Sunday, 22 February 2009

holding our nerve

Several texts in the 'philosophy of psychopathology' arena invite us to make the following kind of choice:
  • Either we should acknowledge that what appears to be some perfectly natural description of certain psychopathological facts ought to force us to reconsider our prior philosophical belief that the domain which has been affected by the psychopathology had a purely transcendental unity.

  • Or we should stick to our philosophical guns and acknowledge that what appears to be some perfectly natural description of certain psychopathological facts is purely that - a misleading appearance - and that all we have really is a nonsense with no apt articulation.
To give just two examples, we find this kind of forced choice (and a plumping for the second option) in work on delusion and rationality (Davidson must be wrong about the constitutive principle of rationality because delusional beliefs seem to be both irrational and beliefs), or in work on disturbances of self-consciousness (passivity experiences show that what we might have thought was constitutively inalienable - our knowledge of our own minds - is only empirically so. Reflection on the alleged psychopathological facts forces us philosophers to admit of distinctions between the ownership and the agency of thoughts which would not otherwise have occurred to us).

My short objection to this forced choice is that it fails to consider adequately a third alternative:
  • That what we confront in psychopathological conditions (especially psychotic conditions) are phenomena that simultaneously and naturally invite, yet also thwart, the application of certain concepts. That what we are dealing with are necessarily exceptions to a rule, phenomena the psychotic character of which is precisely of a piece with the ways in which our language starts to fall apart in the phenomena's articulation. That the background preconditions for the sensible application of our concepts are what falls apart in psychosis. That what we must however learn to tolerate is a situation in which the most apt characterisation of the phenomenon is also and nevertheless one which aptly fails to make it intelligible - since, being psychotic, it is precisely not intelligible in the way in which non-psychotic phenomena are. And that the aptness of this characterisation is not one which can be demonstrated through the application of criteria but is sui generis - is, possibly, one which draws more on intellectual sensibilities that have their most direct expression in, say, poetics.

Friday, 6 February 2009

cbt ain't so bad after all

I've been fortunate enough to experience, recently, three perspective shifts on CBT (you know, the popular psychotherapeutic, not the sadomasochistic, practice), aided in part by my convincingly CBTish, and even more so convincingly humane and therapeutic, supervisor. The shifts have simultaneously helped me to develop a more apt, and in some ways less literal, understanding of both the theory and practice of CBT, and also brought that understanding closer to a 'one take on just what decent generic psychotherapy is all about' perspective on the very notion of cognitive behavioural therapy.

The first shift concerns the status of 'beliefs' in CBT. It's easy to knock CBT for containing an overly intellectualist psychology - as if it really did hold that all feelings and behaviours - especially those which we see in the clinic - are driven by doxastic states of the belief variety. Doubtless there are some die-hard, signed-up-to-good-old-fashioned-epistemology, CBT pundits out there who really do imagine that the everyday notion of 'belief' or 'idea' is, as it stands, with the kind of cognitive penetrability and intrinsically linguistic criteria for individuation that beliefs typically enjoy, apt for describing the foundations of psychopathology.

But the truth is that CBT beliefs are far more akin to semi-conscious automatic structures of anticipation or expectancy than they are to workaday hypotheses. My supervisor said something like 'beliefs are the kinds of things that, when the client is able to arrive at their articulation, typically provoke tears'. That by itself shows something of the distinctive characteristic of beliefs in CBT. The process of the articulation of a so-called 'belief' is not one of simply identifying that which, through the process of identification, retains the same form. The articulation process is one of itself giving increasing structure and differentiation and consciousness to forms or habits of expectancy that hitherto have lurked in the background, as constraining structures of experience. The foregrounding, in its way, creates rather than simply voices what we normally think of as beliefs. A murky from-where of attention becomes something which now, in its very status as belief, acquires an optionality for the believer.

I have a half-lingering doubt that says: perhaps even what we ordinarily describe as 'beliefs' have much more akin to semi-conscious background structures of embodied anticipation than I am here admitting. In other words, perhaps my prior prejudice against CBT's talk of beliefs was more a function of my own overly intellectualist conception of what genuine belief is, rather than CBT's overly intellectualist conception of the foundations of our emotional lives. But I'll leave this whole 'learning', as Rogers would have said, here for now.

