so-called affective disorder is, in fact, qualitatively the same as the depression of the normal person in a state of grief? Given such a hypothesis, one would have to look elsewhere than mood to answer the question of what the illness really is. Consider the possibility that in the majority of patients experiencing a depressive illness, the mood change itself is not the core of the illness. Rather, consider the illness as a failure on the part of the patient to be able to experience in a direct immediate way, the disruptive effects of normal grief, and then to be able to reintegrate afterward to establish a new level of equilibrium. Disruption-loss of homeostasis-is a universal feature of the individual’s response to stress. The challenge as Selye15 described, is for the organism to reconstitute a new homeostasis after the shock has subsided. The ability of a person to experience this disruption-reintegration cycle can be termed psychobiological resilience. The pathways of such resilience include psychological, environmental, and biological dimensions, and the integrity of all of these are essential for successful recovery. In our own research into biological factors associated with states of depression, we observed that depressed patients increased their excretion of calcium in the urine and stool while being maintained on constant dietary intakes. As they recovered from depression spontaneously, or due to the administration of tricyclic antidepressants, or electric convulsant treatments, the reverse phenomenon was noted-a decrease in urinary and fecal calcium excretion, overall retention, and as evidenced by isotope studies, an increased movement of calcium to bone.16s7 With very few exceptions, the actual degree of electrolyte shifts observed were within generally accepted normal limits. These could only be noted and statistically established when, in the large series of patients studied, each patient was used as his or her own control,
PSYCHOBIOLOGIC
RESILIENCE
515
From this data we hypothesized that while the actual level of calcium in the central nervous system at certain critical locations might be significant to the patient’s clinical condition-directly as well as in relation to other metabolic actions, such as those of neurohormones-an even more important kinetic phenomenon might be operative. This kinetic factor was thought to be reflected in the patient‘s biological need to react to stress with a transient increase in calcium loss, and with it his inability to reverse the process without either the passage of an undue length of time or active medical intervention. From this vantage point we envisioned agents, such as tricyclic antidepressants, not as mood elevators or even mood restorers, but rather as drugs possessing the capacity to restore biological resilience, thus allowing the patient to recover from the impact of stress. This concept is reinforced by the clinical observation that many patients who have recovered from states of depression and are still maintained on tricyclic antidepressants nevertheless reenter episodes of depression when confronted with appropriate stress, but seem to be able to limit the depth of response and to recover from the episode much more quickly than before. The healthy person stressed by the loss of a loved one, for instance, will enter a period of disequilibrium and manifest signs of depression at that time. Thereafter. he will recover to reorganize himself and his life under fundamentally new and unfamiliar circumstances. In the process he will undergo physiological shifts. He will also experience the pain of grief, the need to relinquish the past, and the struggle to find new purposes. And the nature of his environment will strongly determine how successfully he can master this experience. The alternative is illness-a failure to move through the normal cycle of disruption-reintegration. This cycle can be blocked or interfered with at any psychobiological level, and in either the disruptive or reintegrative phase. Many patients can, for example. temporarily postpone coming to terms with the disruptive effects of grief-depression, by the use of psychological mechanisms. such as denial and repression, by acting out, ill-timed changes in life patterns, ot the use of alcohol or drugs, and often at a high personal cost. On the other hand, once actively depressed, the patient may not be able to reintegrate. Because he is psychologically rigid and inflexible, because his environment is intolerant. or because he lacks sufficient biological resilience. his depressed state may become chronic. Or the patient may not be able to control the intensity of his response developing psychotic symptoms. If his disorder is ameliorated by means of treatment. the reintegration may be faulty and a serious recurrence of his condition may occur. Examination of the nature of the creative process has shown that it involves basically, the disruption of a former perception and its replacement through a process of reintegration with a new and better one. Loss and renewal are central themes, even as in the experience of depression. And while knowledge of creativity as such has little to offer at present to our understanding of the biological mechanisms involved in states of depression, it seems to afford important insights into crucial psychological and environmental factors. When those personality traits shown to be associated with creativity are present.
