Saturday, 5 December 2009

a simple model of psychotherapy for psychosis

Here is a very simple model for the pragmatic therapy of schizophrenic psychosis. (I say 'simple', and it is, but the theories in terms of which it is cast are not at all simple. I shan't be spelling out these theories here, and will instead assume a ridiculously happy congruence between i) the reader's prior reading and philosophical prejudices and ii) my own.) It is built on a) an understanding of the nature of the core psychotic disturbance drawn from phenomenology and psychoanalysis, b) an understanding on the nature of the self drawn from existential phenomenology, and c) an understanding of the nature of effective therapeutic treatment drawn from the behavioural therapy known as ACT or acceptance and commitment therapy. I'm posting it because it seems fairly obvious, but I've not seen it articulated in just this way in the literature - probably because a) or b) and c) are not often drawn into close proximity, but also because there is much in the RFT background to ACT which is inimical to the philosophical spirit of existential phenomenological theorising about 'the self'.

a) A person 'with schizophrenia' suffers from a schizotaxic deficit. This constitutes a fragility in their capacity to hold themselves together - or, more accurately, a fragility in the capacity of their lived body to remain held together - in the context of (in particular) emotionally significant interpersonal encounters. The fundamental disturbance is accordingly a 'self disturbance'. The boundary between self and world or self and other - a boundary generated by the body schema in action - is always somewhat fragile, and then when stressed too greatly, becomes altered. The boundary between self and world, or self and other, starts to fall apart. From this basic self disturbance arises all the secondary symptoms such as delusions, hallucinations, passivity phenomena, etc.

b) Additional strain is placed on the smooth functioning of the body schema by powerful affects such as anger/anxiety. Psychotic terror at the dissolution of the self itself promotes further self-dissolution. There is however nothing that any of us can do, directly with the resources of the conscious mind, to reduce self-disturbance. Any thinking will occur 'on top of', grounded in, the self-disturbance. The kinds of hyper-reflexive retreats documented by Laing and Sass do not promote genuinely different ways of grounding the self. (Instead they are simply that: retreats from being, however much they are narcissistically dressed up as alternative realities.) The grounds of the self always remain inarticulate, background, non-reflective, aspects of bodily going-on-being which we can only promote obliquely.

c) Part of that oblique treatment will involve any exercises of whichever sort which can aid in the recalibration and stabilisation of the body schema. The kinds of bodywork promoted by Rohricht and Schoop may help here. However ACT surely has something else - and something important - to offer. Which is the idea of dropping control agendas with regards the occurrence of distressing mental events, and also the idea of promoting an acceptance of whatever comes into the mind (acceptance tempered by a distancing acknowledgement of that whatever's mental as opposed to real state). That much has already been said in the ACT on psychosis literature. But I'd like to propose a third piece of groundless trust which it would behove the therapist to promote - namely, a trust that the body schema will look after itself if one allow it to. If one can allow oneself to 'go with' (without 'buying') the psychotic experience. Take courage, re-engage with the lived environment, and do not hyper-reflexively try to create a psychic retreat or a rigidified way of being to 'manage' the psychotic experience.

The self in psychosis has weak foundations, but these foundations are, as for everyone, constantly enacted (the path that is layed down in walking) in the course of a meaningful life lived. Can the schizotaxic patient allow that path to lay itself down, to not try to lay it down and thereby inadvertently build castles in the air which constantly threaten to crash down to earth, to instead take themselves on walks through familiar and comfortable terrains and tolerate the rough ground?

Saturday, 21 November 2009

why psychology is a bit rubbish really

Er... a shamelessly hyperbolic and attention-seeking title I know. Anyway, I thought I (a psychologist) would spend a few moments clearly specifying why it seems to me that psychology is a rather limited discipline when it comes to understanding psychopathology. Of course I'm playing rather fast and loose with what is to count as the extension of 'psychology' but I hope my caricature will at least be recognisable.

Psychology today tells us about - to use a shorthand - what happens 'in minds'. That's just what psychology is. It tells us about what people think and feel and intend and will and 'represent'. And as well as telling us about what representations are in the mind, it tells us about how people think and feel and... We have 'mental states' and then we have the 'mental processes' that link these states together.

The natural deployment of this framework in psychopathological contexts suggests that in psychopathology people's representations of others or themselves or their worlds are faulty in content (a faulty 'what'), or there are faulty links between these representations (a faulty 'how'). Perhaps someone's feelings are out of proportion to a situation; perhaps their beliefs are inaccurate; perhaps they are jumping to conclusions, etc. It is either mental states that are disturbed, or mental processes that are breaking down. And that is the sum of it, of what it means to 'do the psychology' of psychopathological conditions or states, on the story I'm telling.

The problem is, however, that most of what we recognise as proper psychopathology is not at all aptly characterised as due to a faulty contents or broken processes. What most frank psychopathology involves is not a failure in the mind's mirroring capacities, a failure of what is in the mind (states or processes), but rather in the structuration of the mind itself.

By structuration I do not mean 'stage of development' or 'degree of complexity'. That, it seems to me, is (in this context alone) another psychologist's red herring. I have in mind rather the way in which the faculties dialectically unfold into their mutually constituting yet opposing domains. To understand this we need the conceptual resources not of psychology, which can only tell us about what's happening within minds, but rather of existential phenomenology, which tells us about the essential character of mindedness itself.

Here's a rather daft pictorial way of demonstrating what I'm getting at. First we have a picture of a normal mind doing its normal job. (It's not supposed to instantiate a valid faculty psychology, just to help me make a theoretical point!)

Here we've got someone looking at a dog, recognising what to call it, laying down a memory, shutting their eyes and drawing on their memory to call up an imaginary dog, etc. We have a mental process of perception leading to a mental representation etc. etc.

Now we imagine someone suffering from some deficits in their mental states and mental processes. Here's one possible result:

What we have here are a whole host of different difficulties: a faulty perceptual processes leading to the internal representation of the dog being somewhat truncated; dodgy memory processes such that we have a lack of laying down of new memories, and a knackered verbal recognition ability such that the term 'hog' comes to mind instead of 'dog'.

Such a way of depicting matters comes fairly naturally when we are thinking of specific brain injuries or fairly localised dementing processes. What I want to claim is that, despite the ambitions of cognitive clinical psychology or cognitive neuropsychiatry, it just won't do at all when we try to grasp the essential character of psychopathological conditions such as OCD or psychosis.

The essential character of such conditions, I want to suggest, lies in the fact that, under certain pressures and in certain contexts, we have a failure in the structuration of the faculties and of the very mind itself. This is difficult to represent pictorially because another claim on the table has is that to the extent that we have deviation from that structuration which separates what is inside the mind from what is outside, or which separates the imagination from memory or from perception, we have a loss of mindedness itself. I've tried to represent this in the following picture by showing how, when we have a movement of the boundary of the faculty, we simultaneously and necessarily also get a loss of that very boundary:

Our ability to really talk about distinct faculties, to place a representation within one rather than the other, starts to blur. It may become hard to say where the self ends and the world begins (witness the intruding dog). Yet this is simultaneously to say that it starts to become hard to talk about distinct selfhood at all, since self and world-as-experienced-and-understood just are mutually yet opositionally defined. Whether we have to deal with a memory or an imagination or a perception becomes unclear. Verbal recognition starts to intrude into perception. Again, it's not just that, say, something within the mind gets mislocated, or mental processes mediating representations between faculties become impaired. (That's the standard cognitive psychological model of mental disturbance.) Rather, the very possibilities of making coherent distinctions between imagining and seeing starts, especially in particular affectively significant contexts, to fall apart.

Cognitive models of obsessive compulsive disorder tell us that 'everyone gets intrusive thoughts. It's just that the person with OCD wrongly perceives the significance of these, taking themselves to be responsible etc.' To my mind this radically misunderstands the nature of both intrusive thoughts and of obsessional responsibility-taking. The obsessive person 'takes responsibility for' things that it doesn't even make sense to take responsibility for. I mean that quite literally: pushed to an extreme we start to lose track of what it even means to say that they are 'taking responsibility' in these situations. We can have some kind of a psychodynamic understanding of this: faced by an intolerable self-shattering anxiety they enact self-constructions which distort the relation between self and world so that a damaged self can take itself to have more agency and therefore control over the unpredictable beyond than it makes sense to have.

Now normalising is often very laudable, and clinically this seems to be a useful strategy, but phenomenologically speaking it's mighty suspect, and I can't help entertain the thought that, like several cognitive interventions, what is helpful in aiding the patient to return to some kind of relative stability may get in the way of deeper restructurations of the self. One could even say that normalising is the precondition of (im/possibility of) the whole psychological project, since psychology, restricted to talking about what is happening within minds and faculties, simply lacks the resources of existential phenomenology for theorising the character of deep disturbances of mindedness and faculty divisions themselves.

