Monday, 31 March 2008

Panic and the Intentional Order

panic piccy

David Clark's panic model is well-known, and provides a perfect foil for the philosophical critique of certain strands in contemporary clinical psychology that is gradually unfolding in this blog. To pre-empt, this critique has it that:

  • Cognitive psychological models of psychological disorders often aptly describe the kinds of psychopathological processes involved in these disorders.

  • However they can often tacitly assume as a condition of normality what is actually a condition of abnormality.

  • That is, they can tend to assume a conception of our mindedness as, fundamentally, our being disengaged representers of reality. They can assume that what fundamentally grounds our understanding of our world is our thinking and modelling and hypothesising about it.

  • They may thereby cover over the real nature of much neurotic psychopathological disturbance - which can be summarised as the disruption of everyday, pre-reflective, intentionality, and the emergence of disengaged attempts to predict, reason, think, and control one's interactions with the world.

  • This everyday intentionality amounts to the kind of understanding that we carry around with us in our interactions, dispositions, bodily habits, affective responsiveness, praxical capacities - an understanding that is not grounded in, but which instead itself grounds, thought and representation.

  • Cognitive models of clinical disturbance tend to present the disturbed subject as someone in the grip of a faulty hypothesis, and in need of a better one.

  • Alternative hypotheses (provided in cognitive therapy) may challenge the catastrophic thoughts which maintain psychopathological disturbances. Yet whilst they challenge the catastrophic thoughts, and hence prevent run-away anxiety, much of the real work lies elsewhere.

  • It consists, in particular, in the strengthening and activation of behavioural and emotional modes of everyday intentionality. These modes do not primarily involve thought, but rather involve a pre-reflective engagement with, and unthinking trust in, the world.

  • In order to adequately understand psychopathology, we need to attend to the disruption of the underlying intentionality, and see this as the condition of possibility of catastrophising cognitions actually having a genuinely psychopathological impact.

  • That is, it is because of this disturbance of pre-reflective intentionality that we get trapped in a distinctive state of mind, typically untheorised as such by the cognitive clinical psychologist, which makes us prone to anxious rumination.

  • Thus, whilst the cognitive clinical psychologist describes what takes place when the subject is in this state of mind - the rumination for example - they do not theorise what it is to be in such a state of mind, nor provide us with the foundations of a theory as to what is disturbed or neurotic about this way of functioning. This, I suspect, is why we have a prevailing tendency within contemporary clinical psychology to 'normalise' much psychopathology. Because the 'norms' (everyday pre-reflective intentionality) are not themselves adequately theorised, it becomes impossible to understand why what can now start to look like merely quantitative variations in content should be pathologised.

So here's the nuts and bolts of the cognitive theory of panic disorder, as presented by David Clark (from chapter 6 of Science and Practice of Cognitive Behaviour Therapy.

  • People who experience panic attacks have an enduring tendency to interpret their own bodily sensations in a catastrophic fashion.

  • They interpret normal anxiety responses (e.g. palpitations, breathlessness, dizziness, muscle pains, and paresthesias (body sensations like tingling or pins and needles)) as signs of a serious health problem (e.g. heart attack, stroke, collapse, mental breakdown).

  • This misinterpretation causes further anxiety.

  • This anxiety inspires further anxiety responses, thus driving the vicious cycle.

Here's a pictorial example (taken from this GP training website:

Let me say first of all that I'm not here to deny the truth of what the model says - it seems intuitively in order. (An interesting aspect of the model, incidentally, is the way in which it challenges people (like me) who think it is often unhelpful to invoke efficient causality when providing psychological understanding, to see how that which appears to be in psychological order can be reconciled with philosophical anti-causalism.) What I want to question, however, is the comprehensiveness and sufficiency of the model. For it seems to me that, whilst it may let us know part of what is going on for the panicking person, it does not itself seem to feel the need to account for the panicking state of mind. It takes for granted the CBT premise that our affective responses are "cognition" driven. Because "cognition" (a possibly pseudoscientific term of art which covers a vast range of phenomena in a far less scientifically precise manner than do cognate English terms like 'thought', 'idea', 'rumination', 'understanding', 'opinion', 'belief') can do duty for both the catastrophic notions that occur to the panicking person, and for the understanding immanent within our everyday praxis (albeit that it often actually encourages the notion that such praxis is to be explicated in terms of an underlying order of tacit cognition extrinsic to it), the term covers over the phenomena which need to be understood. It presents us with a nice picture of 'getting in a state' or 'getting wound up', but simultaneously fails to theorise what the state is and what it is to get into it, leaving us all too often with only with a bland psychology of bodily reactions, cognitions, and mediating embodied emotional responses.

This, at least, is the critical idea I am exploring here. Let me say in advance why I think it matters. It matters scientifically, of course, just because as psychological scientists we want to get the phenomenology right (that is just what it means to be scientific here - to be careful, accurate, truthful, etc.). But it matters clinically because we need a way of tying together the clinical observations of the in-the-moment maintaining factors of anxiety with broader developmental concerns - e.g. insecure attachment - and biological concerns - e.g. vestibular disturbances - and psychodynamic (relational, personality-based, transferential and clinical) observations - that become apparent in the clinic with panicking populations. And we need to understand why some people may get better through non-cognitive treatments - in a way which does justice to this as a real phenomenon (rather than explaining it away in terms of cognitive changes that were nevertheless occurring unawares).

