Friday, 30 January 2009

moral treatment

Pinel unchains his inmatesEarly psychotherapeutic endeavours were known as 'moral treatments', the category of the moral being drawn on primarily to contrast with that of the medical. The French alienist Pinel freed his psychiatric patients from their manacles and recruited helpers who would treat their wards with respect and kindness using a 'traitment moral'.Whilst 'moral', as Pinel uses it, seems to have more to do with the 'psychological' than the 'ethical', the fact remains that treating the patients kindly, with respect, as real people, remained an important part of that admittedly imperfect evolution of the human madhouse into the humane asylum which he helped to institute.

In this post I want to start to think about the relation between the moral and the psychological. It strikes me that many psychotherapeutic endeavours and psychological schemes treat the category of the moral as merely externally related to the therapeutic encounter. Psychological theory and technique can then (it is supposed) be developed and practiced as something intrinsically separate from - even if always necessarily contextualised by - ethical concerns. So, to be a therapist I must of course be a kind and warm-hearted person who abides by the code of ethics and conduct of my professional body. These are, so (what I believe is) the prevalent conception would have it, (merely) essential preliminaries, practical preconditions, for the therapeutic endeavour. But this endeavour can (it is supposed) be theorised in purely psychological terms which, as such, need make no further essential reference to the moral order. The two goals - to be a (morally) good clinician, and to be a (psychologically) good clinician - are two enterprises which accordingly may (allegedly) be thought to merely run in sequence or in parallel. And whilst the former may influence the latter externally (i.e. be a practical precondition for the efficacy of, but not be actually constitutive of, the psychological therapy), the practice of morality is nevertheless typically theorised as external to the therapeutic action.

There are I believe some exceptions to this from what might at first appear some quite unusual quarters. Kleinian theory, for example, and despite some of its occasional darkness, has particularly powerful things to say about the complex and interwoven relationship of moral factors, goodness, love, envy, etc., to psychological functioning and the development of the self. And Rogerian theory and practice, despite some of its occasional naievity, holds to a view of therapeutic endeavour which makes moral authenticity and openness into a primary therapeutic virtue. But on the whole the rule of a separation of the moral and the psychological seems to hold. One thing that strikes me is that (what I believe is) the typical psychological approach seems to view the moral factors as quite easily instantiated. Follow the BPS Code of Conduct - keep confidentiality, show respect, don't bring the profession into disrepute, don't sleep with the client, don't abuse your position of power - and you'll be alright.

The first 'argument' I wish to make is that this appears to be a very simplistic position on what it is and what it takes to morally relate to another. It seems to make out that it is far easier than it really is to be moral. It seems to take a particularly Old Testament, decalogue-ish, view of morality. Don't: murder, be adulterous, forget to pray, lie, slander etc., stick to the rules - and you're doing alright. (I don't mean to slander through absurd simplification the Jewish faith, and am not at all concerned with making a religious point, only with borrowing a certain, probably false yet popular, Christian conception of the relation of New to Old Testaments to make the ethical point at issue.) But the New Testament tells us it's not so simple as obeying principles such as not coveting your neighbour's wife's ass. Love your neighbour as yourself: is that an easy task? Can we even be confident what is to do it, or know when we've done it? Practicing open-heartedness is, instead, a never-ending challenge, whilst not stealing or murdering or sleeping with the patient is hardly such a burden. Christian writers, such as Rowan Williams, make clear how the spiritual life, understood in its moral dimension - as the cultivation of 'un-principled', un-conditional love - is something we have to continually work at, not simply through effortful self-discipline, but through the never-ending practice of openness, prayer, and humility.

So what about, say, respectful listening in the consulting room? Is it really so obvious when we manage to achieve respect? Is it just a matter of, say, not interrupting? Of course not! And what about treating the patient as a person. Is that an easy matter? To really, fully, acknowledge the otherness of an other? To not project one's own values or beliefs onto them? To achieve true humility in our listening? To locate the humanity in the most challenging of their endeavours or attitudes? To practice with integrity, to fully empathically respond to them, to convey to the client our recognition of their personhood - not in an interpretation but in, say, a spontaneous smile?

This kind of morality clearly speaks not to what massive abominations we refrain from doing, nor of or to a set of procedures or codes of conduct as to what is generally befitting of a psychologist. It speaks to what or who we are as human beings. Open-heartedness, genuine kindness, true compassion are character traits we have to work on, constantly, throughout our lives. It's often only when I'm back in touch with my better self that I realise the darkness in which I've been living - both inside and outside the clinic.