Friday, 20 November 2009

when the puzzle falls apart and can't be recovered

There's a curious state, phenomenologically speaking, to be had when philosophising. I believe it to be best characterised by Wittgenstein's idea of being 'held captive by a picture' and then being set free from this captivity. And the curious thing is that one can then hardly understand what it was one didn't understand before. Hard to understand what the problem was, how one was confused; even to remember the whole problem. It has just dissolved.

I don't believe this state is unique to the resolution of philosophical puzzlement. It also seems to be shared by the resolution of psychotic delusion, the bursting of the bubble of transference, being relinquished from the grips of an unconscious phantasy, and moving from dream to waking consciousness. We know we've just been dreaming, but often struggle to say what about; perhaps sometimes, through the day, we have a vague sense of still living in its penumbra.

Right now I'm caught in a puzzle about the nature of historical explanation. I've not been reading up on it, so this isn't a scholarly post. I thought I'd rather try to note my puzzlement now, since I have an inkling that it may be on the verge of dissolution and I want to use this as an exercise in trying to 'hold onto the madness'.

I'm thinking about the nature of historical explanation (I know nothing about history itself). I want to know, or so it seems to me, what the causes of an event are - e.g. the causes of the first world war.

And then I wonder to what extent I will be satisfied instead by a purely hermeneutic answer. One which specifies the intentions of the agents. One which sheds light on the meaning of the actions. Which recharacterises the actions so as to make them humanly intelligible. Which deploys 'interpretation' as its methodology.

And so I'm tempted to contrast interpretative or meaningful explication with 'efficient' causal explanation. But I wonder now what about the actual causes of the war. The thought goes: ok, so we have what inspired the military leaders, what understandings were reached by whom and when. But is this all? Can't we ask about the causes as well as the meanings? What it was that 'brought it all about'?

Well, it occurs to me now that here I may be in the heart of the kind of puzzlement that wants for dissolution rather than solution. (But can I avoid losing a sense of my puzzlement? That is my goal.) And when I first wrote this post I went on quickly, at this point, to just urge a distinction between reasons and causes, and to suggest that the felt need to articulate a causal as well as a rational story was otiose, since what was really requested by the question as to the causes of the first world war would be best and completely aptly met by a justificatory explication. (I've also had another strange experience: I thought I should go and read up on the issue, and pulled von Wright's book on Explanation and Understanding off the shelf - and found he uses the same example of the beginning of the first world war. Perhaps it is a common philosophical example that I'd forgotten I'd previously encountered?) And I think I then just lost a sense of my own puzzlement.

Donald Davidson and Bill Child both insist, regarding psychological explanation, for example, that it's fine to be told what sense we can make of someone's actions, but we also want to know specifically what made the actions happen when they did. And let me admit (now following von Wright) that we can of course talk of the circumstances, geological and political and economic circumstances which obtained at a particular time and only given which would certain motivations for action gain traction. But to go and tidy it all up in this way now seems to me to risk losing a sense of my original puzzlement. (Like providing a sensible answer (which would in fact be an answer to a sensible but banal question) to a silly (but nevertheless deep) question - I risk just being shut up, rather than being understood, by myself.)

Somewhere around here is where we must 'condense a cloud of philosophy into a drop of grammar'. And here's the thought: It sounds strange if we say 'nothing brought about an action' but this is because it looks too much like a spooky empirical, rather than a grammatical or conceptual, proposition. It looks spooky because it looks now like we're admitting uncaused events into our ontology. But conceiving of actions as events is part of what is at stake here too. We (well, we secularists) don't find it weird to talk about unintended events happening. Let's try not to get similarly freaked out by talk of uncaused actions.

Understanding just what it means to say that ''actions are uncaused' is a grammatical rather than an empirical statement' helps resolve some of the tension here. If I'm right, it's like saying 'colours are weightless', 'emotions are without length or breadth', 'integers are priceless', etc. It doesn't mean that there are these mysterious goings on (they aren't 'goings on'!); it means that no meaning has been given within the English language to talk of 'causing actions'. Perhaps we could provide such a use, and extend our language game in new and interesting and useful (but not 'truer'!) ways. That's another issue though. For now the trick is to know when we've just been un/reflectively assuming that it works in ways which are as yet simply foreign to it.

Last gasp. I find my internal interlocutor now proclaiming: Yes, but Richard, we do need some way of understanding how the world of intentions and actions relates to the world of events and causes. I acknowledge the temptation to ask this, but I suspect that the question once again comes from a mind in thrall to the very conflations which generated the sense of puzzlement which has now left me when I was finding myself wanting to ask about not just the motives but also the causes of actions. Unpicking this is however the task for another day.

Monday, 16 November 2009

making a difference

It is sometimes suggested that there is a perfectly innocuous sense in which an agent's reasons for action can be understood as the causes of her action. A sense which it ought to embarass the anti-causalist about action to not acknowledge and which - if this is all that may be meant by 'cause' in causal accounts - might also give them pause for thought about just what they had been so busy making a fuss about all this time...

That sense is the sense in which a cause is something which 'makes a difference' to what happens or what is done. To whether the action is or is not done.

In what follows I want to risk embarassment by trying to turn the tables on the causalist. What I'll suggest is that, apart from in senses of 'makes a difference to whether something is done' which are not at all intuitively understood as cases of causation, the explanatory function of the proferring of reasons for Jane's actions is not discharged through their citation aiding us in grasping that, were it not for the reason being proffered, Jane would not have done what she did.

Let me acknowledge from the start that people do not tend to act for no reasons. That however is surely part of the conceptual analysis of 'person' and 'agent' and 'action'. So in this most general sense having reasons 'makes a difference to' what we do since, if we are a being who has reasons, then we are also in the runnings for being a being who acts.

Now I don't think that this kind of quite general 'making a difference' is what the causalist who appeals to difference-making can have in mind. In fact it would be better to phrase the actual difference made here in terms of a difference to that we do (that we are agents) rather than to what we do. Here the general having of reasons plays a purely constitutive rather than causal role in the being of actions. It doesn't touch on the issue of the likelihood of any action being undertaken, but rather on the question of whether anything that was undertaken would deserve the epithet of 'action'.

The question remains though: should we understand the role of specific reasons as making a difference to the performing of specific actions? I want to deny that this is the case.

Let's start by pitching the causal account against a hermeneutic account of action explanation. The hermeneut says that reason-explanations work by situating an action in a broader context. The explanatory work is done simply by this situating, which situating allows us to re-describe what was previously not immediately intelligible for what it is in itself as something which is intelligible for what it is in itself.

The situating, as the hermeneut has it, is not a matter of the rendering intelligible of the occurrence of an event in terms of its typical causes. It is not a matter of its origination or servo guidance but of its identity. (Er, and yes of course you can describe something - it's identity - in terms of its causes or effects, but that's not the point here!) The kind of elucidation that a reason-explanation provides is a kind which is to come simply from this identification of the action as what it is.

One of the main ways in which this identity elucidation seems to occur is through the provision of teloi for the actions. John is going across the room to the fridge. "He's getting a can of coke". Ah - that let's me know what this going across the room is: it's a case of going-to-get-a-coke. I can now place John's actions within the 'space of reasons', in Sellars' helpful phrase. The hermeneut's claim is that this placing is all there is to reason-explanation.

(Of course, you have to place it correctly in the space of reasons! One of Davidson's arguments was that you supposedly couldn't distinguish between correct and incorrect such placements in the absence of appeals to causation. Ironic, then, that Davidson himself was unable to provide a straightforward criterion to help us distinguish between cases of supposed wayward causal chains in which reasons which allegedly cause actions do and do not also explain the said actions.)

The causalist however wants to say that there is something more in action explanation by reasons, and that this is a matter of actions not being performed were it not for the reasons in play. John would not have gone to the fridge were it not for the fact that he wanted to get a can of coke. This, it is suggested, is implicit in the very idea of his action being explained by the reason in question.

But is this true? What if, were there not any coke in the fridge, he would instead have gone and got a lemonade from the fridge? It is hard to see why the burden of ruling out this possibility should be placed on the elucidation which cited the coke-getting. (As I write I seem to remember that Bede Rundle has a similar argument in his book Mind in Action.) And this surely generalises to many situations.

Again, it is surely inconceivable that John would have acted thus in the absence of some such reason. But this, I want to say, is not a function of a fact of reasons being causes, but of the fact that John is an agent: a being who acts for reasons. Without reasons we would not here have a case of action or of agency or of a person called John.