516
FREDERIC
F. FLACH
when the individual is creative not only with regard to some particular talent but with regard to himself and his life adaptation, and when environmental conditions are such as to encourage insight and flexibility, the chances of the individual successfully transiting a period of loss and grief appears immeasurably enhanced. CREATIVITY
AND PSYCHOTHERAPY
How the psychiatrist conceptualizes any patient’s illness necessarily influences his therapeutic stance. Frank l6 has identified some of the therapeutic influences common to all forms of psychotherapy. Among these are the need to restore morale and the nature of the relationship between patient and doctoran authority who seems to possess knowledge and experience promising relief, and with whom the patient shares to some degree a common view of life, reality, and the principles of the theapeutic effort. Most psychiatrists conduct treatment within guidelines derived from their own particular theoretical orientation. While this may provide them and their patients with a sense of security and direction, it can easily become counterproductive when theory and its language are too rigidly adhered to; what results is a singular lack of flexibility in the therapeutic experience. In the psychotherapy of the depressed patient, for example, continued, repeated emphasis on those topics associated with sadness, hurt or resentment, can often serve only to reinforce the very affect that the therapist is striving to relieve. By the same token, insistent focusing on problem areas (conflictresolution) without due attention to the patient’s talents and opportunities (self-actualization) can seriously interfere with progress. Decentralization, the intentional tactic of alternately probing into problem areas then withdrawing toward neutral and positive areas of the patient’s lifelx is an essential part of psychotherapy in depressed patients. It represents the use of creativitystimulating strategies encouraging periods of incubation for insight to take place and, at the same time, introducing a necessary flexibility not only in the therapist’s role model but also in the rhythm of the interpersonal interplay itself. The similarities between the steps in the creative process and what happens in successful psychotherapy are especially striking. Parnes’ rules of deferred judgment and extended effort are particularly reminiscent of traditional psychoanalytic techniques. Free association, e.g., in the presence of an empathic, nonjudgmental, flexible therapist, is designed to postpone editorial evaluations by the conscious mind so that the patient producing more and more ideas and recollections can reach into his unconscious. When the goal of psychotherapy is insight, a former perception must be forfeited and replaced with a better one. The more flexible the patient, the more capable he is of changing perceptions; conversely, the more basic resistance he has, the more fixed he is in his existing patterns of thought and behavior, the more difficult it will be to help him move away from unhealthy modes of thought and behavior to assume more constructive ones. Therapeutic environments-hospitals, outpatient units, half-way houseshave often been described as antithetical to the recovery of patients. Many
PSYCHOBIOLOGIC
517
RESILIENCE
have an atmosphere of helplessness, hopelessness, control or disorder, which combines with an overall preoccupation with illness and problems so as to make the patients’ movement toward health and competence excessively slow and arduous. Those settings that work best are usually characterized by welldefined programs that intentionally distract from the exclusive focus on disability. and provide stimulation of the patients’ ability to engage in creative problem solving and self-development. CREATIVITY AND PREVENTION In psychiatry, preventive medicine has been given little attention. Some feel that without greater knowledge of the underlying causes of mental illness such efforts are pointless. Others doubt the efficacy of intelligent strategies to implement preventive programs. However, when the problem of health and illness is redefined in the light of creativity theory and prevention is logically divided into its three main phases, it is clear that the concepts and techniques developed through the study of creativity can serve to implement prevention. The goal of primary prevention is to help the individual to be better able to cope with the inevitable (and at times tragic) changes that occur during life, so that a serious psychopathological disorder can be avoided. Secondary prevention involves earlier diagnosis and more effective treatment. Tertiary prevention means helping the recovered patient remain well by providing him with the instruments, whether medicative or psychological that ensure recovery. If psychobiological resilience is a critical part of staying well-or remaining well after having suffered from a psychopathological disorder-then one should consider mastery of the creative process as part of that resilience. This means training the individual to think of options, cultivating his capacity to change his perceptions of things as situations demand change. preparing him to cope with unexpected events he has never before experienced, and enabling him to gain new insights into his personality as his experience in life broadens. Thus, the direct teaching of the principles of creative thinking becomes an invaluable part of all educational efforts, including those formally referred to as therapeutic. CONCLUSIONS
The ability to think and act creatively appears to be a critical component of the healthy personality and an important factor in coping with stress as well as recovering from the impact of psychopathological disorder. The following recommendations naturally follow: I. An appraisal of creative potential and actual creative ability should be part of the initial personality evaluation of every patient. 2. The utilization of creativity-stimulating strategies should be intentionally incorporated in the treatment of psychiatric patients, whether in individual or group settings. 3. Environment strategies conducive to creative thought and behavior should be introduced into institutions responsible for the care of psychiatric patients. 4. Training in creative problem-solving techniques should be part of educational programs aimed at prevention.
