Tuesday, 27 May 2008

Philosophical Tropes

It is always instructive when doing philosophy to try to discover which the phrases are one most often uses without thought, and then to try one's hardest to question them. These phrases trip off the tongue so readily it is almost impossible not to assume their complete innocence. But...just start to question them and their apparent innocence can slip away faster than we might ever imagine...

The phrase I've found myself using recently has been 'What makes it the case that...?' The idea is that, for example, if I have been imagining going to France, then something must make it the case that what I imagined was going to France. How innocent does this sound? It's pretty much a staple of analytical philosophy. But just pause to consider what it seems to presuppose.

The first thing we note is that answers which merely reiterate the obvious: that I am imagining going to France, seem ridiculous. But the only other way of answering the question, other than tautologously, is by providing an answer which buys one into the following:

  • That what makes it the case that some fact obtains is the obtaining of some other fact.
  • That the meaning of meaningful terms ought to be specifiable through providing necessary conditions for the obtaining of what these terms reference.

And in all honesty I can't imagine wanting to sign up to these. Why on earth should I take it as uncontroversial that my understanding of the obtaining of one fact consists in my appreciation of some other fact? Why on earth should I suppose that meaning decomposes, analytically, in this way? For technical terms introduced into the language by definition, sure; but surely not for all the language which evolved piecemeal in the diverse socio-cultural and predominantly praxical contexts in which we try and cope with the myriad different kinds of phenomena we everyday encounter and construct.

In this respect it is instructive to compare and contrast a Ryleian or Wittgensteinian understanding of the relation between mind and behaviour, and that provided by a logical behaviourist. The contrast is interesting, I believe, not because of the content of the analysis, not because of the metaphysics, but rather because of the different metaphilosophical assumptions that the analyses illluminate.

So the behaviourist takes it that what makes it the case that Henry wants an apple is that Henry is disposed in certain situations to procure and eat an apple. There is the one set of facts: desires for apples, and another set: actions on apples. The former is to be explicated in terms of the latter. What I think is interesting here is not the connection with behaviour per se, but rather the reductionism. We spell out facts about the former with reference to facts about the latter.

The Ryleian is also interested in the non-contingent relations between desires and apple-grabbing behaviour. But when Ryle writes there is (I believe) no attempt to spell out 'what makes it the case that' Henry wants an apple. It might well be specified that, if we are in good faith to continue to consider ourselves rational beings, we must accept that, if someone wants an apple then they will ceteris paribus go and get one. That is, it will be incumbent on anyone wishing to doubt Henry's desire, despite his apple-grabbing behaviour, to provide us with the kinds of contextually specific, most-probably unspecifiable-in-advance or in-general, defeating conditions of the ascription before such a douubt could be couselled as rational. But the preservation here of this very idea of being held 'innocent until proven guilty' (i.e. we need to provide what will be counted as valid defeating conditions, in these particular and possibly unformulable instances) shows how far we are here from a reductive analysis.

For Ryle and Wittgenstein, there is then no 'what makes it possible that...?', no form of question which like this seems to tacitly suggest that were it not for something else which we (somehow, miraculously) can just see is perfectly possible, we should be required to baulk at the very idea of the obtaining of the fact for which an analysis is being sought. They will tell us what further facts (about behaviour) we can rationally expect - what facts determine what couts as a 'rational expectation' here - given the one (about mind) which is being considered, but will not tell us what the further facts are which 'make it the case that' the former obtains.

'What makes it the case that...?' must therefore join what for me is an ever-increasing rubbish bin of philosophical tropes which smuggle in quite optional and questionable metaphysical assumptions - tropes such as 'How is it possible that?', and I suspect the very idea of 'conditions of possibility'. After all, doesn't this idea too seem to encourage the notion that facts must wait on other (albeit grander) facts? (Conditions of impossibility, sure, but specifiable conditions of possibility?) But this must wait for another day.

Sunday, 25 May 2008

A Meta-Perspective on Externalisation

Melanie Klein Michael White

A conference at the Tavistock about a year ago had psychologists from different therapeutic traditions formulating the same cases using these different perspectives. It became apparent to all that the term 'externalising' could stand for either a process which was indicative of emotional progress and recovery, or for a process which indicated just the reverse. Yet whilst this was noted, no meta-perspective was offered which allowed for a theoretical reconciliation of these two uses of the term. This is what I shall try to provide in this post.

So sometimes we think of externalising as a failure to own parts of the self, parts which instead become split off and located in the environment. Here the therapeutic work consists in undoing externalisation - promoting the integration and coherence of the self. When this is done the centre of gravity of the self returns, the patient recovers themselves, they can own their guilt or tolerate their mental pain, they can tolerate healthy depression (i.e. they can start to make movements from the paranoid-schizoid to the depressive position, and can tolerate residing in the latter for longer). This notion of 'externalising' is principally located in a broadly psychoanalytical tradition (and is akin to what Steiner calls 'attributive projective identification'). But we might also recall, more generally, talk of the 'externalising disorders' of childhood (i.e. conduct disorders versus the 'internalising' depressive disorders).

