Abstract
This article explores the psychological and literary aspects of the Der Doppelgänger, The Double. A Double is related to the concept of multiple personality. Such mental conditions are classified as instances of dissociation. However, a much earlier history of a Double exists in literature rather than in psychology. In the literary past, a “Double-Personality” embodied the creative imagination of writers. Aspects of this condition have been reported in all cultures. In some societies a “Double-Personality” is thought to manifest great power whereas in others it represents illness. After Freud, writers fostered psychoanalytic speculations about this condition. The dynamic issues of this condition are discussed together with literary examples by world famous authors. Persons manifesting this condition frequently employ symbols, allegory, and other creative devices. While reason, observation, and experiment are the modes of science, appreciating the symbolic behavior associated with this condition is also important. Clinicians and others should carefully attend to how symbolic behavior may be employed by patients to describe symptoms of their condition not easily conveyed with clarity by complete rationality. There is special value in recognizing how persons may utilize this condition to further their fictive goals. Without this understanding, treatment may be less effective and improvement may not occur.
The concept of Der Doppelgänger, The Double, has usually been associated with psychopathology in clinical practice. It also has a connection to what some theorists and clinicians have designated multiple personality. These manifestations were ensconced under the heading of dissociation in the Diagnostic and Statistical Manual of Mental Disorders, text revision (DSM-IV-TR; American Psychiatric Association [APA], 2000), and now in DSM-5 (APA, 2013). Multiple personality was designated Dissociative Identity Disorder in DSM-IV (APA, 1994). A number of suggestions were integrated into DSM-5 based on the manifestation of symptoms mentioned later.
There is a much earlier literary history of a Double that precedes any discussion of this condition in clinical practice. A Double has been especially well-illustrated in the creative works of two world-famous authors continents apart—Edgar Allan Poe (1809-1849) and Fyodor Dostoyevsky (1821-1881).
Production of a Double has also been utilized by a host of other writers. A substantial corpus of these literary manifestations was formed long before psychoanalysis fostered a psychodynamic interest in such matters. After Freud, psychoanalytic interpretations of a Double became a frequent topic of interest. Contemporary psychopathology often dismisses these matters. Freud, Adler, and Jung never directly addressed this phenomenon in a focused paper, but all three, as did others, commented on this condition. Creating a Double serves some patients as a reflection enabling self-talk and may facilitate communication with others. Lacking a better developed working self, such patients may create the phenomenon in seeking to “explain” their delusions. This viewpoint is not well-addressed by the literature on dissociation disorders.
The clinical manifestations of a Double are strongly influenced by opposing views of multiple personality denying or affirming its occurrence. Literary examples and illustrations of a Double from novels and short stories written over the past several centuries have influenced greater attention to its occurrence, and literary presentations can offer insight into this condition. Everyone may benefit from an understanding of both the literary and the medical/psychological presentation of this condition.
While manifestations of a Double are typically pathological, it is important to recognize how this phenomenon may be utilized by persons to explain their symptoms. To dismiss such manifestations as pure nonsense or as nonexistent is not to listen to the persons presenting their problems in this manner. Mental illness often fosters wide expression to symbolism, metaphor, and allegory. This can be particularly evidenced by persons who are creative, intelligent and educated. Better insight can help us understand this condition in a more productive manner than merely arguing about the label, and whether or not the condition exists. Creative writers have often been more masterful than clinicians in describing this condition and providing insight. Adler (Ansbacher & Ansbacher, 1956), for example, remarked,
Soon it will be realized that the artist is the leader of mankind on the path to the absolute truth. Among the . . . who have led me to insights . . . are fairy tales, the Bible, Shakespeare, and Goethe. (p. 320)
Adler acknowledges a debt, as we all must do, to early folk tales, scripture, and especially perceptive writers whose ingenious insight portrays the human condition more insightfully than texts devoted to descriptive psychology.
Manifestation of a Double is closely allied to the concept of multiple personality. Such a condition now classified as a Dissociative Identity Disorder (DSM-IV-TR, DSM-V) essentially addressing a disruption of identity with two or more distinct personalities accompanied by alternations in affect, behavior, consciousness, memory, cognition, and sensory motor dysfunction. Behavior resulting from blackouts or chaotic behavior from alcohol intoxication, drugs, or a general medical condition must be ruled out.