The second perspective shift turns on the mechanism of belief change in cognitive-behavioural therapy. For it seems to me that the typical idea of CBT in the wider academic and clinical circles in which I move is one of a verbal technology of merely or at least primarily rational disputation - as, say, Ellis' REBT is typically and perhaps more correctly viewed. Even the hallowed behavioural experiments in CBT can be described, within and without the discipline, as ways of simply 'testing hypotheses'.

This seems to me to be almost entirely wrong. For the entire point and continued relevance of the 'behavioural' in cognitive behavioural therapy is that the underlying structures of expectancy driving the psychopathology (the 'beliefs') are, by their very nature, far less opaque to active experiential challenge than they are to verbal discussion of however forceful a hue.

The process of much decent CBT seems then, to me, to work something like this: We invite the client to discuss their difficulties and their formative experiences, so far as they understand them. Together with them we reach an admitedly rather intellectual (i.e. cognitive, representational, schematic) understanding of what distortions may obtain in their relations to the world. For example, they automatically expect on the basis of some unfortunate yet unrepresentative experience that, say, men will be dangerous rapists unless precautions are taken against them. The counter-productive or, at least, problematic expectancy-maintaining, character of these precautions is mutually explored. At this stage the alliance with the healthy ego of the patient, and the content of the discussion, allows for an idea of how change might be possible. However the emotional change - the change in affective expectancies - has not often yet occurred. What now does the real work, in terms of changing the shape of the underyling structures of anticipation, is the behavioural activation - the tentative dropping of the safety behaviours - the learning not merely from, but within, experience.

CBT, as I see it, can then best be understood as a kind of cognitively-, and therapeutic-relationship-, stabilised behaviour therapy. Where by 'behaviour therapy' I don't mean some mechanistic, dry and dusty simple-phobia-exposure treatment, but a therapy which involves active immersed experiential change of the sort that allows for learning within experience to take place. (The relevant behaviour might, for example, and admittedly in an extention from mainstream CBT, even be taken to involve trying to drop both internal and external defences to avoided emotions and thoughts to which a greater tolerance would be therapeutic.) This active element is, it seems to me, one of CBT's greatest strengths; rather than run the risk of simply talking about change, or accruing merely intellectual insight, the therapy promotes real experiential transformation through alteration of bodily praxis.

Rather than explore this further, I want to comment on my third 'learning', which involved me in what I now see as an unwarranted devaluation of CBT at the expense of ACT or other third-wave (cognitive) behavioural therapies. ACT tells us that what is most therapeutically effective is often not thought-challenging - i.e. not trying to alter the content of thoughts - but rather the comprehensive distancing from them - i.e. an alteration in our relationship with our thoughts, or an alteration in their form. To engage in questioning thoughts was, I thought, potentially to invite people into arguments with themselves which were, possibly, ultimately counter-therapeutic.

Well, I now suspect that this may be based in part on an oversimplification of the relationship between form and content. Moreover, though, I suspect that it is based on a failure to appreciate how one of the best ways of changing one's relationship with one's automatic thoughts is through questioning their truth. Furthermore, questioning their truth can be a darn sight more therapeutically easy than learning mindfulness techniques! Done sympathetically, and with an encouragement to the person in their sympathetic treatment of themselves, the questioning of the content of a thought which has hitherto been treated as a fact is a great way to turn that thought into a mere hypothesis. From being something which presents itself as a bit of world disclosure, we get something that acknowledges itself as a possibly mistaken take on the world. And that is itself a significant transformation in our relationship with the belief itself.

None of the above three recantations are meant to suggest an acquiescence in, say, modes of therapeutic practice or theory which devalue therapeutic ingredients not explicitly recognised in the above - say, the power of the therapeutic relationship itself. Nor do I wish to condone forms of therapy which seem to fail to appreciate the intrinsic significance of the ethical - of the power and the bloody hard work of offering true recognition to someone else. CBT is doubtless as guilty as many other therapies when it comes to underestimating the value - and the practical difficulty - of the human/e encounter. I also don't mean to condone the therapeutic fundamentalism that obtains in often highly visible sections of the CBT (and, for that matter, psychoanalytical) community. But these are concerns for another day.

Tuesday, 3 February 2009

need projective identification be unconsciously motivated?