At other times however we think of externalising as a healthy manoeuvre. Here - especially in the narrative therapy tradition - we are thinking of cases where people are unable to make progress because they are so bound up in their identity with a powerful bad object. This entanglement prevents the development of secondary process thinking about their predicament, encourages acting out, and prolongs their stuckness with painful feelings of self-loathing. An example will help: A young child with encopresis is making no progress. In their own (largely unconscious) mind they are this shitty, hopeless, out of control child. They cannot bear to even think about their problem, to do anything about it, because to do so immediately activates self-representations which are too painful to bear. Instead they live in mindless thrall to it. The only two options seem to that mind to be subscribing to a view of the self as loathsome, or obliterating the self and thereby making impossible the process of self-development; typically they choose the latter.

In this latter case, externalising is the move the therapist encourages. Instead of a shitty child, we construct and encourage a view of the child as good and well-intentioned. This good child who has every right to feel good about her or himself is however in battle with a problem which (so to speak) is not of their own cloth. This problem is something which happens to them. Perhaps we call it 'sneaky poo'. Rather than she herself again engaging in shitty behaviour, showing her lack of control, actively partaking of the unbearably shameful, we have a healthy happy child who is having to fight an external monster: the 'sneaky poo' monster who sneaks up on them. How can they outwit it? How can they defeat it? How can they - the good child - along with their parents and their therapist - everyone who is on the same side together (not against the child but against this sneaky poo monster) - how can they tackle the non-child sneaky poo problem?(Psychoanalytically we might talk of the separation of a superego and an ego which had become fused.)

Through the healthy externalising procedure the possibility of recovering the self (recovering agency, recovering the secondary processes) is actualised. Yet then again it was precisely through undoing externalisation - promoting internalisation - that the psychodynamic therapist's patient was recovering. It was through owning rather than disowning their responsibilities - being enabled to do so through being 'held' whilst they allowed themselves to feel the depression which otherwise felt too unbearable - that the analytic patient recovered. How can these perspectives be reconciled?

There are different ways of resolving such apparent contradictions. An obvious one is to look for different meanings or senses of the key terms (i.e. different senses of 'externalise' within the two traditions). Yet tempting as this may be, I'm not convinced this is the right way forward here. What I want to suggest is that we instead hold onto a univocal sense of 'externalise' and think instead of the stage of development of (the relevant part of) the self and of the possibility and viability of taking responsibility for one's thoughts, feelings, and behaviours. (i.e. I shall look for different objects, rather than different intensions, of 'externalisation'.)

Externalising, I want to suggest, is healthy when what it undoes is someone's taking too much responsibility for their actions. The obsessive-compulsive person, for example, is prone to take responsibility for the (sacrilegious, erotic, violent) thoughts that come into their mind. The encopretic child imagines - to the extent that they even allow their mind to engage with the topic - that they are responsible for their soiling (or they are caught up in an angry emotional denial of this responsibility). It is this felt culpability that makes their action so shameful. What externalisation allows for here is the relinquishing of this responsibility, either permanently (in the case of the obsessive-compulsive) or until such a time as a perfectly meaningful and possible degree of agency has developed (in the case of the encopretic child). Now that the young child understands they are not responsible, they can work on developing their agency regarding their bowel movements. Once this agency is installed, then appropriate responsibility may follow. With the obsessive-compulsive person, the degree of agency they imagine themselves to require regarding their own thought is fantastical. What they need is to develop the faith and trust in a world and a mind and a body which is not totally (and at the last analysis, not at all) under their control, to tolerate the anxieties of living and in particular to be helped to put down the anxiety-increasing tendencies to try to take responsibility where none is either due or required.

Contrast the case of someone who cannot tolerate the depressive position and who has unhealthily externalised aspects of their selves - structures of intention and responsibility - for which they are actually culpable. Here, whilst some of their neurosis may spring from an exceptionally harsh superego which inflates the extent of their responsibility for their actions and feelings and thoughts, and which accordingly results in its own projective (externalising) impulses, other aspects of the neurosis may stem from an inability to tolerate genuine feelings of realistic guilt. We only have to think of the patient who comes, through analysis, to be able to own their own contribution to the interpersonal disputes they always find themselves in at work or at home, for which hitherto they had angrily ascribed responsibility to their colleagues or partners. In such cases - prior to their resolution - we often find a seemingly paradoxical structure consisting of both (say) worthlessness and omnipotence. On the one hand I (for example) suppose that others think badly of me; on the other I act as if I were always the bee's knees. By helping someone gain a more realistic appreciation of (for example) the perception of others, their need to deploy narcissistic defences against blame also lessens. I can tolerate my guilt better if I know that others will also tolerate or forgive me for the often practically unavoidable yet still culpable minor thoughtlessnesses which we, as all-too-human, are drawn to perpetrate every day.