The diagnosis of multiple personality has been controversial. Kluft (1994) describes this condition:
Multiple personality disorder (MPD) is a complex chronic form of dissociative psychopathology characterized by the presence of alternating subjectively separate identities and recurrent episode of amnesia, memory distortion, or both. The cause of MPD is overwhelming childhood trauma. (p. 5)
Kluft argues that about 1% of the general population in North America and Europe have undiagnosed MPD or related conditions. He considers the “classic picture” of “highly differentiated and dramatically polarized personalities” to be atypical of this condition. Instead, he argues that MPD patients present with many other psychiatric conditions and a varied set of symptoms.
Criticism of MPD is considerable and McHugh (1994) is one example. His argument is,
MPD is an iatrogenic behavior syndrome promoted by suggestion and maintained by clinical attention, social consequences and group loyalties. It rests on ideas about the self that obscure reality, and it responds to standard treatments. (p. 5)
McHugh’s recommendations include
Close the dissociation units . . . ignore the alters . . . stop talking to them [the alters]. Pay attention to real present problems and conflicts rather than fantasy. If these simple, familiar rules are followed, multiple personalities will soon wither away and psychotherapy can begin. (p. 6)
These two examples represent the gist of arguments from each perspective. Some discussions are often accompanied by acrimony and personal attacks that add little to understanding this matter. However, a listing of symptoms meeting DSM criteria does not produce understanding either. Descriptive psychiatry is necessary but not sufficient for explaining how this condition occurs or how to understand the manifestations producing this condition.
Dennett (1991) argues for the possibility of MPD, and even a fractional personality disorder. His view of consciousness suggests it manifests itself over qualitative gaps instead of flowing continuously because we are not in continuous awareness of being. He further argues that if we are able to create a self for our body, is it not possible to create more selves or even partial ones? He does not answer these questions, but he raises interesting issues about consciousness, an immensely problematic issue, illustrating how little we understand about what the term implies. Some answers might be suggested from literature.
The 19th century has provided a substantial literature concerning a Double. However, descriptions of a Double can be traced back to earlier works by Goethe and other writers from the 17th century. Very early descriptions of a Double are reported in the early anthropological studies of Frazer (1900) and Tylor (1891/1958). Both anthropologists indicated that expressions of a Double are as old as humanity.
Readers may be more familiar with some of the literature of the 19th century illustrating examples of a Double. Two prominent literary examples of a Double were written by an American, Edgar Allen Poe, and by a Russian, Feodor Dostoyevsky, suggesting the phenomenon is universal.
William Wilson by Poe (1839/1966) is an intriguing story. Wilson as a youth encounters his Double on the way to school one day. Over time Wilson observes that his Double reveals more and more of Wilson’s own characteristics. This Double not only shares his age and birthday, Wilson comes to observe that his Double shows similar personal characteristics, increasingly so as time passes. The only thing different between them is that his Double speaks in a whisper, “ . . . the very echo of my own.” Finally, unable to cope with this specter, Wilson flees his current school to enter Eton. His Double joins him there. Forsaking studies for profligacy he tries to elude this specter. Later, he transfers to Oxford only to discover his Double joining him once more. Dismissed from Oxford, he roams Europe. His Double is now present no matter where Wilson travels. Finally, at a costume party in Rome, Wilson challenges his Double to a duel, and plunges his sword into the heart of his Double. The Double, no longer speaking in a whisper, utters these last words,
You have conquered, and I yield. Yet, henceforward art thou also dead—dead to the World, to Heaven and to Hope! In me didst thou exist—and, in my death see by this image, which is thy own, how utterly thou hast murdered thyself. (p. 212)
Wilson dies and the story ends. Poe tells his story with great attention to introspection. Wilson tries at first to figure the matter out. He cannot find an answer and confusion reigns. Wilson becomes increasing unable to cope with the image of his Double and its effect on him. Abandoning everything worthwhile, Wilson attempts to flee without success, finally to self-destruction as his Double announces each will cease to exist.
This is not the only story of such a macabre nature that Poe wrote. He authored a number of other stories in which a similar motif is suggested but not as prominently displayed as in this narrative. Most readers remember Poe as a troubled writer, an alcoholic with severe mental problems. Readers associate elements of his stories to accounts of Poe’s own behavior as recounted by his biographers.