FREDERIC
518
5.
F. FLACH
Training in creative techniques should be part of the regular program of education for psychiatrists and other mental health workers, and applied not only in therapy situations but in teaching and research as well. REFERENCES
I. Kubie LS: Neurotic Distortion of the Creative Process. University of Kansas, 1958 2. MacKinnon DW: The nature and nurture of creative talent. Am Psycho1 17:484-495, 1962 3. Wertheimer M: Productive Thinking. New York, Harper & Row, 1959 4. Maddi SR: Motivational aspects of creativitiy. J Pers 33:320-347, 1965 5. Koestler A: Act of Creation. New York, MacMillan, 1974 6. Stein MI: Stimulating Creativity. New York, Academic, 1974 7. Schubert DSP: Creativity and the ability to cope, in Flach FF (ed): Creative Psychiatry Series, Monograph No 5. New York, Life Sciences Advisory Group, 1976 8. McCully RS: Contributions of Jungian psychotherapy toward understanding the creFlach FF (ed): Creative ative process, Psychiatry Series, Monograph No 4, New York, Life Sciences Advisory Group, 1976 9. Dallas M, Gaier EL: Identification of creativity: The individual. Psycho1 Bull 73:5573, 1970 10. Taylor IA: The nature of the creative process. in Smith P (ed): Creativity. New York, Hastings House, 1959, pp 51-62 II. Rosner S, Abt LE (eds): The Creative
Experience. New York, Grossman, 1970 12. MacKinnon DW: Personality and the realization of creative potention. Am Psycho1 20:273-28 I, 1965 13. Parnes S: Creativity: Unlocking Human Potential. Buffalo, DOK, 1972 14. Gordon WJJ: Synectics. New York, Harper & Row, 1961 15. Arieti S: Creativity: The Magic Synthesis. New York, Basic Books, 1976 16. Flach FF: Choices. New York, JB Lippincott, 1977 17. Selye H: The Stress of Life. New York. McGraw-Hill, 1956 18. Flach FF: Calcium metabolism in states of depression. Br J Psychiatry IlO:558-593, 1964 19. Faragalla FF, Flach FF: Studies of mineral metabolism in mental depression. J Nerv Ment Dis 151:120-129, 1970 20. Frank JD: Psychotherapy: The restoration of morale: in Weekly Psychiatry Update Series No I9 Vol I. Princeton. NJ, Biomedia. Inc., 1977 21. Flach FF: The use of chlorpromazine to facilitate intensive dynamic psychotherapy in depression. Psychiatria et Neurologia 134:289-297. 1957
F. Flach
T
HE NATURE of the creative process has been extensively investigated in recent years. Although still rudimentary, the findings of such studies have serious implications for understanding psychiatric illness and effectively employing treatment, particularly psychotherapy. Kubie’ defined creativity, stating that it implies invention, the uncovering of new facts or new relationships among new and old data. “This is not the whole of creativity,” he commented, “but an essential part of the process without which there can be no such thing as creativity.” McKinnor? called the creative idea one that involves a response or an idea that is novel . (one which) . . must to some extent be adaptive to, or of reality. It must serve to solve a problem, fit a situation or accomplish some recognizable goal. And . . (creativity) . . involves a sustaining of the original insight, an evaluation and elaboration of it, a developing of it to the full.