So my counter to a contrary temptation to say 'To be a good therapist it's not enough, you know, to be a nice person' is to ask: 'Are you so very sure that you have really appreciated, really tackled in understanding, the sheer amount of un-ending work it takes to manifest moral courage in the consulting room?' 'Are you sure that morality can be tidied away into injunctions and niceness, leaving the field open for a more purely 'technical' endeavour called, for example, psychoanalysis?'

Let me be honest: I think I can, truthfully, imagine a truly not-very-kind cognitive therapist, who in their personal life lacks integrity, nevertheless helping a patient to overcome their social phobia in the course of working their job through, say, both providing them with some knowledge about the maintaining influence of safety behaviours, and also by putting them through the paces of a desensitisation regime. (Computerised CBT also provides a good example, as do self-help books, of therapeutic strategies that lack any obvious moral dimension.) Or a hopelessly immoral psychoanalyst who nevertheless serves as a useful object for me to become conscious of the extent of my own disposition to project and of my typical unconscious assumptions about the way others will or should treat me. And I can imagine too that someone who happens to be nicer than the aforementioned therapists, and who has an equivalent merely technical capacity, will effect better results because they may, say, be just that good bit more approachable.

But it is also clear to me that, whilst the above-mentioned patient may have been freed from his phobia, he will not have achieved any change in who he is as a person. He will not have grown through the encounter; his self will not have changed. He will 'be better' in one sense only - in a quasi-medical sense of symptom-relief or change in underlying non-moral beliefs.

And I do not want to say, either, that the psychotherapist ought to be positioning themselves as a moral guide, or view their patients as wishing primarily to make moral progress. To simply collapse the psychological into the ethical would seem as misguided as trying to separate them out from one another in the manner I've been criticising above. What I am claiming is simply that, to help the patient to become themselves - to achieve some of their inmost potential and, through that self-becoming, to be able to relinquish their defences - it may perhaps be necessary for the therapist to be fully morally engaged in the encounter with the patient and for this moral engagement to be in no way be exhausted by, say, simply not being immoral. Achieving recognition of the other - through the receiving of which the other may now be able to change - is I believe not something we - those of us well educated in the theory and techniques of psychological therapy - can afford to take for granted as a straightforwardly cognitive endeavour. The depths of my own humanity are rarely readily accessible, and plumbing them seems to require a constant invocation of humility which, if I am honest, I frequently find hard to muster.

Friday, 9 January 2009

it's phenomenal

There is an entire discourse in the philosophy of mind which - I come away from discussions feeling - I am just supposed to 'get'. And I don't - don't get it, that is. And I want now to start to articulate some grounds for my particular protest against it. That process - of feeling uneasy and then attempting to explain why - seems to express something essential about philosophical method. The fact that I know in advance that what I say will be unlikely to persuade also seems to speak to something essential about philosophical questions, perplexities, and the personal relationships we have to these. But that's a topic for another day; all I want to register here is that it is a topic worthy of philosophical as well as psychological investigation.

The discourse concerns 'phenomenal properties'. It concerns in particular the idea that it feels a certain way to be in psychological states - in particular, to be in emotional states.

And what I want to say about this is that: It is either a) trivially true in such a trivial way that those who find themselves wanting to assert it, in the face of those who appear to not be doing justice to the facts about experience, would not find they were calling on something which their opponents would not equally accept, or b) the product of a 'picture which holds captive' the person who is asserting it.

a) The trivial sense: It is trivially true that when we experience certain emotions we also feel certain bodily sensations - in our chests, stomachs, heads, arms, etc. No-one denies this. It is also trivially true to say that when I have the emotion of happiness, what I feel is: happy. There is a perfectly ordinary sense, that is, in which to feel an emotion is just to have an emotion. But to this extent I take it that it is obvious that 'feeling' an emotion is not some kind of experiential aspect of the emotion, or some kind of inner registering of it: it just is it. Appealing to feels, on this reading of 'feeling', then, is just to repeat oneself.

b) Now clearly this (second, 'held captive by a picture', claim of mine) is going to be by far the harder point to make, and I can't possibly believe that I'll succeed in convincing the apparent majority. But perhaps there is value even in just articulating a contrary view. (The contrary view has it that, in short, the appearance that there is a use of 'feel an emotion' which exceeds talk of simply 'having an emotion' is an illusion caused by an unacknowledged tacit distortion in the way affect is being theorised.) So here is the kind of discussion that seems to prompt people to want to talk about 'phenomenal properties' or 'inner feels':

i) Someone (like me) says something like: emotions are intentional relations to situations or objects. My feeling a certain way about James is my being in a particular intentional relation to James. For example: When I'm angry with him, I have a whole complex set of dispositions to act and think and react - both physiological and meaningful. My emotional reaction to him is his disclosure to me under a particular aspect. Emotion is not an add-on overlay to an epistemically more fundamental relation to the world: it is one of our fundamental ways of encountering the world and an entry point into our finding it intelligible.

ii) And now my antagonist says: But what about 'consciousness'? What about the 'inner feel' of the emotion? Surely that is essential too to what is involved in feeling angry. In fact, in missing out the inner feel we are missing out the essential feature of the emotion itself - the fact that there is 'something it is like' to be angry.