Sometimes, of course, people do also act for no reason. These are surely the exceptions rather than the rules of action undertaking. Their existence is not a prima facie challenge for either the causalist or the hermeneut, since their accounts are of how we are to understand the ways in which actions are explained by reasons when they are so explained. However it is part of the causalist's account of action that a particular action would not have occurred were it not for the actual reason for it's being performed being unavailable. What they must therefore explain is how it is possible for people to act, on occasion, for no reason.

The hermeneut claims that when people do act for reasons, as they normally do, and as is constitutive of the basic idea of action itself, their action is not guided or caused by their reasons. These reasons rather provide us with extra information about the intrinsic character of the action. It is an action aimed at a certain end, or expressive of a certain desire, for example. James is playing the piano. Why? He's practicing for his forthcoming concert. Neither the practicing nor the forthcoming concert cause the playing. Nor, according to the hermeneut, do we need to think of James' intentions or desires as causing the playing. They, too, simply further characterise it.

James may very well not have been playing the piano if he had not had to practice for the forthcoming conference. (Let's imagine he just is a lazy fellow. Then on the other hand, perhaps he is not, and would have been playing it anyway.) Again, this is because James is an intentional agent. It is part of his nature to be an agent, which is to say, act for reasons. To gloss this in terms of 'something which makes a difference to what he does is' to mistake a constituting for a propitiating contribution.

I hope these considerations will make clear why it is not ok for the causalist to simply say 'But are you seriously saying that having such and such a reason made no difference to whether or not such and such an action was undertaken?' Once again, the argument is that people are beings the essential nature of which is to 'act for reasons'; that action itself is generally, as a rule, undertaken for reasons. So of course it is unlikely that, in the absence of the reason, we would have the action in question. It is possible, of course, as an exception to the rule, but unlikely. But the point is here that we do have to do with a rule, and not to do with a cause.

I hope they also show that it wouldn't be ok for the causalist at this stage to appeal to analogies of redescriptions which reference causes. Of course such redescriptions occur (think of explanations of the character of car parts in terms of their functional roles).
But that is part of an appeal to explicate what it might be for a reason to be a cause, rather than part of an argument which shows why we should think of them as causes. The hermeneut is not claiming that we have no causal analogies which, if the causal claim was required in the first place, could not then be appealed to. They were arguing instead that the context-placing, intelligibility-enhancing-through-character-revelation, nature of reasons is all there is to their explanatory power, and that this does not need to be augmented by considerations of causation.

To return to James, at the general level his having reasons makes a difference to that, and not what, he does (ie that he is a do-er). At the specific level of an individual action it makes a difference to what and not that he does (acts).

Consider what I want to suggest is a comparable non-reason-providing explanation which also works by context situation (Julia Tanney has comparable examples in her nice piece Reasons as non-causal context-placing explanations.) I see a fragment of text on a piece of paper on the pavement; 'toes' and 'cumber' it says. How can I understand it? Well, it's a fragment of a shopping list. The shopper was reminding himself to buy tomatoes and a cucumber.

The full words do not cause in the sense of makes a difference to the occurrence of the part words, or in any other sense of cause. To be sure, it is unlikely that someone would have written the part words if they had not been writing these full words, but not impossible. (Perhaps they were writing a holiday memo about being encumbered by mosquitoes.) But this is not because the full words 'bring about' the part words. Neither does mention of teloi, reasons, desires, intentions, or beliefs discharge its explanatory duty through the identification of something which brings about something else. In recharacterising the action, the talk of intentions etc. does not serve to reference anything at all other than the action itself in all its glory.


postscript on the logical connection argument

The Wittgensteinian claims that one way to distinguish reasons from causes is through the fact that the relata in a reason explanation of an action are not 'distinct existences' whereas the relata of a causal explanation of a happening are necessarily 'distinct existences'.

It is sometimes objected to this that a) we can explain what something is in terms of its causes or effects, and b) we can say that 'the cause of A caused A', that this is a causal explanation, and therefore non-distinct existences can be invoked in causal explanations.

Against these: a) yes we can. But we cannot then merely invoke this concept in a causal explanation. If a carburettor is (I have no idea what it is but let's say:) just that which mixes the air and fuel in a car, and you say to me: what causes the air and fuel to mix? and I say 'the carburettor', I think it pretty clear that I have not just provided a causal explanation. This is even clearer in b): to say that the cause of A caused A is not to explain how A came about. It is just to reiterate that it did come about without magic!

Further, we may (perhaps) be able to think of descriptions under which non-distinct existences can be considered distinct, or in which distinct existences can be considered non-distinct (as above with A). But the relevant concern is the 'descriptions' which must feature in the explanations of the action or event. If explanation of action is causal explanation, then it must be that the action and the explanans are distinct existences. This is what the hermeneut denies. An intention is related to doing X through its being an intention to do X; the connection is constititutive and ergo not causal.

Saturday, 31 October 2009

why reasons aren't causes

Donald Davidson gave us a reason for thinking that reasons had to be causes. Julia Tanney killed off his argument - but reports of its death have been greatly played down. I want to start to put this right, and also to challenge a successor argument by Bill Child.

Davidson starts by acknowledging that the rationalising force of reason-giving - coming to understand something by developing a grasp of how it makes sense - is not to be simply conflated with causal explanation. However what he tells us is that by reflecting on certain examples we can see how the rationalising force of reasons is not enough to explain their explanatory potency. This leads him to the prima facie implausible idea that a reason explanation (I turned on the tap so I could water the geraniums) is, despite its univocary appearance, actually an amalgam of both rationalising and causal powers.

What are these examples? They are cases in which someone might have two (or more) reasons for doing an action, but nevertheless act for only one of them. What is it that makes it the case that the one reason eventuates in an action but the other does not? Causation, Davidson says, is the glue that binds the reason (or the reason's representation in the actor's mind - or the 'primary [set of beliefs and desires] reason' of the agent) to the action.

Julia TanneyDavidson, however, has made a mistake that we need more than rationalisation here. Let us start by acknowledging (as Davidson himself would) that we may act for more than one reason. Given this, if someone does indeed have two reasons for performing an action, the best question to ask (Tanney suggests - if I remember rightly a paper I read about 8 years ago!) is not 'What binds the 'operative' reason to the action?' but 'What renders the other reason inoperative?' When we ask this latter question, what we find is that the latter (inoperative) reason must have been rationally trumped by another goal of the agent. Far from needing an extra ingredient - causality - to hitch operative reasons to actions, what we really need is just a deeper understanding of the justificatory play of reasons.

George wants to go for a walk. Two reasons can be offered, both of which index genuine desires of his. First, he hopes to bump into Georgina who he fancies. Second, he could do with getting a bit fitter. George goes for a walk, and we discern that the only reason for which he acts is his hope that he may have an encounter with Georgina. How do we understand this? By positing causal glue between the fancying and the walking? Not at all. What we need to understand is why George's action is not in fact justified by all his reasons. Then we find out: George also has an essay to write. This trumps getting fit for him - but it doesn't trump meeting Georgina. And the 'trumping' here occurs in the space of reasons rather than the space of causes. It is the rationality of his action given his actual preferences, now revealed to us, that the reason explanation makes manifest.

Bill Child tried another tack for making the case that reasons be considered causes:
For any putatively non-causal explanation of an event, we can always make the Davidsonian point: knowing this story allows us to fit the event into a pattern which potentially makes sense of it; but we are still left wanting to know why the event actually occurred, what made it happen when it did.
Later on he suggests:
it is wrong to think that the Davidsonian argument depends on the idea that there are cases in which an agent acts for just one of two equally strong reasons. The point of the argument is that we need to understand the 'because' in 'She phi-d because she believed that p'. Suppose there is never a case in which S has two equally good reasons for an action she performs for only one of them. It is still true that the mere fact that S's attitudes made it rational to phi does not by itself explain her actually phi-ing. ... we must appeal to causation in order to understand the metaphysics of the relation between reason and action.

...the understanding we get from seeing that reason explanation is a form of causal explanation is a reflective understanding of the metaphysics of this form of explanation; we understand what sort of explanation it is, and
how reasons explain actions.