Fyodor Dostoyevsky wrote a similar story entitled The Double (1846/1996), and in The Brother Karamatsov (1880/1958) brother Ivan is visited by the devil who introduces himself to Ivan as his Double. However, it is in The Double that Dostoyevsky richly illustrates the throes of mental illness. The personal travails of the civil servant Golyadkin begin with modest misinterpretations. At first, Golyadkin cannot understand what is happening, but he is increasingly convinced that others conspire against him. His misinterpretations signal a gradual descent to further confusion, progressive paranoia, and finally severe delusions. Dostoyevsky provides extraordinary insight into the mind of Golyadkin whose increasing madness now becomes evident to everyone but himself even as he is driven away to an institution. The story is modest in situational details, but it is richly descriptive through introspection as Dostoyevsky strikingly conveys to the reader the progression of Golyadkin’s mental deterioration. Among his numerous letters to friends Dostoyevsky writes to one of them, “I have a mad love of penetrating to the limits of the real, there where the phantastic [sic] begins.” This novel illustrates Dostoyevsky’s pursuit of this goal for portraying inner depth and musings both real and delusional.
The Strange Tale of Dr. Jekyll and Mr. Hyde (1886/1952) by Robert Louis Stevenson is one more story of a Double presented twin-like. The Double viewed as an “opposing twin” is a common motif in the literature on Doubles. It can also be found in popular narratives of multiple personality including The Three Faces of Eve (Thigpen & Cleckley, 1957; see also Sizemore & Pitillo, 1977) and Sybil (Schreiber, 1973). The twin-ship usually embodies good versus evil, a good self versus a bad self, and there is sometimes a reconciling intermediary self.
The experiments of Dr. Jekyll produce a release of evil behavior diametrically opposed to the pleasant disposition of the good doctor. Jekyll is the personification of kindness. Hyde is evil. When Jekyll begins his experiment, he is in control. However, as the story unfolds, Hyde can no longer be controlled by his creator and by the use of a formula. The standard formula that Jekyll assumed gave him control contained an unknown element that cannot be duplicated. Dr. Jekyll foresees that he will ultimately be in the control of Hyde, so Jekyll records these matters in his journal in hopes that his story will someday be read if the journal is not destroyed by Hyde.
This story of the evil-twin motif is common in clinical case studies of multiple personality. Poe described Wilson as an almost exact duplicate. Dostoyevsky did likewise. Stevenson gives us another popular interpretation of The Double as a twin contrary in character. The creation of an alternate and an intermediary by fictive construction cannot be overlooked in understanding how a Double is mentally produced.
Another reflective and introspective approach is found in Rilke’s (1910/1949) The Notebooks of Malte Laurids Brigge. The poet Rilke describes in this prose work the appearance of specters and other manifestations. He selects Denmark as the location for these reflections seeming because manifestations of spirits and specters are more accepted in the Scandinavian countries. (Remember Hamlet.) Rilke provides another view of fictive construction and introspection in which the author probes his own discoursing about the mind and its pondered content. The work evidences increasing estrangement from reality as the author tries to cope with ever increasing dependence on building a repertoire of symbols. His dependence on symbols such as angel, puppet, and acrobat, provide him the voice needed to express his confusion, and turmoil, especially—das Unsägliche (the inexpressible). Completely overwhelmed, Rilke creates these other voices for the expression of his feelings.
People have read, and more may have seen a movie version of Oscar Wilde’s The Picture of Dorian Gray (1890-1891/1982). Wilde’s protagonist, Dorian Gray, is a handsome young man. His desire is to never grow old; “When I find I am growing old I shall kill myself.” Dorian engages an artist to portray his youth and handsome qualities in a portrait. However, Dorian wishes only the portrait to age while he remains youthful. Dorian becomes enamored with his portrait. “He would creep upward to the locked room and stand with a mirror in front of the portrait,” writes Wilde. With a mirror, Dorian compares his ageless beauty to that of the portrait which now reflects increasing age.
Dorian has always shown little concern for others. His increasing malevolence seems to produce further effects of aging and ugliness in the portrait while Dorian still retains his youth so he covers the ugly portrait and locks it in a room. Dorian eventually drives his true love to her death, and he murders the artist who painted his portrait. “I wish I could love, but . . . I am much too concentrated on myself,” he remarks to himself. Finally, increasingly distressed, he returns to the room to destroy the now aged and ugly portrait by stabbing at the heart. At that same moment Dorian falls dead. Dorian immediately appears old and ugly while his portrait is handsome and youthful.