The phenomenologist's beef with the cognitive model of panic concerns two junctures which may at first appear contradictory. On the one hand, the cognitivist seems to suppose that an understanding of what panic disorder is can be had without understanding the disruption of normal intentionality that occurs in the condition. What I have in mind is the fact that the person who panics develops an intentional relationship with their own body - they take it as the object of their thought. It no longer stands as that from which they attend to the world, as the pre-reflective foundation of their experience, but becomes auto-paralysed when questioned by the mind. The body, or the functioning of the brain, can no longer be trusted. It becomes an object of fear, of attempted control - it becomes a ground or foundation which can no longer be trusted. Yet where are we to stand if the ground is shaky? Perhaps we avoid that bit of ground (safety behaviours), or perhaps we jump in the air and try to reconstruct the ground beneath us (magical thinking). In truth, when the structural disturbance of the ground is fairly pervasive, there is nowhere to stand (perhaps the sufferer stays inside the house). The cognitive theorist describes the catastrophic contents of the person's thoughts about their body, but misses the disturbed intentional relationship with the body. They do not discuss what we might call isssues of 'structure' or 'form'.

On the other hand, the cognitivist's conception of the sufferer's relation to their bodily symptoms as 'evidence' for an 'interpretation' (or rather, a 'misinterpretation') which has a catastrophic content, distorts the character of the sufferer's 'cognitions'. What I have in mind is that the kind of cognition that goes through the sufferer's mind hardly has the characteristic of an interpretation. It can of course be useful in therapy to frame the thought as an hypthesis - this gets the therapeutic process of substituting alternative interpretations or hypotheses off the ground. The decisive step, here, however, is not simply that which is described through the alternatives at the level of the content ('anxiety symptoms', not 'heart attack symptoms') of the thought, but the very move from an imaginal to a rational form of thought. The first was run through with primary processes; the latter, supported by the therapeutic relationship, has the character of genuine secondary process cognition. What gets lost here is not only the character of the catastrophising, imagistic panic cognitions, but also the conditions of possibility of secondary process, rational, reflective, hypothesising, interpretative thought.

Perhaps another image will help to make this clear. Here is a phenomenological image of everyday intentionality:

  1. Ground level, unanxious, bodily being.

  2. Supports our intentionality - i.e. our pre-reflective, affective, motoric, relatedness to the world.

  3. This supports our rational cognition, interpretations, hypotheses, etc.

In panic, we may surmise, we have:

  1. Disturbance of bodily being.

  2. Disruption of everyday intentionality, and emergence of self-focus.

  3. Self-directed cognitions which are catastrophic in not just content but in form: unstable, totalising, exceptionless, imagistic, etc.

The cognitive theorist aims to break the vicious cycle of panic by encouraging replacement of the content of the anxious 'cognitions'. And this, of course, is fine, since the effect is all well and good. Yet what is covered over is the dual sense of 'cognition' in play here - in the one case, imagistic, in the second case, rational. No cognitive therapist worth their salt would encourage the simple substitution of catastrophic with peaceful images. That hypnotherapeutic intervention fails to raise the quality of the thought to the rational and fails, furthermore, to provide the patient with a long-term solution. What they need is the capacity to draw on a resource of rational thought about their own panic reaction, to have some understanding of the nature of anxiety reactions, to be able to effect the cognitive manouevre of re-casting their bodily sensations as symptoms of anxiety rather than heart attacks or strokes or what have you.

What is also disguised by any approach which simply urges us to change the content of the cognition is a real understanding of the power of distraction (or, better, what Frankl used to call 'dereflection'). Once we understand the self-focus in panic as being an instance of disturbed intentionality, rather than of thoughts which a content which just happens to concern the self or body rather than the world, then we can come to understand the importance of re-establishing everyday intentionality again. We encourage the person to carry on with their business regardless of their sensations; we encourage the lived body to maintain its living intentionality. We encourage the patient to pick short-term goals, so that their temporality will not be hijacked by catastrophic cognitions. We understand, then, how a strengthening of pre-reflective intentionality can serve to prevent panic.

There are those who appreciate the simple-mindedness of the cognitive formulation of panic. This simple-mindedness is the appeal of the idea that we can practice psychology with a combination of learning principles and with a cognitivist's focus on the content of cognitions. What dismays me about this state of affairs in clinical psychology is not only its banality and breeziness, not just its explicit downplaying of the therapeutic relationship as anything other than a vehicle of the positive or negative therapeutic effect, and not just the existentially trite view of human beings as proto-scientists sustaining their connection with reality through rational inference-making. What dismays is the way in which so much of this is made to seem possible, reasonable, sensible, ethical through the un-negotiated premises of the theory. That is, once we have in place a view of the subject's comprehending relation to the world as grounded in representation and reasoning, it is hardly surprising that a focus on the ethical and relational and personal and embodied and affective aspects of personal being will come to be seen as distractions.