I want to conclude by commenting on the ways in which these different (narrative and psychoanalytical) discourses often become totalising. Narrative therapy draws on postmodernist conceptions of the self - in particular on constructionist conceptions of self and agency. The self is seen as a function of the narratives which are installed about it. By contrast, the psychoanalytic tradition draws on a romantic conception of the self - as an inner domain to which our narratives must conform if they are to do justice to the psychological truths about our functioning. These two conceptions of narrative and of its relation to the self are often presented as doing justice to 'the human condition' per se, and theorists argue about which is correct.

What I want to insist on is the need for a meta-perspective which makes room both for description and construction - both for the idea of narrative as needing to be responsible to the self, and for the idea of narrative movements as constituting the self's auto-creation. These surely are the two poles between which we oscillate every day. On the one hand we are given - in virtue of being genuine agents - some degree of 'say-so' or 'constituting authority' regarding our own thoughts and feelings and desires. I need serious grounds to not take your word as definitive when it comes to what you yourself are thinking or feeling. Absent such grounds and my doubt becomes a demeaning failure to take you seriously as an agent or as a person. On the other hand we are also beholden - in virtue of our only being subjects to the extent that we are subject to social norms - to standards which are not simply of our own making. These exist both socially but also intrapsychically; this possibility makes room for infelicity when it comes to my avowal, and accordingly constitutes the condition of possibility of defensive disavowal. Achieving this balance - between what we could call doing and creating justice, or between owning and creating - is the task of all of us as subjects or agents striving to live up to these designations. At the same time, it is the duty of us psychologist students of human nature to achieve this balance in our theorisations. Achieving a theoretical distinction between the two different objects that 'externalisation' may take is but a small part of this project.

Friday, 23 May 2008

Listening to Paranoia

So (an imaginary case): my client tells me that the SAS are always after him, that the royal family are plotting against him, that everyone is involved in a conspiracy against him, that everything that goes on around him goes on 'somehow for him'. What am I to make of it?

What I know is that he does not mean these things 'in the same way' as someone who is not paranoid. The clue comes in the way in which these things go on 'somehow for him'.

He might sometimes talk, of course, as if this was all meant in the normal way. But then at other times he makes it quite clear that it isn't to be understood in the normal sense.

Yet it is true too that he is not talking in metaphors. If anything, his ability to make the metaphor / reality distinction has become a little hard to hold on to.

And yet it is also true that it doesn't seem right to say that the words themselves have a different meaning. At least, it is not as if we have here something which makes perfect sense yet which is just making a different sense than normal.

My struggle is that I don't know how to listen to him. I easily get caught up with taking what he says as a literal normal truth, or as a metaphorical expression. Neither of these helps him to feel heard, to feel understood.

And perhaps I say that the 'Background' (cf John Searle on the Background) to his belief has changed. And this is surely right. The difficulties he experiences are not psychologically explicable, in the sense of explicable as consequences of unusual belief contents. But even so: How can I listen to him?

The question matters to me because I conceive of therapeutic listening as constituting a bridge between where the client is at, and where reality is at. The act of listening is the forming of this bridge, the making safe of the passage across it. It is through the connection that both understanding and healing occur. But how to connect?

Louis Sass gives us the best answer we currently have. He compares paranoia with solipsism. The solipsist 'believes' that she is the only person, only consciousness, there is. All experiences, all life, is theirs alone. (Solipsism is the reductio ad absurdum of empiricist theories of mind...) Words gain their meaning by referring to what is evident only to the solipsist herself, in her own experience.

The paranoid person is like a solipsist. Yet rather than coming to these views in philosophical reflection labouring under certain reflective presuppositions about the nature of experience, they arrive at them spontaneously. Their experience is solipsistic through and through; their (delusional) belief is merely an outgrowth of this.

But as Rupert Read discusses, following on from James Conant and Cora Diamond's 'resolute' readings of Wittgenstein's Tractatus, what the solipsist says is meaningless. It grabs us, it pulls us in, we engage with it, but we do wrong to take it 'seriously'. When we talk metaphysically we are acting without the constraints of everyday grammar, making distinctions where none can be sustained, held captive by pictures.

So too, what the paranoid person says is, sensu stricto, meaningless. That feels like a harsh thing to write, and I want to make clear that in declaring it thus I am not advocating not listening to it, not engaging patiently with it. That is precisely what I want to find: A way to listen to it.

Wittgenstein talks intriguingly about finding a way to bring words back to their ordinary meanings. The cure for the solipsist is patient reminders of how we normally use words. Words are brought back from 'holiday' through these patient reminders, these assemblies of cases.

What doesn't help is to argue against the solipsist, to put forward empirical evidence, and so on. And this is because every piece of evidence can just be caught up within their solipsistic system.

When we offer reminders as to the uses of words, we are not simply trying to get them to acknowledge that what they have been saying is meaningless. That would leave them with their experiences which they are trying to describe in solipsistic language, and yet without the language to so describe them. The attempt to engage with the solipsist is an attempt to help them shift the very structure of their experience.