...perhaps we can add strength to the intuition by showing how naturally we exploit the idea of causality in thinking of the relation between an agent's attitudes and her actions. For example, one way of producing a result is to produce in someone else a motive for bringing it about; by inducing attitudes in you, I can affect your actions and, through them, the world beyond you. It is hard not to think causally of the whole transaction, and equally hard not to think causally of each of its stages. The first stage is clearly causal; when I induce some motive in you, I am evidently affecting you causally. And it is equally natural to think causally of the relation between your attitudes and your actions. And that, perhaps, may go some way to vindicate the causalist's conception of the
explanandum in action explanation.
Well, perhaps. But the old-fashioned Wittgensteinian anti-causalist is hardly going to be moved by an approach which simply assimilates actions to events (rather than holds out for an analysis both of them, and of their relevant accountings-for, as sui generis in character), which supposes from the start that explanations of actions are interested in accounting for just why they occurred when they did (perhaps reason explanations are not that specific!), which also denies from the start what the Wittgensteinian suggests: that putting an action (which might not best be thought of as an 'event' or happening) in the context of a sense-making pattern precisely provides us with knowledge of why it was undertaken (if not of why it 'occurred'; similarly we wouldn't expect to explain why events are undertaken since it's only actions which are undertaken), and which in the process construes the art of rational persuasion as a matter of the 'production' or 'induction' of attitudes in someone else. (Although the point of the Wittgensteinian's analysis, it ought to be said, was not to issue a fatwa on the use of causal rhetoric in action-intentional context (although for the causalist to use it to vindicate an argument is a bit rich!). It was rather to suggest that a.) assimilating reasons and causes obscures more than it illuminates, and b.) that some of the reasons why we may feel compelled to bother offering causal analyses in the first place have (historically at least had) more to do with the unwarranted assumption of an estranged conception of the relation of (a disembodied) mind and (a deanimated) body in the first place, a relation which then will seem to be in need of causal glue to link together what the analyst has unwittingly sundered.) Further, no-one (so far as I know) has suggested that the mere fact that it would be rational to act for a certain reason makes it the case that someone acts for the reason in question (the reason needs to be theirs).

What then makes it the case that what could be a reason for someone to act is in fact one of the reasons - one of their reasons - for their action? In answer to this question the anti-causalist is typically happy to cite the kinds of factors which the causalist themselves would, if they were not beguiled by estranged and decontextualised conceptions of mindedness and embodiment, presumably also want to cite - such as the agent's ownership of the reason (do they cite it when asked? for example), or the meaningful contextual character of the situation of their action (the arm raising occurred in the context of a bicycle turning manouvre - John raised his arm in order to signal his exit from the main road). All they hold on to is the (alleged) fact that adding causation to the analytic mix is de trop.

This, the anti-causalist will claim, is just what it is to 'understand the 'because' in 'she phi-d because she believed that p''. We receive the kind of illumination we get when we see what the action in question really is: what the smaller fragment which eluded our prior comprehension is a fragment of. (If someone asks: "Well, and why is that illuminating?", then I think I'd just have to say the same about causal explanations: "Why are they illuminating?" The truth is: these just are what amount to two modes of understanding here: we need to understand what it is to 'understand something' in terms of such particular explanatory endeavours, rather than take it that we possess some prior notion of what 'understanding' consists in which can then be wheeled out in questions such as "And why [what do you mean "why"?] does this count as 'understanding'? ) Causal explanations and reason-giving explanations simply are - on the Wittgensteinian position I am recommending - to be considered two separate sui generis forms of explanation, and there's little sense in analysing either in terms of the other. If however what it is to understand a 'because' in either context is to apprehend something more than the differences between these conceptual contexts - for example, to be able to provide a reductive analysis of the concepts bound up in one form of explanation in terms of quite different concepts - then the anti-causalist of a Wittgensteinian bent will simply reject the project ab initio. Why should we even think such an analysis was necessary or desirable?

Wednesday, 28 October 2009

campbell's causal control criteria

John Campbell gave a talk last night at the Oxford Philosophy Faculty. He talked about the nature of causal relationships, with particular focus on psychological causation. Against those who view causation purely 'extensionally' as one might say - as a fact about the relationships between (say) microphysical aspects of the world, relationships which may be very complex and leave quite unsatisfied our demands for straightforward and simple causal understanding - Campbell seemed to tie the nature of causality itself to that which is explained by satisfying causal explanations.

In particular Campbell explored the nature of 'control variables'. The idea here is that we can rightly claim to have identified the cause of something (e.g. what causes the volume of a radio to increase is the volume knob being turned) when the explanans stands in the relationship of a 'control variable' to the explanandum. I don't recall all of the characteristics of these 'variables', but they include the notion that there should be no gratutitous redundancy, a total mapping of causes onto effects, a dose response, and a ready computability of the cause, etc., in bona fide causal explanations.

Upshots of Campbell's view include the idea that there can, even in a 'deterministic physical universe' be non-physical (i.e. psychological) causation (since the best explanation of most human behaviour is psychological rather than physical: psychological factors behave more like control variables for behaviour than do microphysical brain states). This, to say the least, challenges in a very interesting way some of the presuppositions of mainstream physicalist philosophy.

An obvious worry - that was reflected in at least two of the questions (I had to leave after a few of these) - with Campbell's position is its apparent 'anthropocentrism'. One way to put this worry is to say: Campbell seems to be trying to derive a metaphysical conclusion about the nature of causation itself from explanatory considerations - about what we (humans) find explanatorily satisfying. This is a move which many hard-nosed metaphysically-minded sorts will want to resist.

Despite the worry, I find myself attracted to Campbell's position - mainly because of the easygoing, unpretentious way it pricks the side of the 'oh-we're-so-hard-nosed-and-scientific' contemporary physicalist philosopher of mind. And so I naturally wonder what a good defense of what may appear to be its anthropocentric bias might be.

I found myself thinking of the ways in which Wittgensteinian conceptions of the relation of meaning to use, or of the nature of the will, or of the relation of perception to its objects, have been defended against the objections to them lodged by Grice et al. The Wittgensteinian attempts to draw conclusions about what is intelligible - conclusions about meaning, what it makes sense to say - from premises about what people would say in various situations. For example, they would say that there are many situations in which we would not describe someone as trying to perform some action (because it's so easy and they just succeed straight off 'without having to try'). This then is used to count against theories of action which suggest that intentional action just is, at a minimum, action which we are trying to do.

The Gricean says: 'Well, just because we wouldn't it doesn't mean it's not true. Perhaps we don't say it because it's just too obvious - it goes without saying - it's already implied in the conversation.' Against this the Wittgensteinian (e.g. Glock in his Wittgenstein Dictionary, p. 389) may claim that it's hardly less obvious to say that John is trying to tie his laces when he struggles and fails than when he effortlessly succeeds. The fact of his trying is in truth far more patent in the former case.

Just as the Gricean seems to want to extend talk of (say) 'trying' to a whole gamut of cases - regardless of whether we would normally find it helpful to locate trying there - to the end of providing us with an objective account of what makes for intentional action, so too the metaphysician seems to want to extend talk of 'causation' to a whole gamut of cases regardless of whether we would normally find it helpful to cite the cited events in explanations, all to the end of providing an account of what makes for the happening of happenings. In both cases they find themselves tempted to say "In restricting your talk of 'trying' or 'cause' to those cases in which talk of causes or of trying is genuinely informative, you are merely demonstrating your anthropocentric bias."

By contrast the Wittgensteinian could reply: "The burden of proof lies not with I but with you. You are assuming that I am being anthropocentric (letting my sense of what counts as a good explanation get in the way of my ontology), but I am claiming that the concept just is like that. You are trying to remove it from the context which gives it its life in the first place. It's not that I'm giving a biased account of what a cause can be. It's that you are giving a misleadingly broad account of causation. A cause isn't to be defined as that which features in a satisfying causal explanation (that would just be circular), but we can look at which explanations are and are not successful in specifying causes to give us a good sense of what a cause is. (After all, as I seem to remember Campbell saying, causes just are that which are cited in causal explanations.) In your desire to secure the objectivity of genuine causality you try to distance it from human concerns, but unwittingly thereby also uproot it from its sense-conferring context of application."

Campbell's homely account of causation, to the extent that I understood it, brought that concept nicely back down to earth for me. That process was also helped by Wittgensteinians such as Anscombe - who talk of the ways in which pushing and pulling and cutting and startling are causal notions which jointly determine what is meant by causality (rather than instantiating some further hidden connecting phenomenon called 'causation'). As a result I find myself less inclined to turn to some special discipline called 'metaphysics' to help me work out what that mysterious causal relationship 'really' consists in. Causation is now even more than ever just one of hundreds or thousands of (albeit abstracted) concepts jostling around our richly elaborated form of life.

Saturday, 12 September 2009

psychotherapy and prostitution

Sometimes it's proposed that psychotherapy is really a form of prostitution. (R D Laing suggested it, for example - as more recently has Rupert Read.) The suggestion, I believe, is usually intended as a criticism of psychotherapy. The force of it derives from the supposedly morally repulsive idea of paying for something - in this case a human relationship - which, just through this very fact of payment, allegedly degrades the character of that - the relationship - which is bought. That 'you can't buy love' is, it could be said in a Wittgensteinian spirit, a 'grammatical' remark about the concept of love. (But then, people don't go to prostitutes for love - they go to them for sex. And they get it.)