Dorian illustrates extreme narcissism. Narcissism as a pathological concept is derived from the Greek legend of Narcissus who was enamored of his own reflection in a pool of water. There are many variations to this story. Freud (1914/1953) in Narcissism: An Introduction explained that it could be viewed as an aspect of normal development but further indicated that this condition could also evolve into a self-absorbing perversion. The issue of narcissism has remained a constant issue in psychoanalytic writings and Lowen (1985) offers a review of this condition.
The above literary examples illustrate how insightful writers have viewed the dynamics of mental confusion. Poe and Dostoyevsky were thought by their biographers to be greatly troubled by their own musings. Their musings may have provided each of them with disturbing personal reflections incorporated into their creative works.
The attention that writers such as Dostoyevsky and Poe gave to their creative works may have also delayed their demise. It was far too early in life for both to die. Their deaths may have deprived us of still greater works, but their creative activity might also have kept them usefully productive for as long as possible. Stevenson explicates the positive and negative aspects in twin-like behavior. Wilde brings narcissism to full force. While these creative works of literary genius do not provide an account of the scientific information required for explicit treatment, they can offer insight into what patients may be experiencing. These literary examples can serve to encourage clinicians to be more sensitive to a patient’s manifestations of suffering, and feelings for those patients unable to explain their thoughts and feelings directly. These expressions, seemingly bizarre on first hearing, may contain mythic clues that should be heard. Their bizarre stories may provide useful hints to what the patient cannot face, recollect or express in a rational manner. The strategy should be not to reinforce pathology but to understand its various manifestations and expressions in patients.
Severe mental illness often manifests itself in abstract and symbolic ways. Jung (1961) reminded readers to recollect in their own dreams such unreal experiences and symbols so as to understand the experience of severe mental illness. It is important to appreciate a client’s recitations of information. Attention may be given to answers provided in diagnostic assessments but not heard when other recollections are expressed. Metaphoric and convoluted progressions sometimes illustrate the first signs of deterioration in severely ill persons. Later, they may convey hidden and coded content. The poet Rilke illustrated this point by his literary ruminations. A patient’s symbolism is frequently subtle and creative. It is often misinterpreted as simply odd or eccentric. “I am a Doppelgänger, I have a ‘second’ face in addition to the first. And perhaps a third,” writes Nietzsche (1888/2000, Ecco Homo p. 681). Whether Nietzsche was cogent or ill when writing this remembrance, he, nevertheless, offered insight.
One diagnostic dilemma is to determine a truly eccentric person from the onset of an ill one. We can be confused when interpreting responses that accompany the deterioration of reason compared with those expressions that are unique. A patient’s words and expressions may be taken too literally and dismissed as nonsense. A literal interpretation of what is expressed may serve to misinterpret the context of these expressions. Words out of context can be greatly misleading. Lacking a full understanding of their condition, patients are often unable to adequately explain their symptoms without recourse to symbolism to explain what is happening. Cracking the code is important so irrational appearing comments should not be dismissed.
Normality and Pathology in Reflection
A variant theme to a Double involves the matter of reflection. Is a Double the reflection of the person? In Dorian Gray the portrait showed creative insight by the artist. Portrait artists usually seek to convey not what a photograph can do, but what the artist recognizes as important in portraying the dynamic “image” of the person. Dorian subsequently murdered his artist. Did that occur because Dorian came to understand what the artist portrayed? Perhaps Dorian recognized the portrait was not merely a painting but a reflected portrayal of his character. Wilde shows great insight in conveying the phenomenon of narcissism present in Dorian. Psychoanalysis views narcissism as the condition of self-engrossment or self-love. Frederich Nietzsche (1879/1996) remarked, “Man’s shadow, I thought is his vanity.”
The mythology behind Narcissus has passed through many versions, but the essence of the story is that Narcissus falls in love with the reflection of himself having become mesmerized by constant viewing. It has been suggested that Echo [his partner] played an important part. Narcissus rejected Echo because narcissism is never satisfied by a lone admirer. Narcissism requires ceaseless admiration; the narcissist must receive continual appreciation by others. Reflection plays an important role in understanding this pathological need for continued self-aggrandizement as described by Wilde in Dorian Gray. Dorian compared himself to what he observed happening to the portrait. The portrait aged, but Dorian remained young and beautiful. For Narcissus the reflection from the water preoccupied him. Contemplation of his idolized self became more gratifying than even the attention of Echo.