And so, yes, what do I say now? Well, my main claim is that:

iii) My antagonist is caught up in a fantasy of 'the inner'. They have unwittingly split the living feeling human being into two - an outer dead mechanical relational part of 'mere dispositions' and an inner zone of immanence and subjectivity. Because they have done this, when they hear someone talking of intentional relations and dispositions, it seems to them like the whole 'feel' of the emotion has been missed out. Their unconscious dualism drives them to feel a need to supplement what is felt to them as the affectively lifeless role of corporeal and other relations to disclosed objects with a 'subjective aspect'. This is not the feeling of anger itself - since that is what is being discussed by both sides - so it is the 'feeling of the feeling'. A kind of inner duplication of the emotional relation to the object - an inner relation to the first relation.

iv) A parallel: A mentalistic cognitivist may be inclined to say that when we are speaking intelligently, the intelligence cannot be immanent within the 'mere words'. It must obtain instead in an inner set of cognitive accompaniments - a stream of thought which guides their production. By response I'd want to say: These are no mere words - this is my discourse, the embodied enactment of my intelligent life. I have my being in these words, not behind them. This is me. There is no need for a shadow set of inner words; all that needs to happen is for the mentalistic cognitivist to stop reading my living intelligent engagement with others as some kind of 'merely outer', mechanical or merely physical, upshot of the 'inner action'. "Quit being so alienated from your own life-with-language!" is what I want to say.

v) So, my claim is, if my antagonist could quit their dislocating of the subject, their alienating of us from our own engaged embedded lives - from our affective relations with others in particular - then this idea that we not only have feelings, but feelings of feelings, could just be left behind - as the product of being 'held captive by a picture'. When we leave it behind, in no way do we leave behind 'consciousness itself', the 'heart of affect', the 'feeling of what happens', the 'what-it-is-like-ness' of emotion. We just leave behind an unhelpful dualistic construal of the human being which denies the immanence of intentionality in our actual engaged, embodied, affective lives, and which tacitly estranges us from the ways in which our affects are our relational windows into the lives of others, and not the mere causes or effects or accompaniments of such intentional engagements.

Postscript 27 Feb 2009

The night after I wrote this post originally the radio spread the news regarding a 'blind' man with 'blindsight' who could nevertheless 'find his way around' an obstacle course without using touch or aids. This way of talking invites, and is itself invited by, an understanding of experience as involving, ultimately, a stage of 'perceptual consciousness'. This 'perceptual consciousness' is said to constitute the real deal, and we are even said to have a kind of special self-awareness of this inner experience - an awareness of our own awareness. These 'truths' about consciousness are trotted out in all sorts of semi-philosophical corners, and if you deny them, you may as well be thought to deny that there really are conscious people with feelings and 'inner lives'. But this just seems to be another example of the tacit superimposition of a layer of 'phenomenal experience' between us and the world, or an idea of an experience of which we might or might not have self-conscious awareness. And as John Hyman wrote years ago regarding so-called 'blindsight', what we have is simply a condition in which the various criteria for vision (finding your way around, being able to say what's in front of you, etc.) dissociate. Which is a completely different matter than the idea of us having or not having 'phenomenal subjective experience'. If we insist on having an explanation of blindsight, then some such story will start to seem inevitable. But we need to reflect on whether the very idea that there ought to be some such psychological explanation is not itself a product of the vision of the mind hereby (in this post) being resisted.

Postscript 3 March 2009

The residual question is how to theorise unconscious emotion. For a very natural way of theorising it is by talking of, say, an emotional state with the feeling shorn from it. And that, I have been implicitly claiming, must just be a mistake. I think we can get some purchase on the psychodynamic concept without lapsing into reduplicative fantasies by reconceiving our relation to emotion itself. Rather than thinking of emotions as states that are in us of which we may or may not be aware, we can think of emotions as states that we are (more or less) in (not them in us). When I am unconscious of my emotion, it is so greatly the from-where of my attention, it so greatly constitutes an inflection at my very source, that it hides its contribution to the way the world is unfolding to me. Laplanche and Bollas might be our guides here, though clearly this is a topic requiring much further elaboration and clarification.