I've noticed I'm starting to rant, so had better draw matters to a close. To finish, however, consider the way in which the above-described banalised vision of the human mind and accordingly of the therapeutic relationship revealed itself in a recent episode of the excellent Radio 4 show 'Am I Normal?' (you can also listen again to this show, which will also enable the tone of the following exchange to be grasped). The topic was social phobia (sorry to change the subject...), and at one point there was an exchange between a young female CBT therapist (T) and a young male patient (C). Part of it went like this (verbatim transcript):

  • C: Mm.
  • T: So now we’re going to start challenging that [cognition of yours].
  • C: Mm.
  • T: Is it true that your saying one or another thing to the shopkeeper means that you are inadequate, odd, or stupid?
  • C: Erm … no.
  • T: Even if someone says something stupid, does that make them a stupid person? Is there such a thing as a stupid person?
  • C: Mm … I think, I think there is … But that’s obviously if someone does something that’s really embarrassing...
  • T: So there’s behaviours that are stupid.
  • C: Yeah.
  • T: But all of us do stupid behaviours.
  • C: Yeah.
  • T: So … is there such a thing as a stupid person?
  • C: [long pause]. Not really, no. Because I don’t look at other people and think ‘You’re stupid’.
  • T: Good [said in a tone of voice indicating the meaning: ‘You have answered correctly’].

I have no idea if this was a real or an acted encounter. But in either case, consider first the rational failures that T (the therapist) perpetrates. We have T and C both agreeing that everyone does stupid behaviours, and that doing a stupid behaviour does not make one a stupid person. Then T jumps to the extraordinary conclusion that there can't therefore be such a thing as a stupid person! (Whether or not the 'conclusion' is true or false, it is clear that no evidence for it is presented in the transcript. Just because non-stupid people can do stupid things doesn't mean that stupid things can't also be done by stupid people! It also obvious that this conclusion is not necessary for the apt challenging of C's putatively pathogenic beliefs: if C's belief that he is stupid is based in behavioural evidence, then challenging the evidence from the behavioural evidence should be enough to be getting on with...) C holds out for rationality for a while, but eventually gives in. In the process he is forced to come up with an alternative (equally bad) reason to believe that there is no such thing as a stupid person (he (claims he) doesn't look at people in such derogatory terms).

Now, perhaps unlike the prototypical CBT therapist, I don't myself believe that the global irrationality of this exchange need pose much of a problem for the progression of the therapy here. (What matters is the relationship, the gradual unfolding of shared understanding, and the genuine re-shaping of the patient's non-relective self-understanding in the context of the relationship.) What I want to note, however, is what can happen to the therapeutic relationship when the idea sets in that it is just the content of the patient's thinking that causes them their problems. The therapeutic relationship seems to go out the window, or is at least preserved mainly by the client who tries to accommodate to the therapist's forced-choice format. The therapist sets the agenda, the client tries to answer their school-mistressy questions as best he can.

The example is perhaps unfair. It hardly qualifies as an example of the cognitive therapist's beloved Socratic method. But it is not just the leading tone of the therapist that I am considering here. It is not just the method, but the goal. The goal is to change the cognitions which are supposedly underlying the social phobia. The perversities of the method are undoubtedly not all caused by the goal, but they are surely the kinds of hazards we can imagine once such goals are adopted. And what rationalises the goal is, I am claiming, a view that it is the content of the cognitions that must be changed. Once the view is taken that it is the content (and not the structure or form) of the cognitions that is driving the psychopathology, then it will be natural to adopt methods that aim to change this content. The categorical character of the cognition, the relevance of the subject's pre-reflective intentionality, and so on, is just covered over.

This post is straying rather wide of its remit, so permit me one further such stray. 'Third-wave' cognitive therapies often present themselves as having overcome the typical CBT therapist's focus on content. It is not the content, they say, but rather the person's relationship with this content, that matters. The goal, accordingly, is not to change content, but to change the way that the person entertains their thought. Do they see it as a thought which happens to pass through their mind? Do they see it as revelatory, absolutely disclosing of the truth - do they inhabit it or consider it? Can they be brought to a mindful detachment from it? And so on.

I feel sure that this is an advance over content-focused CBT, but am unconvinced that it provides a truly adequate phenomenology for understanding the psychopathology. (This may of course not be the goal of the ACT therapist, who is rather concerned to promote skillful means.) (Nor am I convinced of the merely facilitative conceptions of the therapeutic relationship that abound in ACT and other third-wave behavioural therapies.) For what we do not have is a seemingly free-floating notion of 'content' - conceptualised perhaps as 'inner word presentations' - to which we may adopt different relations. What I am wondering is whether or not a sleight of hand may be being played here by this notion of apparently free-floating content the form of which is provided by a simple relationship to it - a sleight of hand similar to that perpetrated by the generic notion of 'cognition'...