How this happens remains to be understood. What is clear is that, in the process, they are brought back within the fold of our common humanity. All of this makes me wonder what would be the equivalent for the person with paranoia. What kind of 'reminders' would be apposite when it comes to his solipsistically structured (and hense sensu stricto nonsensical) belief that the SAS are always after him, that we are all plotting against him?

One kind would be 'reminders' which re-engage him with his life. Or which acquaint him with the operations of the SAS: a day-trip to SAS headquarters perhaps? These are not suggested as ways to help him test his belief, but rather as ways of returning his belief to the domain of the testable (i.e. non-solipsistic).

It escapes me, right now, how to fully learn Wittgenstein's lessons regarding the solipsist, and how to apply these to paranoia. I shall start by reading up on his actual encounter with solipsism.

Thursday, 15 May 2008

Listening to Madness

Whether in politics, philosophy or psychology, extreme and opposing views have an unfortunate tendency to appear to define the field and scope of our options. Accordingly, real theoretical innovation can depend on our being able to notice what non-mandatory assumptions are shared by both extremes, assumptions which prevent the novel and genuine development of our understanding.

The only example (aside from what I'm shortly going to write about!) which comes to mind will probably be too obscure for many. But let's risk it: In the philosophy of mathematics, the doctrines of Platonism and Conventionalism have been thought of as two option-limiting extremes. (In metaphysics, we have Realism and Idealism often playing a similar role to Platonism and Conventionalism.) Platonism tells us that our mathematical truths are true in virtue of their correctly describing a mind-independent Platonic world of sempiternal hard as crystal facts. Conventionalism tries to bring us down to earth, instead suggesting that necessary truths (including mathematical truths) are true in virtue of how human beings in their communities 'go on'. The former preserves necessity at the expense of invoking spooky words we don't know what to do with (Platonic realms); the latter preserves naturalism at the expense of necessity (since if we change how we go on, the necessary truths will no longer be true). Both views share the idea that necessary truths are true in virtue of something - that they are to be modelled, in this sense, on empirical truths. (The Wittgensteinian solution is to accept that necessary truths are not descriptions of our conventions, but are our conventions.)

At any rate, the two extremes I wish to consider in this post are (particular forms of) existential and psychiatric takes on 'madness'. A caricature of the latter (which caricature of course serves my purposes well) may promote the idea that there is nothing to be heard when we 'listen to madness' other than noise. What the 'mad' person says simply reflects their 'broken brain'. The tempting task of trying to discern a hidden meaning in what is said is thought of as thankless and pointless. We would do better ministering to material needs and waiting for the drugs to kick in. A caricature of the former (i.e. of the existential position) reverses this diagnosis. Madness is simply another way of going on, another way of being human, and we have to learn how to listen to the meanings implicit in what the 'mad' person is saying. Our deafness to these meanings reflects our own shortcomings in decoding the cryptic yet ultimately fathomable messages that we are given.

These two extremes, it seems to me, share a fundamental assumption, an assumption that prevents us from making psychological headway in understanding the nature of madness. To put this assumption in a form which makes denials of it look ludicrous (if pithy): it is assumed that when we understand something psychologically, what we understanding is its meaning. The alternative I want to promote, here, is the idea that what we may better do is to learn to tolerate, stand amidst, madness, to feel the full force of its pull on us to comprehend it (i.e. not to run away from it like the psychiatrist), without ever supposing that we really might or could and without supposing that a failing to do so would down to the listener (i.e. unlike the existentialist). For it seems to me that in order to do justice to the 'mad' and to madness, we need to find a way to listen to precisely what is mad about madness.

Psychiatric labels, it seems to me, are unhelpful in ways other than is commonly supposed. They are unhelpful because, once we learn to apply them, we can stop thinking about the utter bizarreness of the phenomena they are used to describe. Oh yes, he is 'hearing voices in his head', she is 'seeing things that aren't there', she is experiencing 'thought insertion' or 'thought broadcast' or 'thought withdrawal' or 'made actions'. He 'delusionally believes that he is the messiah'; she 'delusionally thinks that the secret services are watching her every move'. "Ah yes, they are mad, of course, and these are their symptoms; next case please". Or alternatively: "Let's pause to see what sense we can make of what they are saying, what distorted truths they contain".

There are many things that are right in the two extremes I have already outlined; I find myself very sympathetic to that which I labelled the 'existentialist'. Yet my concern here is with ways of approaching madness which, despite their desire to genuinely engage with and find meaning in what is said, thereby assimilate the mad to the sane, assimilate what is constitutively nonsensical to the sensical. The very madness of the mad can thereby be overlooked. We find such approaches in the mainstream of today's clinical psychological approaches to psychotic symptomatology. For example, perhaps it is believed that sense can be made of thought insertion if we distinguish a sense of agency and of ownership for thoughts, and see thought insertion as involving a failure in just one of these psychological mechanisms. My belief, though I shall not spell it out here, is that all such (neuro)psychological approaches tacitly assimilate the insane to the sane, and that it is this tacit assimilation which gives rise to the appearance of explaining psychosis through supposedly explaining the symptoms. (This comes about because it is assumed that we really can isolate such individual contributions to thinking or believing - that thought or belief can be understood as due to the collaboration of independent psychological mechanisms. Or that we, say, normally identify our own thoughts or feelings as such, yet develop a trouble epistemic relationship with ourselves when we become mad.)