In any case, I don't terribly mind being thought of as a prostitute - if that's just what it is to offer psychotherapeutic services. But in fact the comparison seems a little weak to me. For it isn't that one is (impossibly) buying the friendship of the therapist - that is never on the cards. What is rather being bought is a service which, if it goes well, will make possible the establishing, say, of meaningful friendships again - or for the first time - or friendships of a richer quality - by the patient. What is being paid for, then, is a certain kind of relationship of a different order which serves to clear the way for friendships of the usual order.

The good therapist will be boundaried; they will not excuse bad behaviour in the name of psychological distress or trauma. They will 'call' the patient if they act disrespectfully; they will not do them a disservice by letting them 'get away with' dishonourable acts towards the therapist. Yet again, they work to clear a space for regression, they tolerate it to the utmost, they strive to locate the humanity of the patient within or behind his or her hysteria. First regression, then progression anew. Troubles are 'worked through'. Conversations which arouse defensive anxieties and all the difficulties these generate are positively encouraged, made space for. In friendships troubles are shared; therapeutic relationships are designed to (re)establish the embodied conditions of possibility of such sharing.

The patient is an adult who is paying another adult to function in ways akin to a parent. In ways akin to a parent, but also in ways akin to another non-parental adult at the same time. That is the trick of therapy - to pull off both those roles simultaneously. That is what is being paid for. (Perhaps we could even argue that to not pay for therapy would be odd, potentially reducing it to the status of an attentive and oddly asymmetrical adult-adult relationship.)

The sex therapist will sometimes call on the services of a 'surrogate' - i.e. of a person experienced in sex with whom the patient can practice as they develop their confidence in their own sexual performance. Payment here is essential to the meaning of the interaction for the patient. They are buying the surrogate's patience, they are buying their non-intimacy. Unlike the prostitute the surrogate functions as a way-station for someone who is trying to emerge from solitude into an intimacy they find overwhelming. Sexual relationship, and not sexual relationship, at the same time: that is what is being paid for.

I believe it is more accurate to describe my own practice as surrogacy rather than prostitution. The person who visits a prostitute is just getting a quick fix of something to satisfy their immediate desires. I hope I do not function as an emotional palliative for my patients. Sometimes, in fact, the session may be more painful than pleasurable. To function as a therapeutic prostitute would be to engage in giving the patient the temporary illusion of an adult-adult relationship - in other words, to collude with their narcissism - only to leave them just as vulnerable as ever in those real-world encounters from which they will typically shy away. To function as a prostitute would be to try to merely bolster their self-esteem, make them feel better, let them (even despite their better selves) get away with bad behaviour 'because they are paying for it', etc. To function thus is to function anti-therapeutically, and this is the real failure of the 'prostitute' analogy.

To function as a surrogate, however, is to provide something which is explicitly understood as on-the-way to elsewhere - as an inbetween of defence/phantasy and reality, as a stepping stone to real relatedness. That role is not best captured by the literal meaning of 'surrogate' - a mere stand-in for the real-thing, but rather by an appreciation of the surrogate's role in an ongoing, therapeutic, adaptive process.

Thursday, 20 August 2009

psychotherapy and the ethics of acknowledgement

For a talk at the forthcoming 'Fifth R. D. Laing Conference'...

1. In his paper Pat Bracken charts the unwitting suicide of the evidence-based medicine (EBM) paradigm in psychotherapy. Large-scale studies have found evidence that, when we consider the psychotherapy of people judged 'depressed', therapeutic success has far more to do with the putatively 'non-specific' - than with the specific, technical - factors in the therapist-patient relationship. What really matters, that is, are not so much the model-driven 'interventions' of the therapist - 'interventions' which the EBM paradigm has done so much to assess - but rather the quality of the therapeutic relationship, as well as client-specific factors. So: whilst so much of the evidence-based paradigm is concerned with documenting the efficacy of this or that specific intervention, the research as a whole itself shows us that it is not these technical interventions that are doing the majority of the work.

Perhaps I should start by voicing my own perspective on this. I want to note first that the research Pat cites is research on the therapy of patients judged 'depressed'. It is not concerned with patients struggling primarily with circumscribed anxiety difficulties, for example. My own clinical experience is that patients 'with depression' seem to benefit less from an approach in which therapeutic techniques are derived rationally from models of psychopathology than do patients diagnosable with discrete 'anxiety disorders' such as OCD or panic/agoraphobia or various phobias. My own limited experience is that (CBT and mindfulness) techniques can be very useful for a substantial majority of this latter group of patients, especially when they are otherwise secure and intact in their emotional functioning, whereas they seem to add little to a person-centred, dynamically informed, therapeutic stance - a stance characterised by the listening therapist's restrainedly making their own humanity maximally available to the patient - for those who struggle with depression.

In what follows I want to pursue a line of Pat's presentation further, and to consider whether - and if so in what sense - it may not be merely a fact, but a necessity, that good therapy often cannot be reduced to the performing of technically good interventions. I shall prosecute this through first considering the significance of the therapist's ability to recognise the patient's individuality. (The philosophers Raimond Gaita and Cora Diamond will be my philosophical guides in starting to unpack what such recognition and such individuality amount to.)

The patient's individuality is often put forward by psychotherapists as a reason for the inapplicability of therapeutic approaches based on the application to the individual of generalisations derived from research on groups of individuals. I think that such arguments, while (probably, usually) representing attempts to articulate a perfectly apt intuition, often end up making a mistaken empirical point (for the details as to why this point is indeed mistaken, see Gloria Ayob's (2008) Do People Defy Generalizations?: Examining the Case Against Evidence-Based Medicine in Psychiatry in PPP, 15, 2, 167-174). The articulation goes awry because the arguments have often already unwittingly conceded too much to the EBM paradigm - conceded too much through making use of what I shall call 'empirical' rather than 'ethical' conceptions of the patient's individuality and its recognition by the therapist. What this all means will be explained later in my presentation.

2. The standard 'but everyone is unique!' argument against using an EBM approach in psychotherapy goes as follows: "You want me to apply this research-based bit of advice in my clinic. But in my clinic I see a lot of individual cases. As such they have their own unique difficulties and their own unique historical trajectories. Therefore it's meaningless to try and treat this person as an instance of a general type. That misses out what is particular about them - and their psychopathology is inevitably bound up with their particularity. To understand the individual person we must use an idiographic mode of comprehension, to see how they uniquely have been formed, and how they uniquely can be helped. It would be unethical to apply EBM approaches since these are not tailored to the individual, and as such would just not be effective in helping them achieve their own goals."

I will come on to the question of ethics later on. For now I want to note that the argument as presented depends upon a (to-my-mind dubious) empirical premise: People are just too dissimilar to one another in their personalities and in their troubles to warrant the application of general methods. But is this true? And how often is it true? After all, the EBM pundit is not claiming that using their technique for someone who meets a particular diagnosis will always lead to success. What they are claiming is that it will lead to success often enough - let's say, 7.5 out of 10 times. Unless we can claim better success rates for our idiographically derived treatments, then we should just shut up and practice evidence based therapy.

Furthermore, if this really is the argument, then why not just compare a version of therapy designed to tackle particular problems against a version which relies on individual clinical judgement derived purely from particular case formulations? The idea that one would come out tops is a perfectly empirical postulate, and readily testable. What it isn't is something that should just be evident from argument alone - something that can just be said by way of defence of one's own practice, for example, during a conference.

I want to note too that it had better not be the case that idiosyncratically tailored treatments - treatments designed to accommodate this particular individual with his or her particular difficulties and particular history - function just as well as, but no better than, the EBM treatment. If our argument is that the EBM techniques do not attain to the requisite level of specificity to meet the individual needs of the individual client, then it ought to be the case that an individual-case-formulation-based approach should meet those needs better. That is a direct implication of the above argument which treats what it is to be an individual to be an individual case - even if a case of a class which has only a few - perhaps only one - member.

On this 'empirical' approach to the individuality of the patient - this approach which takes the form of individuality which matters to us here to consist in the idiosyncrasy of the patient's history, character, beliefs, etc. - the connection between the ethics of the psychotherapy relationship and the patient's individuality can only be construed as 'external'. What I mean by this is that the only significant reasons why it would be considered morally better to treat the patient 'as an individual' are, on this approach, to be located in the prior framework for, and the posterior upshot of, the therapy.

First the framework: follow your professional code of conduct, be respectful to the patient, do not abuse your power, and treat them as you would treat anyone. This provides a background moral framework against which treatment is to be provided: it isn't itself typically understood as a piece of distinctly clinical advice.

Second the upshot: treat the patient in such a way that their presenting problems will be most speedily and successfully remitted. Here the best analogy would be with medical practice: provide that treatment which has the best chances of success. The therapy is morally good or morally bad depending on how it leaves the patient. A doctor or therapist who practices forms of therapy that don't work, or don't work very well compared to ones which do, is practising in a straightforwardly unethical manner.