The Evil Queen in the story of Snow White demonstrates a reflective nature. The evil queen is enamored from constantly observing herself in the mirror until the day when the mirror informs her she is no longer the most beautiful, and the story unfolds. Everyone has experienced the “honesty” conveyed by the mirror. The mirror reflects not what is desired but what is self-evident. Reflection humbles the greatest and the most beautiful.
But what we “see” in the mirror is not an exact interpretation of the reflection; not because of image reversal but the result of a personalized, subjective interpretation of the reflected image. Rilke illustrated this behavior in his Notebooks by his reflected distortions. Seneca (1958) wrote two thousand years ago, “Everything depends upon [one’s] opinion” (p. xv). While most persons must content themselves with less than mirror-perfect beauty, movie stars and models may agonize over what they believe are imperfections shown in reflections. Subjective interpretations influence perceptions but only in severe cases of pathology do they dominate.
Stories of reflection/mirrors have been written by E. T. A. Hoffman, Hans Christian Anderson, and Hugo von Hofmannsthal. Von Hofmannsthal wrote Die Frau ohne Schatten, The Lady Without a Shadow, which became the libretto for Richard Strauss’s opera. Numerous examples are given by Rank (1958, 1979) who lists considerable literature in The Double, while The Double in Literature by Tymns (1949) provides numerous examples for study.
The Role of the Shadow
The role of the shadow is common to the mythology of a Double and akin to reflection. Nordic legends speak of the “fylgje.” Such an un-embodied shadow in this culture signals a forthcoming death. The Brothers Grimm (1875/1903) included numerous stories of lost shadows in their collection of German myths. Maupassant, Kipling, Dickens, Schnitzler, Hoffman, Mann, Flaubert, and numerous other writers have portrayed a specific Double or alluded to its presence by a shadow. Homer addressed the shadow treating the soul as one. It is may be further portrayed by an idol or icon (έιδώλον) of a once living person as in The Iliad (Homer, 1944, xxiii, 104). Achilles exclaims, “Then there is really within the portals of Hades a psyche [soul] and a shadow” (Homer, 1944, x, 495, x, 207). The Bible (Revised Standard Version of the Bible, 1971) likewise employs this figure of speech in the original Greek found in Matthew 17:5 and Luke 1:35. The Greek expression (έπισχιάσϵι σόι) in these Bible passages can be translated as “overshadowing” or “casting a shadow.” What these illustrations share is how reflection and shadow distorted by a private logic unravel reality. The psychodynamics underlying a Double are based on a rich literary basis furthered by dynamic speculation that complicates how it should be interpreted. The role of reflection and the shadow have remained an important literary device often associated with Jung’s psychological investigations.
Illustrations of a “shadow,” or lack thereof, can be found in Goethe’s Fairy Tale, and Wilhelm Meister. Robert Louis Stevenson’s poems provide more examples. The popular legend of Dracula is a character producing no shadow. Mythology abounds to illustrate the importance of the shadow or its absence. Young children play tag games whereby they must step on another person’s shadow but avoid it happening to them. Playmates ridicule fear by teasing, “John is afraid of his own shadow.”
Glass (1985) argues that delusion provides an “individual identity” and “absolute character” for developing a resolute and unyielding spirit. Disconcerted by lacking a clearly developed sense of self, the patient finds direction and resolution in the fiction of an alternate self to answer frustration. This fiction directs the person in thought and action toward relentless pursuit of whatever is deemed essential in order to make life appear sensible. Unfortunately, these fictions are typically useless constructions that do not resolve the predicament (Vaihinger, 1924).
Apperceptions of a shadow reinforce narcissism, self-focus, echo (the need for recognition), and fear of death (taphephobia). All these conditions have been evidenced in early culture before Tylor (1891/1958) and Frazer (1900) formally addressed them. Their studies indicated a shadow serves as a visual manifestation of one’s soul resulting in taboos forbidding a portrait, photograph, or image be made lest one die. Frazer found such mythic examples in Russia, Germany, Greece, England, and Scotland, and considered them to be universal.
A modern expositor of shadow is C. G. Jung (1961) who views it as a hidden, alternate attribute of one’s personality that embodies the negative side by expressing attributes unrecognized by the individual. The shadow may be thought to embody the soul as a mirror image of the body significant because it produces a “reversed” view of physical appearance. In one of the many variations of Snow White, the wicked queen, obsessed with observing her beauty, concludes when she is imprisoned in a room of mirrors never to escape.