But what is it to listen to madness, then? Well, the psychiatrist does not trouble themselves with why it is that what the patient says does not make sense. They recognise it (for example) as nonsensical in a delusional way, and diagnose it as such. But psychiatry famously lacks an adequate reflective account of what it is for a belief or other such attitude to be a delusion. A good place to start to listen might simply be to listen to the ways in which the 'mad' person feels compelled to say what they do, and to track too the ways in which sane listeners - ourselves in our sane moments - feel compelled to try to understand, or to shun understanding of, what we are being told.

The truth, I believe, is that the very ideas of hallucination, thought insertion, and delusional belief are as crazy as the phenomena that they are supposed to track. It makes no sense to say that I see something that isn't there, that I believe something that defies belief, that thoughts are put into or taken out of my mind, that I receive messages in my head. Psychiatrist/Existentialist: "Well of course I'm not saying that the person really does do these things; I'm saying that they take themselves to be doing this." Well perhaps we can sanction this in the case of hallucination, although it isn't clear to me that we really have the language to do justice to this, nor that psychotic hallucinations such as hearing of voicse are aptly understood in this way. (For example, we say: it 'seems to him' that he sees something that is not there; but in what does this 'sensory seeming' really consist? It is 'as if' I am seeing something, but am not seeing something. 'For me it is as if'... The phrases come naturally, but it's hard to know what to do with them...) But in cases of thought insertion or incomprehensibly delusional belief, what is meant by a phrase such as 'It is for him as if a thought has been removed from his mind'.

The claim I want to stress is as follows: We are driven in psychiatry to use phrases such as 'as if' clauses ('as if a thought has been removed') although we don't have any meaningful grasp of the comparison object. And whilst it is tempting to believe that the important thing to do is to furnish ourselves with just such a grasp or simply to move on to something that does make sense (the existential and psychiatric alternatives), what we might benefit from could be a willingness: To sit with the phenomena, hear their craziness, hear how both the patient and the listener are driven to say things that don't make sense in order to 'do justice to' the experience. To note how the nonsensical descriptions are actually constitutive of the experiences in question: they are the experiences which we find ourselves compelled to characterise in this way.

My plan, then, is to learn to listen to madness itself. In particular it is to begin to spot all of those occasions in which the patient or the doctor is driven to say 'Here it is as if 'x'' where x is not something that we can really understand. Moving from prodromal to apothanic stages of psychosis we see such 'as if's' dropped and the person now really starts to 'delusionally' believe in these impossible beliefs. It occurs to me that, to the extent that a person's madness is at the time an important part of them, learning to listen to madness might also be a way of learning to listen to my patients. Perhaps my own acceptance of their madness, without explaining it or dismissing it, may even be a beneficial experience for those to whom I am trying to listen.

Wednesday, 14 May 2008

Reconciling Biological and Psychodynamic Perspectives on Psychosis


Different models of psychotherapy, which present themselves as treatments for 'various difficulties of the human condition', often turn out to best be suited for the treatment of particular kinds of people with very particular kinds of problems. So too, different models of either psychosis in general or of psychotic conditions such as schizophrenia in particular present themselves as 'the theory' for the symptoms one finds in the clinic. This can be very puzzling when we are confronted with two different models which both seem to have value, and when we want to avoid any overly easy explanatory pluralism. Thus the evidence for a genetic predisposition to schizotaxia (a trait itself disposing towards schizophrenia) seems fairly strong, and the various movement disturbances and other 'soft signs' of psychotic conditions seem to rule out any purely psychodynamic explication. And yet at the same time we often meet, in psychotic conditions, with extraordinary defence mechanisms and with delusional and other contents which seem to cry out for psychodynamic understanding. How do we understand their co-occurrence?

In this post I want to propose one simple answer for certain particular difficulties. And it takes its lead from offering a recognition of the fact that particular defences, like particular plants, require certain soils in which they can grow. Many 'primitive' defences would be very hard to mobilise in the well-adjusted. Even defences such as self-deception or denial would often be hard to pull off, since we are so often brought up in front of ourselves that the effort required to sustain the denial would be near impossible. Only in certain conditions can certain defences realistically stand a chance of being employed.

I want to focus on the defences often operative in paranoia, in which bad parts of the self are located in the world (as a defence against feeling bad in oneself), only for the projector to then experience the world as a bad and persecutory place. What kind of soil is required for this defence to grow in? It seems to me extraordinary to suppose that we can just help ourselves to the idea that this defence itself explains the entire psychotic state. This is because the mind boggles when it tries to understand how such a defence could ever be pulled off in the first place.