I do not wish to criticise either of these moral principles: of course we should be generally humane, and of course we should not provide treatments with less than optimal outcomes. What I wish to say, however, is that this 'professional ethics' reading of the connection between ethics and psychotherapy is banal. It fails to explore the possibility that there is a more intimate connection between therapy and ethics - fails to explore the possibility that it might be illuminating to consider whether there is a sense in which one might meaningfully and truthfully say "therapy is ethics".

There is, I believe, something very convenient about this exclusion of the ethical from the heart of psychotherapy for the practitioner. The convenient implication is that to act ethically all one has to do is to act professionally (follow your professional body's code of conduct, aim for optimal outcomes, and there you are). Therapy itself now becomes all technique - practised in a humane way, of course - and the moral probity of the practitioner becomes a straightforward matter requiring little or no reflection. Knowing that we have met the ethical standards of the code of conduct and the technical standards of the therapy manual is knowledge that is not too hard to come by. (Good therapy, I want to suggest by contrast, constantly has the practitioner calling him or her self into question. Did I really understand, did I really offer acknowledgement, did I really make myself available or take myself out of the way? If anyone thinks such questions can be answered with any confident certainty they have probably just missed the trick about what it is to live an examined life.)

I shan't pursue the following thought in detail here, since I believe it better honours Laing's memory to use a paper at an 'R D Laing conference' to pick up his themes anew than to retrospectively mull over his thought or his person. But - briefly - it strikes me that much of R D Laing's work and thought can be seen as an enacted repudiation of this professionalised approach to the ethics of psychotherapy. (Importantly, Laing also repudiated the idea that therapy consisted in any set of techniques - I shall ***???*** return to this in the final section.) Laing's trickster identity led him to counter the banalising effects of professionalism by acting in deliberately unprofessional ways. This, I believe, served to highlight - for those with ears to hear - what I am arguing is an aspects of the ethics of therapy which professionalised approaches leave untouched: the ethics immanent in the authentic therapeutic encounter itself, an encounter which professionalised approaches tend to render merely humanely and technically managed. For those without such ears, all that was heard in Laing was his unprofessional manner, the GMC investigation, and so on. (This, it seems to me, is the danger of deploying the trickster approach - its failure to save those who most need it - those damned by their own institutionalised banality.) At any rate, in what follows I start to unpack the 'who' of this authentic ethical therapeutic encounter.

Raimond Gaita3. I now wish to outline an account of individuality - I shall call it an 'ethical' account - an account of 'individuality' as an ethical concept - which lies in contrast to the above-described 'empirical' concept of a numerically distinct individual with qualitatively distinct psychological attributes. (It is here that I shall be drawing heavily on the work of the above-mentioned philosophers Cora Diamond and Raimond Gaita.) I shall start by considering philosophical considerations before moving on to consider psychotherapeutic ramifications in section 4.

To rehearse a point made above, what it isn't to be an individual human being, in the (ethical) sense of 'individual' which concerns me here, is to be a particular member of the species homo sapiens, nor is it to have empirical characteristics which serve to distinguish one from one's conspecifics. Neither my numerical identity (I am this singular person here, not you, that one over there) nor my biological or psychological qualities (I have such-and-such skeletal or postural attributes, such-and-such a profile of neuroticism or extraversion, an IQ of 80 or 130, weak or strong ego boundaries, a poor self-image, this or that profile on the BADS or WIMS or TAT or Rorschach, these beliefs and those desires, etc.) constitute my individuality. But what then is it to be an individual in the ethical sense? What is it that we recognise when we show recognition of someone's essential individuality, and what is it to recognise this?

One unhelpful way to answer this question is to search for objective facts about people which constitute their individuality and which warrant our ethical recognition of one another. This is not to say that certain facts about us do not condition our practice of acknowledging individuality. Take the living bodies and faces of others, physiognomies capable of embodying character, faces capable of expressing emotion, faces which can show moral as well as physical wounds - - without these we should struggle to ethically encounter one another. (We struggle to show instinctive solicitude for those creatures which least embody the human form.) A certain unity of experience and memory - both autobiographical factual memory, and the 'memory' of sedimented habits of motion and emotion - provide some foothold for our ethical appreciation of one another. Yet there would seem to be nothing in such objective facts about us that compels us, in the way in which a demonstration of right- or wrong-headedness would wish us to be compelled, to offer one another recognition. (That, perhaps, is why ethical recognition is offered - it neither consists in, nor rests upon, our exercise of extra-ethical cognitive skill.)

Philosophers have tried various idioms for articulating our ethical individuality. For Kant it was an essential part of a viable (i.e. non-consequentialist) ethics that we treat one another as ends in ourselves, and not merely as means to ends. "Act in such a way", he said, "that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end." To recognise another's individuality, then, is not so much to become acquainted with some fact about them, but rather to act towards them in a particular way - to treat them not merely as means to ends, but as ends in themselves.

Gaita tells us that to see someone as an individual is, in part, to see them as an intelligible object of someone's love. We may not be able to love them ourselves (perhaps they have terribly hurt someone we do love), but we must at least, if we are to be able to acknowledge their individuality, be able to see them as lovable by someone. Gaita also draws out internal relations between the concepts of an ethical individual and friendship; to see a man as an individual:
he must be seen as someone who is subject to the demands which are internal to friendship, as someone of whom it is intelligible to require that he rise to those demands, no matter how often he actually fails to do so. That is compatible with him being such a nasty fellow that nobody could befriend him, for it is to see his nastiness from the critical standpoint of what is required for friendship. He is not like a bad-tempered dog.
Our offering recognition to one another shows itself in a range of further facts such as (those noted by Diamond:) that we give our children names and not numbers, and that we have respect for people, and treat them in a particular way, even when they are dead. It may also be brought out in talk of the moral preciousness of any individual's life, or of the essential irreplaceableness of any true person. By 'preciousness' here I mean the 'infinite preciousness' of a person - the fact that their worth is necessarily immeasureable. Individuality is reflected in the fact that if I wrong you, then what I feel remorse for, if I do, is not that I have broken some general moral rule, nor that I have decreased the stock of happiness in the world, but rather that I have hurt this particular person - you. Similarly with grief: a mother who grieves the loss of one of her four children may have grieved equally deeply if she lost any of the others. Nevertheless, in this instance, it is precisely for this particular child that she grieves - she does not grieve for her loss, but for this child. (Such examples bring out the meaning of Kant's above-cited categorical imperative far better, it seems to me, than any abstract formulation regarding 'ends' and 'means'.)

Ilham Dilman memorialThere is a further feature of our individuality to which I wish to draw our attention. This is reflected in the necessary limitations of the scope of psychological discourse, and has been expressed most cogently by the philosopher Ilham Dilman. If I am treating someone as an individual, then I am treating them as someone with an inalienable authority over their own motivations and intentions. This is not to doubt the applicability on occasions of explanations in terms of unconscious motivations or emotions or intentions, and not to doubt that, on occasion, we may be in error regarding our own desires. Nor - I believe - need acknowledging this authority saddle us with implausible theories of mind, such that we start to take it (as an 'epistemic realist' might) to arise either from putative direct introspections of our inner motivations and intentions, or (as a 'constructionist' might) from an alleged constructive power that the act of avowal has to shape the contents of our hearts. (Avowals neither report nor construct - but rather avow! - that which they express.) However it does require us to suspend the hermeneutics of suspicion that would have us see every utterance or action as a function of someone's psychology, and instead to see a good part of them as a function of their person.

To see someone as a person is, I suggest, to see her as somebody who, at least in part, or at least potentially, has her sight set on the true and her heart aligned to the good. To see someone as a person is to see their thought and action as (to redeploy some of Donald Davidson's terminology) potentially 'regulated by the constitutive ideals' of the good and the true. Hearts and minds may be corrupted, but what it is to have a mind or a heart is to be someone who seeks out the true or the good. To be able to offer someone recognition is to be able to hear what they say as a sincere expression of what here they have to say - as a sincere expression of their thoughts and feelings. Acknowledging their individuality is, then, acknowledging the necessary limit here to explanations of their behaviour which reference unconscious desires and motives.

None of this is to say that, were we to fail in this endeavour, the cause of the failure need be all our own. Perhaps we are confronted with such a despicable psychopath that we cannot - to use Gaita's criterion - discern how to view them as an intelligible object of anyone's friendship or love. Their heart and mind are so perverted and corrupt that we struggle to locate their humanity, struggle to know even how to offer them recognition. The above brief sketch of what it is to offer someone acknowledgement does however lay out the task ahead of us, in any encounter worthy of the designation of 'ethical'. In what follows I shall consider the extent to which a pursuit of the ethical, thus understood, lies at the heart of the therapy relationship.