Wertheimer, summarizing the Gestalt definition, referred to the process as the act of “destroying one whole in favor of a new and better one.“3 These definitions are in close agreement. Most important, they separate the process of creativity itself from any particular product of creative thought and action. Thus, the concept of creativity need not and should not be restricted to the field of science of artistic expression. Rather, it can be viewed as a human faculty, as central to the understanding of personality structure as affect or intelligence. STAGES
IN THE CREATIVE
PROCESS
Analysis of the creative process has more or less established four stages in which the creative act takes place. The importance and duration of each stage varies, of course, from individual to individual and from problem to problem. The first stage is called preparation. As Maddi stated,4 “A long period of purposeful, relentless, organized thought precedes creative insight.” One must acquire and possess a sufficient degree of knowledge of the subject and master those skills necessary to accomplish the creative event. The second stage is called incubation. Having once recognized that a particular problem has no obvious solution in spite of serious effort, one must often put the problem aside for an indefinite period of time-to let it “simmer’‘-so that the preconscious mind in its complex and rich manner, can rapidly mobilize large quantities of data and superimpose dissimilar ingredients into new percepFrom the Department
Cornell University Medicul College. NeKs York. Associate Professor, Department of Psychiatry, Cornell University Medical College. Nets York: Attending Psychiatrist, Payne Whitney Clinic, New York Hospital, New York: Attending Psychiatrist, St. Vincent’s Hospital and Medical Center, New York, N.Y. @ 1980 by Grane & Stratton, Inc. 0010-440X/80/2106-0013$02.00/0
Frederic
510
of Psychiatry,
F. Flach. M.D.: Clinical
Comprehensive
Psychiatry,
Vol. 21, No. 6 (November/December),
1980
PSYCHOBIOLOGIC
RESILIENCE
511
tual and conceptual patterns, “reshuffling experiences,” as Kubie’ stated, “to achieve those fantastic degrees of condensation without which creativity would be impossible.” Arthur KoestleIS called this activity bisociation, since the thought processes involved occur on more than one plane of consciousness. He described this activity as a relaxing of the controls that normally characterize logical thought processes and a “regression to modes of ideation indifferent to the rules of verbal logic.” His description is quite reminiscent of Kris’ well-known phrase. “regression in the service of the ego,” when the individual remains in control. yet can relinquish secondary process thinking enough to permit more primitive modes of thought and feeling to emerge in the course of traditional psychoanalysis. The third stage is called illumination. Here the new insight breaks into consciousness. Under conducive environmental conditions as well as in the presence of inner personal openness of mind, solutions, connections, and novel ideas may literally flash into awareness. Kekule’s description of his search for the nature of the benzene ring is a classic one. He had pursued his research as far as he could. Then, he put it aside. One evening as he dozed in front of the fire “the atoms were gambolling before my eyes . . . all twining and twisting in snakelike motion. But look! What was that? One of the snakes seized hold of its own tail. and the form whirled mockingly before my eyes. As if in a flash of lightning. I awoke.” At once he saw that here was the form and structure, in the ring created by the six carbon atoms, for which he had been looking all along. The fourth stage is verification. Stein” forcefully emphasized the importance of this step when he stated that, “No one ever wins a Nobel prize for an idea, but rather for carrying that idea to its completion.” At this point the individual must painstakingly explore the validity and effectiveness of his new insight and be willing, if wrong, to go back to the beginning and start again in his quest. It is apparent that movement from conscious thinking of a more logical type to preconscious thought processes of a more allegorical, figurative, and unbiased mode-and back again-requires the flexibility to transit the boundaries of consciousness in a relatively unthreatened manner. Thus, as Schubert’ pointed out, the person with severe psychoneurotic obsessive-compulsive traits employing repression, for example, usually lacks the required fluidity because he cannot relinquish secondary process thought, whereas the patient with a severely disorganizing illness, such as acute or chronic schizophrenia, is usually unable to organize secondary thought patterns so as to effectively understand and employ original ideas. Kubie’ particularly stressed that the preconscious and not the deeper unconscious was involved in the creative process. The latter he felt could not be the source of original responses, since it is made up of powerful stereotypes, unoriginal perceptions, and emotions dating back to the earliest years of life. often with enormous degrees of rage and fear, and in effect, serving to block free access to the preconscious if strong enough. In Jungian theory, the role of the unconscious in the creative process is formulated somewhat differently. As described by McC~lly,~ it is the collective or objective part of each person’s unconscious rather than the personal part established as a result of one‘s own