But consider now the possibility that the neurobiological foundations of what the phenomenologists call our intentional field (the spatio-temporal 'clearing' which constitutes our orienting relation to a world of objects, and which separates out, as its two poles, the self and the object/other) become fragile or vulnerable. Or, to deploy Pierre Janet's schema, the neurobiological tension required to sustain certain levels of consciousness up to the fonction du reel becomes compromised in certain conditions. As a consquence we are left with a soil ripe for the operation of particular defences.

If we consider a weakness in either of these functions, we understand how a proliferation of merely associative thinking and correlative lack of fonction du reel may make possible the frequent use of defences such as self-deception. Character structures with marked splits in their associated associative webs will also play their part here. But what interests me more is the idea that, when the intentional field is weakened, the possibility of a reversal, an inside-out flip, an involution of intentionality, may occur. The ease with which the two poles may be conflated is greatly increased.

Now we only have to imagine someone with this vulnerability encountering the kinds of interpersonal emotional insults that we all encounter (guilt, shame, inability to deal with (to 'think' as Bion would say) one's own murderous feelings, anger, sexual identity confusion, unrequited love, and so on), and it becomes readily apparent how and why they can deploy defences that could not even get off the ground in someone without a psychosis (but with the same conflicts). What better precondition for the operation of projective identification than an intentional field that only takes a little affective shove before it becomes entirely involuted?

What seems important to me about this kind of explanation is that it is in no way an over-easy invocation of, for example, the need for 'bio-psycho-social' models, nor a facile invocation of 'identity theories of mind and brain' at a general level to supposedly perform the reconciliatory work for us, nor an obscure Jungian theory of the supposed toxic efffect that certain ideas can have on the brain, nor any theoretically un-derived divvying out to different sciences the task of explaining diverse symptoms. Nor, I believe, is there here a failure to apply Occam's razor (or at least, there is a 'failure' to apply it indiscrimately, yet such a 'failure' could hardly count against anyone attempting to do justice ot the complexities of the diverse structures of experience met with in for example the schizophrenias.) Instead we have an honest acknowledgement of the undeniable fact that the conditions for the possibility (the 'soil') of certain defences that strike us in the face in the psychoses may well be precisely provided by the neurobiological disturbances encountered there. The neurobiology does not account for the content, only for its possibility. The content does not account for the vulnerability, only for its exploitation. This, I believe, is just one example of how what Charles Taylor called 'peaceful coexistence in psychology' may one day become possible.

Saturday, 3 May 2008

Form, Content, Metaphor, Body, and Delusion

The notion of the 'form' of a delusion has often landed phenomenological psychiatry in a bit of trouble - if only because it seems terribly hard to spell out just what it means. Here is the way I myself used to (attempt to) distinguish between form and content:

  1. Content: What a delusional belief is about - i.e. 'intentional' or 'representational' content.
  2. Form: The rational relations of the belief to other beliefs.

The temptation is to think that delusions are conceptually manque just to the extent that the person who is deluded is making a funny bunch of inferences.

But first, like, does anyone really believe that? Are they just irrational in the sense of being poor reasoners? To my mind, this seems a million miles away from the deep kind of irrationality we meet with in, say, certain schizophrenic conditions.

Second, there appears to be an untenable dualism buried in this scheme. At least, there is if one takes it that form and content are distinct aspects of belief. As if we could understand what content a belief had without having understood the kinds of inferences that holding to it licenses us to make. It always seems intuitively obvious to me that the content somehow determined the form in the case of (delusional) belief - as if one could help oneself to a notion of content and then, from that, see what inferences it legitimated. This, however, is surely, well, at least rather doubtful. Could I really be said to understand what an expression of a particular belief meant if I did not grasp what inferences from this were and were not permitted? Would not my idiocy about formal matters reflect badly on my self-attribution of a grip on content? If we defined form and content at a sub-semantic (causal, naturalistic, non-intentional) level - as, say, a matter of the words used in the (putative) expression of a belief (for the 'content'), or of the ('formal') associations to such utterances that tend to be made, then the distinction stands. But it isn't clear that it has anything to do with the belief qua belief - nor on the delusion qua delusion.

So my question is: Can we arrive at another notion of 'form', in psychopathology, which allows us to unpack just what might be awry with delusions, in a way which doesn't commit us to the above-described untenable dualism? I think we can, but the contrast with content must be abandoned as misleading. For what the idea of a formal disturbance is, I suspect, trying to articulate, albeit badly, is the idea of a disturbance which is 'deeper' than any kind of inherently correctable 'mis' phenomenon - such as a mistake or misperception or misapprehension or misunderstanding. What is articulated, although it will take our best epistemological efforts to arrive at the necessary understanding of what we mean here, is the idea that the delusion represents a disturbance in that contact with reality that consists not simply in the absence of a 'mis' phenomenon, but rather in that contact which is a precondition for intelligible talk of take and mistake, apprehension and misapprehension, understanding and misunderstanding.