Searching for family roots or investigating genealogy is a search for the reflected self and its origins. Looking back (nostalgically) is a reflection on one’s previous life (as though another person). Seniors reminiscing about earlier experiences often speak of them as if from a previous existence. Case studies of twins or siblings have identified reflective competition for affection and love. The self conceived as a mirror image of another soul, sometimes an alien self, are another elaboration.
These examples show a schism of self, or a separate attendant spirit sometimes human, and sometimes taking the shape of an animal. Killing this self is thought to occur by taking a picture, stabbing, or destroying the image according to anthropological studies, and creative literature. The image or icon of the person is thought to be at one with person, but this phenomenon presents confusion for those who cannot differentiate between the real and the image. Some case histories of suicide indicate that the deceased wished to kill only that part of the person about which they were displeased. Death by suicide produced an inadvertent outcome, to wit William Wilson and Dorian Gray.
Loosening one’s grip on reality, and subsequent confusion in discerning between reality and delusion is the underlying theme in the works by Poe, Dostoyevsky, and numerous other writers. There is also some connection between this state and the issue of optical illusions, that is, confusion in moving back and forth in one’s perceptions. Is it the old witch or the young lady we are asked in one commonly employed picture for illustrating an optical illusion. Can we alternate these two perceptions, or do we fixate on only one? This common visual illusion is not far removed from discerning the difference between reality and its shadow or reflection. Luckiesh (1922/1963, p. 1) concludes, “Seeing is deceiving. Part of what is perceived comes through the senses from the object; the remainder always comes from within.”
Neurological Influences
Devinsky (1994) argues for an “autocopic phenomenon with accompanying seizures” found in many of his patients. Their supernatural, mystical, and out-of-body experiences are explained as the result of subcortical seizure activity not a psychiatric condition. Such patients speak of no longer existing in their own body. They are outside, looking in, or down from above. Devinsky thinks some of these thought disturbances result from activity of cerebral cortex in the region between the temporal and parietal lobes. Dostoyevsky had a controversial history of epilepsy. Some accounts indicate it never occurred; it was the consequence of trauma. Other biographers disagree about the extent and frequency of occurrence. Dostoyevsky acknowledged symptoms while searching for a cure by consulting European physicians but nothing of substance appears to have occurred.
Nelson, Mattingly, Lee, and Schmitt (2006) and associates at University of Kentucky have identified what they believe is a connection between dissociation, euphoria, other mystical experiences and cerebral dysfunction. Their studies also suggest a connection between instances of dissociation or related manifestations and seizures, albeit the seizures may often be mild and transient. This transient seizure condition makes the symptoms difficult to diagnose, and more likely to be seen as manifestations of mental illness. Were Dostoyevsky’s troubles throughout his life the result of early prison trauma (see Stone, 1999), psychiatric manifestations triggered by the conditions described by Devinsky, Nelson, and others, or some combination?
When psychotropic medication is immediately employed, the condition may appear improved, but sometimes serious symptoms are merely masked. Occasions of serious brain disease may sometimes appear in the guise of bizarre behavior. George Gershwin, the famous American composer and pianist, was offered therapeutic treatment for many years while his symptoms and complaints suggested a neurological condition. He constantly complained of smelling “burning rubber.” Talented, engaging and narcissistic, his complaints were dismissed as symptomatic of his eccentric and self-centered behavior. Dying on the operating table, his death resulted from a progressing brain tumor too late for a successful operation. Pathology in blood chemistry can also produce psychotic-like features. Serious bio-medical conditions may produce aberrant behavior or bizarre manifestations complicating diagnosis.
Implications for Treatment
What is the meaning of life? How do we answer the question? We construct the answer as a creative exercise in living. We are creative beings building our lives from dreams and plans. Failure to create useful answers to these questions troubles a person making life appear hopeless. What cannot be denied in psychopathology is the attempt of a person to answer the questions of life by a creative solution. Addressing this condition requires a mix of science and the art of human understanding conveyed by creative insight manifest in relevant literature.
A Double suspends the person between two extremes, real versus unreal, good versus bad, happy versus sad, and so on making any formulation a creative act. The mentally ill person who creates a Double is not similar to anyone’s “creative style,” which is an interpretation of being-in-the-world to answer the meaning of life. A reality-based answer invokes “common-sense” compared with distortions and “private-sense” alternatives.