512
FREDERIC F. FLACH
life experience, that is the source of original insights. The so-called “archetypal sources” that are activated under appropriate conditions give rise to archetypal images that possess special characteristics containing the essence of human experiences repeated enough and formative over the centuries of man’s existence to make a permanent imprint on the neural structure. Such images concern themselves with things that are fundamental and universal to the human experience, such as fathering, mothering, femininity, masculinity, goodness, and evil. PERSONALITY
TRAITS AND CREATIVE ABILITY
A number of studies have identified certain personality characteristics that seem to be strongly correlated with the ability to engage in creative problem solving. Dallas and Gaier,O for example, point out the following: independence; intuitiveness; dominance; flexibility; introversion; social presence and poise; openness to stimuli; unconcern for social norms; wide span of interests; and self-acceptance. These findings are in agreement with those of other investigators. Taylor,lofor instance, observed a higher degree of intellectual precocity, strong curiosity, and outstanding talent in many creative persons; he stated that these traits were often evident very early in life. Rosner and Abt” noted a special confidence and boldness in such persons, as well as an open-mindedness and freedom from preconceptions, the ability to tolerate the uncertainty of not knowing exactly where one’s work and life might be going at any given moment, yet with a definite sense of personal destiny and purpose. MacKinnon12 used psychometric tests to study creativity among a group of architects and found the following traits significantly related to creative ability: intellectual competence; originality; curiosity; sense of responsibility; cognitive flexibility; stability; good judgment; and sense of destiny. These characteristics seem to be similar to those which, by common experience, the psychiatrist associates with the ability to successfully weather stressful life experiences and, among patients, to foster a more rapid and complete recovery from states of decompensation. For many patients, their cultivation represents a major goal of therapy. STIMULATING
CREATIVITY
The research of Stein6 and Parnes13 has focused heavily on the development of methods that can be systematically used to stimulate creative thinking. Synectics, a method developed by Gordon14 and employs the use of analogies is considered by some the most effective way to achieve such stimulation, but it is far too complex for review here. Stein emphasized that to become more creative, it is critical to value the process of creativity and to actively think of oneself as actually or potentially creative. He also stressed the importance of identifying those circumstances and conditions-unique to each individual-under which one is more likely to discover new insights. Something as simple as changing one’s manner of dress can represent a strategy to let go of stereotypes attached to one’s self-image and role model in order to free up the imagination.
PSYCHOBlOLOGlC
513
RESILIENCE
Parnes emphasized two rules to stimulate creative deferred judgment; and (2) quantity leading to quality.
problem
solving: ( I)
Deferred Judgment Withholding evaluation while searching for new ideas is more than restraining one’s critical faculties to avoid premature closure of the flow of ideas. It appears to be intimately related to the process of perception. Parnes quotes McKim: l9 Since all perception involves some degree of imagination we all see imaginatively-in the broad sense of the word. We do not all see creatively. however. The key concept is flexibility. The person who can flexibly use his imagination to recenter his viewpoint sees creatively. ‘The person who cannot budge his imagination to see alternative viewpoints, by contrast, experiences only a one-sided. stereotyped vision of reality.
is this stereotyped vision that Parnes calls prejudgment. seems to facilitate perceptual restructuring.