The best way, I think, to grasp what is aberrant in true delusion (and I'm including delusional mood and delusional perception in this too, since I think these labels accurately reflect a pre-understanding that the kind of disturbance we meet with here is not a function of the mistaken nature of just delusional beliefs, but something which affects the very possibility of talking of taking or mistaking in the domain of belief, mood, and perception) is through reflection on a Wittgensteinian conception of the foundations of our grasp of meaning.

One way in to start to understand the foundation of delusion is through thinking about the way in which our experience of our own body provides the causal template for so much of our understanding of causality in general, psychological comprehension, social understanding, and so much more. Consider the following:

  1. In schizophrenia we often have a disturbance in metaphorical understanding. As John Rhodes and Simon Jakes have discussed - and others before them such as Hannah Segal have noted - schizophrenic delusions often involve a conflation of metaphor and reality. The well-known example (from Segal) is of the patient who "was once asked by his doctor why it was that since his illness he had stopped playing the violin. He replied with some violence: 'Why? do you expect me to masturbate in public?'" Perhaps 'fiddling with himself' was what connected the two (musical and onanistic) cases, or perhaps it was just an associative web of more personal allusions.
  2. Much of our everyday discourse, and our capacity to learn and understand it, depends upon conceptual metaphor and our ability to grasp it. As Lakoff and Johnson suggest in Metaphors we Live By, pretty much all of our language games are metaphorically structured. Take their example: ARGUMENT IS WAR, and consider the following idioms: "Your claims are indefensible. He attacked every weak point in my argument. His criticisms were right on target. I demolished his argument. I've never won an argument with him. You disagree? Okay, shoot! If you use that strategy, he'll wipe you out. He shot down all of my arguments." We start with some grasp of what is involved in shooting, attacking, defending and so on. And then - without our ever even thinking about it - our brains use this associative structure as a template for our understanding of argumentation. We intuitively understand what someone means when they use a military metaphor, and don't even realise that it is such a metaphor.
  3. In order to be able to perform this transformation of frames, we need to be able to do two things. One is to draw on the source domain (warfare). The other is to keep the source and the target (argument) domains apart.
  4. This need to both identify yet also to differentiate underpins vast swathes of our understanding. For example, there is a sense in which we need to be able to identify with other people (nearly act, think, feel, as if we are them) whilst also holding onto our difference - in order to be able to relate to them at all.
  5. The dance of this back-and-forth between proto-identification and proto-differentiation amounts to what the analysts call the 'capacity for symbolism', which Winnicott so closely linked to the child's ability to engage in pretend play.
  6. In schizophrenic delusion, however, the capacity to effect the differentiations is lost. The distinction between self and other becomes troublesome. But so does the distinction between metaphorical and real.
  7. It is unhelpful to think of this as the literalisation of metaphor, any more than to think of it as the metaphoricisation of reality. What we have is a breakdown in a distinction which is needed before the metaphorical / literal distinction can get off the ground.
  8. The other aspect of conceptual metaphor I mentioned was their anchoring in the human body. In a fascinating paper Tim Rohrer discusses how we speak metaphorically about the landscape as if it were a body (face of a mountain, mouth of a river, foothills, etc.). He also notes that in fMRI scans during tasks involving landscape-as-body metaphors, hand sensorimotor cortex became activated. This suggests that we truly do not have to do here with, simply, a borrowing of conceptual structure and a totally separate deployment of it, but a secondary deployment constrained by the old discourse and rooted in our neurobiological habits of reaction. At any rate, the idea I need is just the one discussed in a previous post - that the body schema becomes disturbed in schizophrenia (perhaps even in an underlying compensated schizotaxia), and as a result fails to constrain, in the normal way, the uses and extensions of the word that are normally met with in the target domain discourse.
  9. The body schema, then, becomes frail and not ideal for guiding comprehension in target domains at some distance from the literally bodily. Different extensions are naturally made. Further, the ability to recognise secondary senses as such becomes lost.

Friday, 2 May 2008

Bodily Basis of Schizophrenic Disturbance


In this post I wish to distinguish between two different theories of the bodily basis of schizophrenic delusions. Well, between three different theories, if we start by definitively laying to one side the potentially unproblematic yet often overly simplistic aetiological idea that 'schizophrenia is [caused by] a disturbance in the brain'. That won't be my concern here, which is rather to distinguish between two different ideas of the relation between abnormal bodily experience and delusional belief.