Carl Rogers4. In his paper, Pat Bracken describes how it is that what the EBM paradigm purports are the 'non-specific' factors have been found,time and time again, to be by far the most significant therapist contributions to therapy for people diagnosed with 'depression'. In what follows I shall suggest that these factors - which are I believe often thought of rather vaguely as something to do with the warmth of the therapist's manner - how friendly they are, for example - can be better understood as reflecting the therapist's capacity to offer ethical recognition to the person who is their patient.

Such a perspective suggests itself in the writings of Carl Rogers, who provided us with a set of ('non-specific') factors concerning the attitude that the effective therapist takes towards his or her patient. In fact he considered these to both be essential elements of any genuine human and humane relationship, and he considered too that the formation of such a relationship was the key to therapeutic success.

The factors Rogers cited were:
  • congruence: ‘It has been found that personal change is facilitated when the psychotherapist is what he is, when in the relationship with his client he is genuine and without “front” or fa├žade, openly being the feelings and attitudes which at that moment are flowing in him.’

  • acceptance / unconditional positive regard: ‘when the therapist is experiencing a warm, positive and acceptant attitude toward what is in the client, this facilitates change. It involves the therapist’s genuine willingness for the client to be whatever feeling is going on in him at that moment – fear, confusion, pain, pride, anger, hatred, love, courage, or awe. … he prizes the client in a total rather than a conditional way. … without reservations, without evaluations.’

  • empathic understanding: this is ‘when the therapist is sensing the feelings and personal meanings which the client is experiencing in each moment, when he can perceive these from “inside”, as they seem to the client, and when he can successfully communicate something of that understanding to his client’
Now there were elements of humanistic psychology at which Laing baulked, and at which I find myself baulking too. (It's version of self-realisation, for example, as well as degenerate versions of empathy (i.e. parroting what the patient says back to them).) But, so long as we do not offer an uncharitably trite interpretation of what 'unconditional positive regard' amounts to, nor demand that it should be present more than the therapist's 'congruence' could allow, then I suspect that there is little that could reasonably be said against these factors as significant elements in what makes therapy therapeutic.

But what I wish to urge here is that these factors are precisely what it means to offer ethical recognition to the patient. In other words, to be in touch with a patient as a unique and 'infinitely precious' individual, to do genuine justice to their individuality, just is to engage with them with the kind of solicitude outlined by Rogers' three factors of empathy, honesty and unconditional acceptance. The unconditionality Rogers mentions, for example, might at its worst be merely a suspension of judgement where judgement is due. This, it could be said, is a way of taking 'unconditionality' as an empirical feature of a therapeutic relationship: I think you're being unreasonable but I prevent myself from saying it. Or I would think that you were being unreasonable were it not for the fact that I've learnt to suppress my own judgements, shut down my own critical faculties, to the supposed - and misguided - end of 'being therapeutic'. But at its best, 'unconditionality' will not represent any such merely empirical function, but rather function transcendentally to constitute whatever it is to acknowledge another's individuality. The question is: can I allow myself to view you under this aspect - under the aspect of a uniquely and infinitely precious human being? Can I find this in you - but more importantly, can I find what allows for this perspective in myself? Can I bring myself to be fully alive and present - to bring myself spontaneously and unguardedly online - in this moment, to offer a recognition of your humanity by means of drawing fully on my own? Offer recognition of what you spontaneously offer me by responding from my own capacity for spontaneity?

Rogers acknowledged that when he put aside all thought and especially all theory, and approached the patient with wholehearted devoted attention, his therapeutic powers were enhanced (. He talked of his 'complete subjectivity', of how he 'let my self go into the immediacy of the relationship where it is my total organism which takes over and is sensitive to the relationship, not simply my consciousness. I am not consciously responding in a planful or analytic way, but simply react ... based on my total organismic sensitivity to th[e] other person. I live the relationship on this basis.'). Martin Buber, reflecting on what it is to meet someone as a 'you' - as another subject rather than as an object, comments that
The relation to the You is unmediated. Nothing conceptual intervenes between I and You. No prior knowledge, and no imagination. And memory itself is changed as it plunges from particularity into wholeness. No purpose intervenes between I and You, no greed and no anticipation. And longing itself is changed as it plunges from the dream into appearance. Every means is an obstacle. Only where all means have disintegrated encounters occur.

Bion put it more pithily: our task, he suggests, is simply to 'listen without memory or desire'. This mode of listening was, for him, a way of affording himself a faith in his own unconscious - in its capacity to respond directly to the unconscious of the patient. By 'unconscious' here Bion meant not a sphere of repressed desire, but rather, and amongst other things, a mode of mental functioning which dares to be playful and associative.

For all three authors, albeit with their different understandings of the work of healing in therapeutic relationships, therapeutic listening involves: listening with one's whole being, attentively, in a manner unmediated by thoughts of case formulation, without deploying special techniques, without explicitly trying to recall what was said before, in the absence of desires to have the patient reach a certain goal. It means meeting the person of the patient in that moment, and meeting them from a point of maximal involvement with them rather than with one's own thoughts.

In characterising the nature of that meeting it is far easier to say what it doesn't involve than to say what it does. I think this is not to psychotherapeutic theory's detriment. When Rogers, for example, tries to be more explicitly positive in his characterisation of therapeutic listening, he tends to risk becoming off-puttingly, humanistically, cloying. Rather than simply having an unconditional regard for our patient, we are invited to have an unconditional positive and warm regard. (This appears to risk contradicting his own emphasis on the significance of 'congruence'.)

By sticking to Bion's 'listening without...' formula we do better. The goals of therapy involve being able to 'relate without...' i.e. to engage with others without using defences. They involve too being able to 'be oneself', which means, again, simply an absence of certain neurotic fears which incline us to the use of contrived self-presentations. Some of the means of therapy - the listening without: trying to be clever, trying to explain, keeping an ear out for the data which will confirm one's theory, theorising what is being said - have a similar logic. In the final section of this talk I shall discuss this logic further, and explore analytically how it resists codification.

5. I started this talk with an appreciation of Pat Bracken's critique of the idea that specific psychological techniques provide the means for treating individuals struggling with depression. Over against such techniques Pat stressed the importance of the non-technical therapeutic relationship. I now want to finish by considering what could be said to someone who wished to attempt to turn the provision of that relationship itself into a technique. I (perhaps inaccurately) recall a passage in a book on Treating Affect Phobia I have that recommends going 'mmm' at certain points in the interview to convey understanding and empathy. That will strike anyone with ears to hear as righteously absurd, but I wish to ask now why this is so. Is it merely because, if we are thinking about what we ought to be doing, then we are less likely to be really listening to them? That is, is the uncodifiability of relationship merely a function of the contingent limitations (in attentional resources) of human psychology? Or is there something more principled at stake here: that the provision of true relationship cannot be codified, as a matter of what it means to enter into such relationship?

This at any rate is what I should like to suggest. In Buber's words, to attempt to codify relatedness would amount to attempting to reduce an I-Thou relationship to an I-It one. (I do not mean to say that one should not engage in both forms of relationship with one's patients, nor that a certain kind of movement back and forth between the two will not be highly productive at times, nor that I-It thinking may sometimes be helpful to clear the way for I-Thou modes of relating which have become thwarted. What I am concerned with here, however, is with the question of whether human relatedness could itself be codified.) I suggest that this is impossible, and this is not because we can't imagine deploying some set of rules which if the therapist deployed them, the patient would feel recognised, but because to deploy such rules is just not to respond to the patient, but instead to respond only to what they say or do. It is not to meet them as a person, but to (somewhat immorally - cf Michael Morris, The Good and the True, p. 116) build an explanatory or predictive model of their behaviour.

Buber writes, in defining what it means to relate as to a Thou: 'The relation to the You is unmediated. Nothing conceptual intervenes between I and You. No prior knowledge, and no imagination.' By 'imagination' here I suggest that Buber means: no imaginative projection of myself into your shoes. When I listen to you qua Thou, I discern straightway what it is like for you to be you - not what it would be like for me if I were in your situation. I do not, that is, first imagine what it would be like to be me were I in your shoes, then ascribe the output of this 'simulation' to you. I stress this here because I do not believe for one moment that Buber meant to deny imagination an essential place in our understanding of one another - only to state that such imagination should not function as a mediating, intervening, step between listening and understanding. To suppose that it would do is just to view you as another instance of a being like myself - and to do this is to fail to respond to your individuality.