It
Deferring judgment
Quantity Leads to Quality Parnes’ second rule is called the principle of extended effort. He has demonstrated experimentally that the more ideas one comes up with in search of any solution, the more likely one is to shake loose obstructive perceptions and to arrive at ideas that are indeed both original and ultimately effective. Interestingly, this procedure closely resembles the technique of free association used in traditional psychoanalytic psychotherapy. Parnes has also shown that the ability to use this method can be learned by practice. More is involved, however. than the elucidation of ideas. The individual must also be able to synthesize his thinking as he goes along or at least toward the final phases of the exercise; such synthesis is akin to what Arieti has describedI as the additional factor required to draw from the material at hand that new form that makes it truly creative. IMPLICATIONS
FOR PSYCHIATRY
Current knowledge about the nature of the creative process has important implications for the practice of psychiatry. I5 I would like to highlight three areas in particular: (1) reconceptualizing the nature of certain psychopathological states, in particular depression; (2) recognition of creativity as a critical element in successful therapy, regardless of the theoretical position of the therapist; and (3) prevention of mental illness at all levels. primary. secondary, and tertiary. RECONSIDERATION
OF THE NATURE
OF DEPRESSION
A major step forward in understanding the nature of affective disorders was made when Kraepelin offered his important distinction between those illnesses in which a disorder of mood seemed of primary importance and those in which it did not. Over the years, different types of affective disorders have been classified, ranging from the cyclical manic-depressive or bipolar disorder to the simple, reactive, unipolar depression often triggered by significant personal
514
FREDERIC
F. FLACH
stress. Necessarily, considerable thought has also been given to contrasting normal grief with illness in which depressive affect is the prominent component. Traditionally, the diagnosis of depression is made on the basis of the patient’s history and the presence of certain key symptoms. An alteration of mood is central. Lowered spirits, sadness, hopelessness, sleep difficulties, loss of sexual drive, appetite and weight loss, retardation or agitation, and at times delusions and other severe manifestations are included. In some patients socalled endogenous factors seem most evident; in others, environmental and psychological factors. Psychodynamic issues are also considered: the loss of something or someone valued, internalized rage, guilt, excessive superego formation. This information not only deepens the understanding of a particular patient but also guides the therapist toward his therapeutic choices, both biological and psychological. However, the existence of such theory and classification, while serving eminently practical purposes, may well prevent one from seeing the real nature of the disorder in depressed patients. For instance, it is widely assumed that normal grief and depressive disorders are two fundamentally different responses. But what if they are not? What if the depression of a patient with a so-called affective disorder is, in fact, qualitatively the same as the depression of the normal person in a state of grief? Given such a hypothesis, one would have to look elsewhere than mood to answer the question of what the illness really is. Consider the possibility that in the majority of patients experiencing a depressive illness, the mood change itself is not the core of the illness. Rather, consider the illness as a failure on the part of the patient to be able to experience in a direct immediate way, the disruptive effects of normal grief, and then to be able to reintegrate afterward to establish a new level of equilibrium. Disruption-loss of homeostasis-is a universal feature of the individual’s response to stress. The challenge as Selye15 described, is for the organism to reconstitute a new homeostasis after the shock has subsided. The ability of a person to experience this disruption-reintegration cycle can be termed psychobiological resilience. The pathways of such resilience include psychological, environmental, and biological dimensions, and the integrity of all of these are essential for successful recovery. In our own research into biological factors associated with states of depression, we observed that depressed patients increased their excretion of calcium in the urine and stool while being maintained on constant dietary intakes. As they recovered from depression spontaneously, or due to the administration of tricyclic antidepressants, or electric convulsant treatments, the reverse phenomenon was noted-a decrease in urinary and fecal calcium excretion, overall retention, and as evidenced by isotope studies, an increased movement of calcium to bone.16s7 With very few exceptions, the actual degree of electrolyte shifts observed were within generally accepted normal limits. These could only be noted and statistically established when, in the large series of patients studied, each patient was used as his or her own control,
PSYCHOBIOLOGIC
RESILIENCE
515
From this data we hypothesized that while the actual level of calcium in the central nervous system at certain critical locations might be significant to the patient’s clinical condition-directly as well as in relation to other metabolic actions, such as those of neurohormones-an even more important kinetic phenomenon might be operative. This kinetic factor was thought to be reflected in the patient‘s biological need to react to stress with a transient increase in calcium loss, and with it his inability to reverse the process without either the passage of an undue length of time or active medical intervention. From this vantage point we envisioned agents, such as tricyclic antidepressants, not as mood elevators or even mood restorers, but rather as drugs possessing the capacity to restore biological resilience, thus allowing the patient to recover from the impact of stress. This concept is reinforced by the clinical observation that many patients who have recovered from states of depression and are still maintained on tricyclic antidepressants nevertheless reenter episodes of depression when confronted with appropriate stress, but seem to be able to limit the depth of response and to recover from the episode much more quickly than before. The healthy person stressed by the loss of a loved one, for instance, will enter a period of disequilibrium and manifest signs of depression at that time. Thereafter. he will recover to reorganize himself and his life under fundamentally new and unfamiliar circumstances. In the process he will undergo physiological shifts. He will also experience the pain of grief, the need to relinquish the past, and the struggle to find new purposes. And the nature of his environment will strongly determine how successfully he can master this experience. The alternative is illness-a failure to move through the normal cycle of disruption-reintegration. This cycle can be blocked or interfered with at any psychobiological level, and in either the disruptive or reintegrative phase. Many patients can, for example. temporarily postpone coming to terms with the disruptive effects of grief-depression, by the use of psychological mechanisms. such as denial and repression, by acting out, ill-timed changes in life patterns, ot the use of alcohol or drugs, and often at a high personal cost. On the other hand, once actively depressed, the patient may not be able to reintegrate. Because he is psychologically rigid and inflexible, because his environment is intolerant. or because he lacks sufficient biological resilience. his depressed state may become chronic. Or the patient may not be able to control the intensity of his response developing psychotic symptoms. If his disorder is ameliorated by means of treatment. the reintegration may be faulty and a serious recurrence of his condition may occur. Examination of the nature of the creative process has shown that it involves basically, the disruption of a former perception and its replacement through a process of reintegration with a new and better one. Loss and renewal are central themes, even as in the experience of depression. And while knowledge of creativity as such has little to offer at present to our understanding of the biological mechanisms involved in states of depression, it seems to afford important insights into crucial psychological and environmental factors. When those personality traits shown to be associated with creativity are present.