There is a commonplace understanding of projection and projective identification according to which it doesn't make sense to think of them as unmotivated. Why project - why even call it 'projection' - when we don't have to do with the functioning of defence mechanisms?

And that's fair enough. I want to suggest, however, both that some - many? - ersatzes of the phenomena referred to in these ways need not be defensively motivated, and also that, even when defences are brought into play, we can understand the basic process on which the defences are working without essential reference to the motivational dynamics themselves.

The significance of this possibility was only brought home to me after I was asked, following a presentation at the Tavistock, whether I didn't think that projective identification always has to be 'active'. I guess I hadn't noticed an implication of my own account - that perhaps 'it' (or rather - the mechanism at play in the cases I was referring to) need not be motivated.

Providing an account of (what I'm going to, albeit confusingly, insist on still calling) projective identification as not intrinsically motivated would bring it into line with, say, the psychoanalytic theory of phantasy and the primary processes. If I understand the matter correctly, such basic mental processes constitute the functioning of the mind, but are best understood as exploited by, rather than created by, the defences for their own purposes.

So here goes:
  • We start with an existential phenomenological conception of selfhood and it's relation to experience. This involves the following key claims:
  • The self boundary arises neither prior to, nor posterior to experience.
  • It arises equiprimordially with experience.
  • In experience we have arising, all together, a self, an object, and an experiential relation between the two.
  • It may be more helpful to speak of 'aspects of the self' rather than 'the self' per se. It is not that the whole person is reborn in every perceptual act.
  • Rather, that, in perception, I am separated off from this or that object - this perceiving aspect of myself is differentiated from this perceived aspect of my lifeworld.
  • And now that this separation has arisen - or better put: equiprimordially with this separation - we have the possibility of a perceptual relation.
  • Better put still: the separation, and the experience, are of a piece with one another.
  • Sometimes there will be disturbances to this separation/perception process.
  • These disturbances may or may not be motivated. We may nevertheless explain, teleologically, why they arise again and again for someone, inscribed into their character and interactions, by reference to the operation of defences.
  • The disturbances involve a failure of adequate separation of subject from object (i.e. a kind of identification occurs). Either the boundary between self and object (the 'chiasm', as Merleau-Ponty describes it) is placed 'too near' the self, or 'too near' the object.
  • If the former, then what would normally belong to the self is experienced as belonging to the object. Part of what would normally be the self now belongs to the object. In these cases we talk about projective identification or (with Bleuler) 'transitivism'.
  • If the latter, then what would normally belong to the object is experienced as belonging to the self. Here we would speak of 'introjective identification'. Identification with the aggressor might be another example. The object is witnessed as not having some of its essential properties - hence talk of psychological 'scotoma'.
  • There is an essential confusion in this discussion which must not be tidied away too quickly. The confusion concerns the possibility of talking, as I have done, of boundaries being placed 'too near the self' or 'too near the object' when we are talking about a disturbance in the very constitution of the self and of the object-as-perceived. It might seem like I want to have my ontological cake and eat it.
  • I think we just have to acknowledge this confusion. The truth is, there is no better way of describing what is happening in projective or introjective identification.
  • We cannot appeal to what is 'really' the case - where, say, a feeling 'really belongs', or what 'really does or does not' belong to the self. For we are talking about the very constitution of feelings themselves.
  • Neither is it apt to talk of, say, feelings as if they may genuinely transmigrate between people.
  • If we are employing an epistemological attitude, we will find ourselves wanting to say the former, misperception, kind of description of the processes. If we are employing an ontological attitude we will find ourselves wanting to say the latter. In practice we will probably wobble unsteadily between the two, sensing the inadequacies of both.
  • But the truth is that projective and introjective identification involve a disturbance in the very preconditions for the intelligible talk of selves and experiences. What remain are selves and experiences manque. We are drawn to use everyday terms to describe processes that could only, ultimately, receive an intelligible elaboration at the subpersonal level of description.
  • We can however note what people are inclined to say and do. We use an extension of our everyday psychological vocabulary, and talk of primitive mental processes of phantasy, although some of the preconditions for the intelligible application of everyday psychological discourse have been abrogated.
  • To return to the principle theme. To be sure, it may often be that (what I am forced to describe for now as) the displacement of the self boundary, the partial identification of aspect of self with aspect of experienced object, arises, is sustained, repeats itself, under the influence of a defense mechanism. Projection is a way of getting rid of parts of the self that are intolerable; introjection can be (as Fairbairn described) a way of getting rids of parts of the object that are intolerable (their apparent cruelty, for example).
  • But the very same instability in ego boundaries may itself arise for purely biological reasons - as part of the essential vulnerabililty in schizophrenia, for example. It arises in conditions of profound sensory deprivation too. The enactive processes whereby the self-boundary is normally maintained cannot operate so smoothly in such disturbed environmental or internal (neurological) conditions.
  • This is not to say that the disturbances in the self-boundary in schizophrenia might well not too have their motivating factors (defensive origins). With a weakened self boundary constitution, there will be all the more opportunity for defences to succeed in, say, ridding the self of intolerable aspects of itself. And so these primitive defences may have more of a chance of succeeding.
  • But this is not to say that disturbances in the constituting processes must only arise under the influence of a defence. To assert that would seem to be simply a prejudice: what could be its justification?
Postscript (18.2.09): It has occurred to me since writing the above that the question about the 'activity' of projective identification might not have referred at all to its being motivated or not. After all, it's a common enough bit of psychoanalytic understanding that projective and introjective processes are part and parcel of the very means of our emotional communication and empathy, and not simply the materials of defensive offloadings from or accretions to the self. Perhaps what was meant instead was simply the idea of a process of movement from pre-projective to post-projective moments - I start off in a non-identificatory relationship with you, and then move into an identificatory (of whichever sort) relationship, and then back again, in a dynamic pattern of fluid engagments. And these movements might have been what the questioner was getting at. Whereas my account is, admittedly, rather static. On reflection, I am attracted to the idea of such movement. What I suspect, now, is that it is the absence of such movement - back and forth between projective and introjective and non-identificatory moments - that makes for the possibility of normal, healthy, object relations, including the normal and healthy constitution of the self boundary. And that what I was describing was simply instances of 'frozen identification' in which the normal healthy dynamic dialectical motility - the fluid dance of merging and separation - has been lost.