Again, the relevance for the present discussion is not the likelihood of any such imaginative simulation-gained understanding being true or false. I may be correct 100% of the time in my making of such sympathetic inferences. Or perhaps I rely instead on 'prior knowledge' of what people in situation Z who report X are likely to feel or think or do or say, and I use this to explain or predict your behaviour with perfect accuracy. Again, I do not believe for one moment that Buber meant to deny our accumulated knowledge and prior experience of humanity a role in our understanding of one another. The point is whether such knowledge is to function as an intervening or mediating factor in my relationship with you when, truly listening to you qua Thou, I hear the meaning of what you say. Rogers' point, to reiterate, was not that listening to someone as if to an It made for poor individualised formulations and hence poor therapeutic interventions. It was rather that listening to someone as to an It made for poor therapy, since good therapy just is in part listening to someone as to a Thou.

Let me follow up this point regarding the relevance of the accumulation of knowledge to the therapist's activity, as a way of concluding, and summarising some of the main themes of, this presentation. In his essay 'Paradox and Platitude' (quoted by Ilham Dilman in his essay Science and Psychology), the philosopher John Wisdom wrote of how

It is, I believe, extremely difficult to breed lions. But there was at one time at the Dublin zoo a keeper by the name of Mr Flood who bred many lion cubs without losing one. Asked the secret of his success, Mr Flood replied 'Understanding lions'. Asked in what consists the understanding of lions, he replied 'Every lion is different'. It is not to be thought that Mr Flood, in seeking to understand an individual lion, did not bring to bear his great experience with other lions. Only he remained free to see each lion for itself.
The same, I believe, can be said of the enterprise of therapy. Of course the therapist brings to bear his or her experience with other people in the encounter with a particular patient. This, however, does not mean that the encounter need be mediated by this knowledge. And if the therapist is offering genuine solicitude to the patient then, I suggest, the encounter cannot be so mediated. The accumulated experience has informed who the therapist is, in their spontaneous engagement with the client, in (to use Winnicott's term) their carrying-on-being and this, I have been suggesting, is precisely what makes possible the carrying-on-being of the patient. To really meet the patient out of who one is, and not from what one knows, is just what I have been calling 'offering them recognition'.

Monday, 10 August 2009

metaphysics 0.101

How is it that metaphysical debates get generated and sustained? Here's my abstract grasp of the essential character of metaphysical thought.

...I'm aware of how ridiculous that sounds, of course. Let's put it more modestly: here's my abstract grasp of the essential character of whatever fits the forthcoming characterisation...

Using the conceptual resources of some particular 'discourse' or 'language game' we can raise empirical questions regarding the viability of some or other judgement regarding an instance of it's subject matter. I say "Katie seems sad", but you question my grounds for saying this, and I come to see that I had jumped to a premature conclusion. In fact she was crying out of relief, ecstacy, or boredom.

But now a certain doubt strikes us - not regarding the viability of some particular judgement, but of the whole discourse in its truth-stating deployments. Not: how do I know I was right about Katie? But rather: how do I know that I am ever right about what people think or feel?

With that kind of sceptical doubt in place, we all too readily find ourselves imagining that we now need to find a way of holding up this language-game against reality. To find some vantage point from which the moves made within the game can be shown - or shown not - to tally in toto with the facts about the thoughts and feelings of others.

This leads us, then, quickly to a position called 'Realism'. Realism wants to tell us that it not only makes sense to talk of particular judgements corresponding to the facts (or not), but also makes sense to discuss whether an entire domain of discourse corresponds to the nature of reality. Not just: is this judgement made using this concept a good one, but: are these concepts themselves good ones - do they 'pick out' (or whatever other dead metaphor you prefer) anything 'real' in 'reality'? (That's right - you also have to be prepared to talk not just about regular things like tables and cats, and how solid or furry they are, but also now about some super-thing called 'reality' which too is thought to have some or other character.)

We struggle with this for a while, and find it hard to occupy any vantage point that doesn't tacitly presuppose, for any affirmative answer, our entitlement to the conceptual resources which are here being sceptically questioned. By accepting the Realist's answer we seem to have unwittingly preserved our ontology (if you like) at the expense of our epistemology. We find ourselves attracted to phrases like 'mind-independent reality' but simultaneously at an anxious epistemic remove from precisely that reality.

So perhaps we oscillate into another position - lets call it 'Constructionism'.

As a Constructionist we find ourselves wanting to reject Realism's epistemic immodesty. Rather than attempt to answer our question by reference to the world, we instead try to answer it by reference to the discourse itself. What I, or what we, say or think determines the answer to the sceptical question. So, there 'really are' cows because we speak of cows. And so on. Language or thought determines the nature of reality. Oh, no, we don't mean to say... er... anything too drastic ... er, transcendental idealism all comes good in the end ... er... Or does it? Haven't we now substituted ontological immodesty (now we're world-makers) for epistemological immodesty (claiming to know stuff that we don't seem to be able to reflectively accommodate within the Realist worldview)?

As I see it, metaphysics is all-too-often the practice of jumping on to this see-saw of Realism and Constructionism, of trying to load the weight all on one side, of hoping that if we manage this well enough we can get it to touch the ground of both our epistemological and our ontological needs. But accept the sceptical question, and the game never ends.

How to dismount the see-saw? Well, we find ways to reject the sceptical question in good faith. For example, we remind ourselves with Ryle that 'existence' is not a generic word, but one tied to the logical space opened up by some particular discourse. From within the sceptical fantasy we imagine ourselves and our language games standing over against some super-thing called 'reality'. But 'reality', 'existence' and the like tend to be philosophical hypostasisations of perfectly good existential terms which have their scope of application individually set by the rules of the diverse language-games which deploy them. Or - another example which takes us away from hypostasising generalisations - we remind ourselves with Wittgenstein of the 'paradigm case' character of deployments of particular terms. So that it just isn't clear what is being asked when someone says, in the vicinity of a ripe tomato, 'Yes, but does 'redness' really exist?' Because to be red is to be just like that tomato, and so on.

So yes, we use such particularising examples to help to free us from the metaphysical impulse. We also develop, perhaps this time with Austin, a less tinny ear when it comes to spotting the philosopher's (the philosopher-inside-us's) decontextualised (and thereby de-meaning-alised) uses of terms such as 'reality' and 'appearance'. With Wittgenstein we 'bring words back to their everyday use'. But more than this, we need to keep a handle too on our diagnostic formulations. We have an account of how the sceptic has unwittingly alienated themselves from the world, or from the mentality of others, before they even ask their question, and of how their question bears the logical traces of this alienation, an alienation which is now inscribed in the question's every iteration.

I would like to add one further suggestion, this time lifted from psychoanalysis. It might be thought that neurotic defences are typically and for-the-most-part deployed against the real anxieties that confront us in the midst of our lives - managing our relationships, illness, injury, death, work, etc. And as a result we inhabit a phantasy land in which the mind tries to narcisistically ground itself within itself - to (impossibly) be an other to itself, rather than rely on the vicissitudes of the availability of the love of others, or of meaningful employment. To generate a phantasy object which then gets treated like a real object (compare what Wittgenstein's private linguist tries to do - how he tries to get real normativity out of imagined normativity) within the mind, which can now stand (it is fruitlessly imagined) as something to which the mind can be in relation - something which can ground its representations.

Well, that may sometimes be true. Life is hard. But what makes it much harder, what continually inspires the need for the further deployment of defences, is not so much - I believe - the original pains and fears of life. Rather it is the ongoing oscillation of the defence/anxiety cycle. For the phantasy objects that are narcissistically installed as if genuine others to thought are always threatening to reveal themselves in their fantasy status. And by inhabiting the domain of phantasy we become further estranged from whatever sources of love, reality contact, engaged work, there are in our lives. The defences, in other words, generate further anxiety. The cure becomes a poison.

The same, I believe, obtains in the metaphysical context. What sustains, and sometimes makes increasingly desperate, the metaphysical impulse is, I believe, the vicious cycle of metaphysics and scepticism itself. Once caught up within it, and responding to the needs of the sceptical questions, we find it hard to put it down. That would seem, from within the ambit of this metaphysical vortex, to amount to a capitulation to scepticism and a loss of the world.

In setting aside the metaphysical impulse, however, it is precisely the world that we find. (This, I believe, was what Wittgenstein was on about when he talked about looking for that which would enable him to give up 'philosophy' - i.e. not an expression of an anti-reflective impulse, but an expression of a desire to in good faith lay to rest his sojourns into the phantasy world of sceptical questions and metaphysical answers in endless symbiotic hock to one another.) Or to put it better - what we find are the diverse particulars that show up in the diverse byways of our days. To acknowledge that we need and can do nothing, cognitively, to hold on to these - that we cannot earn our worlds but must accept them as gifts, as instances of grace - now that is the real challenge. Can I tolerate relinquishing the phantasy that I could sustain myself if my world is taken from me?