516
FREDERIC
F. FLACH
when the individual is creative not only with regard to some particular talent but with regard to himself and his life adaptation, and when environmental conditions are such as to encourage insight and flexibility, the chances of the individual successfully transiting a period of loss and grief appears immeasurably enhanced. CREATIVITY
AND PSYCHOTHERAPY
How the psychiatrist conceptualizes any patient’s illness necessarily influences his therapeutic stance. Frank l6 has identified some of the therapeutic influences common to all forms of psychotherapy. Among these are the need to restore morale and the nature of the relationship between patient and doctoran authority who seems to possess knowledge and experience promising relief, and with whom the patient shares to some degree a common view of life, reality, and the principles of the theapeutic effort. Most psychiatrists conduct treatment within guidelines derived from their own particular theoretical orientation. While this may provide them and their patients with a sense of security and direction, it can easily become counterproductive when theory and its language are too rigidly adhered to; what results is a singular lack of flexibility in the therapeutic experience. In the psychotherapy of the depressed patient, for example, continued, repeated emphasis on those topics associated with sadness, hurt or resentment, can often serve only to reinforce the very affect that the therapist is striving to relieve. By the same token, insistent focusing on problem areas (conflictresolution) without due attention to the patient’s talents and opportunities (self-actualization) can seriously interfere with progress. Decentralization, the intentional tactic of alternately probing into problem areas then withdrawing toward neutral and positive areas of the patient’s lifelx is an essential part of psychotherapy in depressed patients. It represents the use of creativitystimulating strategies encouraging periods of incubation for insight to take place and, at the same time, introducing a necessary flexibility not only in the therapist’s role model but also in the rhythm of the interpersonal interplay itself. The similarities between the steps in the creative process and what happens in successful psychotherapy are especially striking. Parnes’ rules of deferred judgment and extended effort are particularly reminiscent of traditional psychoanalytic techniques. Free association, e.g., in the presence of an empathic, nonjudgmental, flexible therapist, is designed to postpone editorial evaluations by the conscious mind so that the patient producing more and more ideas and recollections can reach into his unconscious. When the goal of psychotherapy is insight, a former perception must be forfeited and replaced with a better one. The more flexible the patient, the more capable he is of changing perceptions; conversely, the more basic resistance he has, the more fixed he is in his existing patterns of thought and behavior, the more difficult it will be to help him move away from unhealthy modes of thought and behavior to assume more constructive ones. Therapeutic environments-hospitals, outpatient units, half-way houseshave often been described as antithetical to the recovery of patients. Many
PSYCHOBIOLOGIC
517
RESILIENCE
have an atmosphere of helplessness, hopelessness, control or disorder, which combines with an overall preoccupation with illness and problems so as to make the patients’ movement toward health and competence excessively slow and arduous. Those settings that work best are usually characterized by welldefined programs that intentionally distract from the exclusive focus on disability. and provide stimulation of the patients’ ability to engage in creative problem solving and self-development. CREATIVITY AND PREVENTION In psychiatry, preventive medicine has been given little attention. Some feel that without greater knowledge of the underlying causes of mental illness such efforts are pointless. Others doubt the efficacy of intelligent strategies to implement preventive programs. However, when the problem of health and illness is redefined in the light of creativity theory and prevention is logically divided into its three main phases, it is clear that the concepts and techniques developed through the