Sunday, 1 February 2009

mood

My everyday psychological understandings and clinical practice give me little handle on mood. Yet it is mood which so often radically constrains and inspires those habitual actions that bring people to the clinic.

My psychologist's training certainly helps me think about emotion, and about thought, and about belief. It is through such notions that I formulate and address a client's difficulties together with them.

Lying in the background, however, is mood. And mood constrains the way in which anything, at any time, is understood. It constrains motivation. It shapes belief. It is a kind of total framework within which the whole of my experienced world shows up. It is more general than an emotional feeling.

I am thinking of pervasive states of boredom, agitation, numb neediness. I am thinking too of the kind of state of mind in which an obsessional person performs their compulsions, or of manic excitement. And, to put it simplistically, whilst emotions disclose the self and the other in relation to the self to itself, moods disclose the entire world to us. They are always 'behind' us, the from-where of our attention.

Perhaps there is a sense in which it is true to say that mood is, or can be, repressed emotion. It is what happens when emotions are not able to be felt; they are flipped inside out - and now they have us, rather than us having them. (It is we who are in moods, not vice versa.) Freud, for example, explained feelings of unfamiliarity - which are not simply the absence of feelings of familiarity but have a positive yet baffling content - as due to the repression of something familiar. (Freud, The Uncanny).

In the group I run for people trying to lose weight, it has become apparent that people tend to overeat when they are in a particular mood. It is often a kind of numb and compulsive state, an opaque neediness, a restless oral urge, a boredom. Everyone understands what they have to do to lose weight; everyone very much wants to. But the charioteer of their actions is at these times not their better self, but an uncomprehending mood. A different mood prevails in the group, and the difficulty of transporting the message home consists, in part, in the different mood-states in which good intentions and restless orality find their repose.

In the psychotherapy literature, I am only aware of two methods for tackling mood. The first is the psychoanalyst's interpretative endeavour: trying to condense out a mood into that emotion which has hitherto been 'held from awareness'. The second is Gendlin's focusing, where a mindful and respectful interrogation of the body invites the articulation of the felt sense operative in the self. I am not sure that either are readily applicable procedures in many therapeutic contexts. My challenge to my CBT colleagues is, now, to develop a new therapy of mood.