A useful creative style fosters growing competence. Competence in youth is nurtured by parents and teachers. When trauma occurs, competence may be thwarted. However, more important than what happens to us, is our interpretation of it. This interpretation illustrates what the Stoics emphasized: What we think happened to us is of greater consequence than what occurred. Shakespeare (1604/1947, p. 63) said as much when Hamlet remarks, “There is nothing either good or bad but thinking make it so.”
How we interpret events explains why great trauma can be overcome by some persons, while lesser trauma is greatly magnified by others. The capacity to formulate fictive explanations is both a boon and a ban depending on how it is applied to life. Fictions can productively serve as heuristic devices. Fictions can be destructive. The creation of a Double is just such a fictive device (Vaihinger, 1924). It appears to offer a solution, or a way out from a seemingly impossible state. Attempts at a solution may only bring further problems making the appearance of a solution actually a detour. The individual becomes trapped in a snare of their own creation. The simplest illustration is the young child who tells a lie to escape a problem only to become embroiled in a bigger problem. Parents tell their children not to lie and may illustrate this truth by allegory with reference to Pinocchio’s growing nose as his untruthfulness increases. Appropriate for children, the moral appears universal inasmuch as everyone creates myths and stories as part of living. Such creations may even form a Double or multiple-personality that appears real serving to facilitate the embodiment of feelings, emotions, and troubles into additional personalities that become named for intrapsychic reference. Extreme demands on the psyche of a person appear to cause these aberrations to be created not as fictions and myths but assumed real. Lacking the insight to view them “as-if” they were real, they are created to be authentic. This confusion between real and unreal only adds further stress.
Treatment requires the clinician to nurture the patient as a parent nurtures a child. The least useful solution is to point out the problem to the person as though it were a simple matter of clearing up some confusing thoughts. Sounding like a know-it-all expert to the patient may provoke resistance. No one feels heard or appreciated by this approach. The condition requires engaging deeply with a difficult patient. Unless the clinician is prepared to indefinitely and unconditionally engage there is no opportunity for improvement, and referral is required.
The task of the clinician is to hear the patient and appreciate how they have attempted to solve the problem. This is easier said than done because such persons will require extraordinary effort on the part of the clinician and present a challenge to the clinician. The challenge of working through this condition will present a formidable test to both of them. The related problems of working with narcissistic clients have been described by Kernberg (1975) and Masterson (1981).
Harold Searles (1961) offers a sensitive statement of these matters:
As the years have gone on, the author has found that the case presentations (at Chestnut Lodge) have come to convey less and less of blame, and to convey more and more of the tragedy of the patients’ lives—tragedy which is so much of a piece with the tragedy of life for all of us that the presentation is often a profoundly grief-laden experience for both the presenter and the listeners. One feels that the staff-presentations now give a truer picture of a patient’s life, but a picture which is much more deeply shaking than was the blame-centered picture previously seen. (pp. 633-634)
What may be the most challenging is the severity with which this condition can be manifest. While we must be cognizant of evolving neurological findings, clinicians cannot engage with a client merely to described the case, or satisfy personal curiosity. Clinicians must prepare to engage all clients but especially address those who manifest these conditions. This will obligate the clinician to a long-term commitment. Such a commitment is not for the casual therapist but only for the well-trained and committed clinician who willingly accepts this long-term obligation. Total commitment is required to assure the patient of continued support and assistance without fear of abandonment. All clients test the will of the clinician to persevere in their behalf, but many offer an extraordinary challenge. A client manifesting the conditions thus described will tax even the most committed clinician. Clinical work requires patience, perseverance, and sensitivity coupled to humility. Mental confusion and accompanying delusions manifest in severe pathology are especially challenging if we are to go beyond classifying and judging this condition once more illustrating the necessary but nonsufficient application of DSM-IV or DSM-5. Descriptive psychiatry and psychology cannot fathom complex conditions merely by listing symptoms. Clients who disguise their condition beneath a fabrication of personalities complicate diagnosis and treatment. The role of treatment in these difficult cases may be no different from any other difficult case except for the depth of the condition. However, literary psychology offers insight into the realm of delusion which clinicians may find helpful in establishing support and empathy. There is a role for poetry, metaphor, narrative, and symbol in the humanistic treatment of clients.
Footnotes
Author’s Note
The Double in italics introduces the topic and is employed for a published or artistic work. Double with a capital identifies its manifestation or a story character.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.