study of creativity can serve to implement prevention. The goal of primary prevention is to help the individual to be better able to cope with the inevitable (and at times tragic) changes that occur during life, so that a serious psychopathological disorder can be avoided. Secondary prevention involves earlier diagnosis and more effective treatment. Tertiary prevention means helping the recovered patient remain well by providing him with the instruments, whether medicative or psychological that ensure recovery. If psychobiological resilience is a critical part of staying well-or remaining well after having suffered from a psychopathological disorder-then one should consider mastery of the creative process as part of that resilience. This means training the individual to think of options, cultivating his capacity to change his perceptions of things as situations demand change. preparing him to cope with unexpected events he has never before experienced, and enabling him to gain new insights into his personality as his experience in life broadens. Thus, the direct teaching of the principles of creative thinking becomes an invaluable part of all educational efforts, including those formally referred to as therapeutic. CONCLUSIONS
The ability to think and act creatively appears to be a critical component of the healthy personality and an important factor in coping with stress as well as recovering from the impact of psychopathological disorder. The following recommendations naturally follow: I. An appraisal of creative potential and actual creative ability should be part of the initial personality evaluation of every patient. 2. The utilization of creativity-stimulating strategies should be intentionally incorporated in the treatment of psychiatric patients, whether in individual or group settings. 3. Environment strategies conducive to creative thought and behavior should be introduced into institutions responsible for the care of psychiatric patients. 4. Training in creative problem-solving techniques should be part of educational programs aimed at prevention.
FREDERIC
518
5.
F. FLACH
Training in creative techniques should be part of the regular program of education for psychiatrists and other mental health workers, and applied not only in therapy situations but in teaching and research as well. REFERENCES
I. Kubie LS: Neurotic Distortion of the Creative Process. University of Kansas, 1958 2. MacKinnon DW: The nature and nurture of creative talent. Am Psycho1 17:484-495, 1962 3. Wertheimer M: Productive Thinking. New York, Harper & Row, 1959 4. Maddi SR: Motivational aspects of creativitiy. J Pers 33:320-347, 1965 5. Koestler A: Act of Creation. New York, MacMillan, 1974 6. Stein MI: Stimulating Creativity. New York, Academic, 1974 7. Schubert DSP: Creativity and the ability to cope, in Flach FF (ed): Creative Psychiatry Series, Monograph No 5. New York, Life Sciences Advisory Group, 1976 8. McCully RS: Contributions of Jungian psychotherapy toward understanding the creFlach FF (ed): Creative ative process, Psychiatry Series, Monograph No 4, New York, Life Sciences Advisory Group, 1976 9. Dallas M, Gaier EL: Identification of creativity: The individual. Psycho1 Bull 73:5573, 1970 10. Taylor IA: The nature of the creative process. in Smith P (ed): Creativity. New York, Hastings House, 1959, pp 51-62 II. Rosner S, Abt LE (eds): The Creative
Experience. New York, Grossman, 1970 12. MacKinnon DW: Personality and the realization of creative potention. Am Psycho1 20:273-28 I, 1965 13. Parnes S: Creativity: Unlocking Human Potential. Buffalo, DOK, 1972 14. Gordon WJJ: Synectics. New York, Harper & Row, 1961 15. Arieti S: Creativity: The Magic Synthesis. New York, Basic Books, 1976 16. Flach FF: Choices. New York, JB Lippincott, 1977 17. Selye H: The Stress of Life. New York. McGraw-Hill, 1956 18. Flach FF: Calcium metabolism in states of depression. Br J Psychiatry IlO:558-593, 1964 19. Faragalla FF, Flach FF: Studies of mineral metabolism in mental depression. J Nerv Ment Dis 151:120-129, 1970 20. Frank JD: Psychotherapy: The restoration of morale: in Weekly Psychiatry Update Series No I9 Vol I. Princeton. NJ, Biomedia. Inc., 1977 21. Flach FF: The use of chlorpromazine to facilitate intensive dynamic psychotherapy in depression. Psychiatria et Neurologia 134:289-297. 1957