The first idea, which is fairly widespread, takes abnormal bodily experience (altered somatosensory and proprioceptive experience and micro-motoric behaviours, cenesthesias and the like) to provide a content for delusional thought. The theories of Brendan Maher and Philippa Garety come to mind here. Delusion, it is said, amounts either (Garety) to the deployment of abnormal reasoning ranging over sensation and perception, or to (Maher) normal reasoning ranging over abnormal sensory input. I hallucinate, for example, and, taking up this abnormal perceptual experience within my troubled or untroubled powers of reason, I arrive at a belief the bizarreness of which is either just a function of the hallucinatory content, or is due in addition to inferential disturbances in the cognitive processes by which I try to make sense of what I take myself to hear or see. Similarly, altered somatosensory rather than perceptual experience may give rise to delusional beliefs which have the altered bodily experience featuring in some way as a content of the belief. We only have to think about cenesthesias and delusions of objects or organisms lodged in the body to understand how this relationship might obtain in the somatosensory domain.

Now it might be tempting to consider this the end of the psychological story for the relation between subjective bodily experience and delusional belief. The second idea I wish to consider, however, takes the first as only a small part, and only the end, of a far more comprehensive account of the relation between our embodiment and our thought. All I shall try to do here is to briefly, and piecemeal, attempt a sketch of this latter possibility.

  1. Schizotaxia. The theory of schizotaxia is owed to the venerable American psychologist Paul Meehl. It posits the idea of an inheritable predisposition to developing schizophrenia, which predisposition has characteristic features of its own, and which may be found not only in the pre-prodromal schizophrenic, but also in their kin. The schizotaxic diathesis includes spatial, vestibular, and kinesthetic disturbances, and results in dysdiadochokinesia, a tendency to cognitive slippage, and other symptoms, and when partially decompensated may lead to distortions of body image, blurred ego boundaries, chaotic and confused sexuality, etc. According to Meehl, perhaps 90% of schizotaxic subjects remain compensated throughout their lives, or at least will not develop schizophrenia. The unfortunate 10%, perhaps (we may speculate) because of overt traumata or perhaps (again, speculation) because of developmental (including psychosexual) disturbances, decompensate into the acute and then chronic schizophrenic state. What causes and characterises the decompensation may be psychodynamically explicable; the nature of the experiences may best be characterised using existential phenomenology; but the underlying schizotaxic disturbance, which should be considered a sine qua non of schizophrenia, remains explicable, causally, solely in biological terms.

  2. Conceptual Metaphor and the Body. The theory of conceptual metaphor and its bodily foundation is owed to the well-known cognitive scientists and linguists George Lakoff and Mark Johnson. It depends on two theoretical posits which strike me as prima facie plausible. The first is the metaphorical nature of much of our discourse. Lakoff and Johnson note the way in which many abstract concepts are structured by, and can be understood through a prior acquaintance with, other conceptual domains. For example, ideas to do with warfare play a large part in the language-games to do with arguments (beating, defending, launching an attacking, dealing a striking or killer blow, etc.). We understand what someone means when they describe verbal exchanges in such militaristic terms because we appreciate the conceptual mapping that is going on here. The second posit is the way in which our understanding of 'the mind' is dependent upon our understanding of 'the body'. We intuitively grasp what people are saying when they talk of feeling up tight, grasping the point of an argument, feeling up or down, high or low, spaced out, disturbed, seeing what is meant, thoughts that escape us, etc. ad infinitum. In fact (although this point is somewhat irrelevant to my argument here) our vocabularies of mental disturbance are themselves run through with such bodily metaphors. (The nice idea has even been put forward - by T S Champlin - that the very idea of mental illness stands to bodily illness as a 'rhyme to the eye' stands to one 'for the ear' - i.e. in a metaphorically mapped sense which cannot be further justifies but relies on our innate dispositions to take the discourse in the way we do (cf Wittgenstein on secondary sense).)

  3. The key idea in Lakoff and Johnson's work on the bodily basis of meaning is that our experience of our bodies informs our understanding of the world and of one another. And the way in which it informs it is not through our thinking about our bodies and what is going on in them. Our bodily experience does not inform our comprehension through by our reflecting on it, but rather directly and causally informs our cognitive dispositions. It does not provide us with reasons for our beliefs, but rather structures our extra-rational and foundational dispositions to take one another and grasp events in the way we do.

  4. The thesis which results from the combination of 1 & 2 should now be obvious. Delusional beliefs in schizophrenia may result from the way the schizophrenic's entire world-relation, the way they pre-reflectively grasp at meaning, the way their dispositions to go on (or not go on) in ways which themselves constitute (or fail to constitute) our practical rationality, have altered. Failures in somatosensory integration lead to failures in thought, not through constituting peculiar objects for such thinking, but through leading to disturbances in what we could call its form. But the notion of 'form' must be handled carefully here; we cannot rely on any simple form/content distinction, and we must avoid any facile dualism along these lines at all cost. The appeal to the form or shape of the thought here (another nice couple of conceptual metaphors, note), signifies solely that we cannot help ourselves here to any notion of the perfectly rational grasp of merely perceptually or interoceptively bizarre content (a la Maher).

As a preliminary sketch, this will have to do. I wish to mention here only on the support such a view could also gather from what today is a widespread phenomenological literature on disturbances of the lived-body in schizophrenia - from writers such as Giovanni Stanghellini, Josef Parnas, and Thomas Fuchs.