Saturday, 6 June 2009

before mind and body ... again

I'd like to start to flesh out, just a little, the idea mooted in a previous post that so-called 'psychosomatic' disturbances may sometimes be a function of a failure of 'mind' and 'body' to co-emerge as they normally would out of a pre-differentiated 'id'.

Why tackle this topic? Well, two sets of reasons - one set theoretical, one clinical. Theoretical reasons first: Several supposedly enlightened perspectives on psychosomatics strike me as ultimately rather hopeless. I'm thinking for example of attempts which depend upon what I find to be one of three rather unpersuasive metaphysical pictures.

The first picture has it that we can unproblematically 'sum' independent contributions from mind and body in some rag-bag 'bio-psycho-socio... model' which uses hyphens to synthesize what our genuinely theoretical imagination baulks at. The second has it that 'minds are really brains' or some other more inclusive portion of the material world - and so simply finds it ultimately unremarkable that 'mind' and 'body' are of a piece with one another. (First unthinkingly entify the mind, then 'identify' it with (part of) the body, is the idea here.) The third has it that the mind and the brain are 'two different sides of the same coin'. Goodness knows what the coin is supposed to be, but the moral anyway is that we can once again dispose of the necessary theoretical work just by reference to 'double aspects'. The truth is however that whilst we perfectly well understand the idea of 'two aspects of the same thing' in other contexts, we don't (I believe) really know what we're talking about when it comes to 'mind and brain'. It's just odd to think of a substance (the brain) as an aspect at all...

When all I've got is the above, I feel that I'd rather just stick with the non-theorised notions of 'conversion' and 'symbolic manifestation', although these too can be cheap tricks when they pretend to an explanatory value they simply can't muster.

Finally, a clinical reason for positing a foundational disturbance in the co-emergence of mind and body at the foundation of certain difficulties: that in encountering people who are struggling with so-called 'psychosomatic' conditions one sometimes finds something so fundamental, profound, outside-of-consciousness in its character, and ultimately baffling, hard-to-think, and hard to engage with, that normal psychological or biological approaches - or any combinations of these - just don't seem to work. The clinician can end up feeling like banging their own head, since the patient's mode of being-in-the-world somehow leaves no room for a mindful or emotional engagement with their difficulties.

Well, to step back a paragraph, I would stick with talk of 'conversion' etc. if that was my only choice. But I do think there's a chance of an alternative - which involves the idea that our experience of ourselves as having either physical or psychological experience is a function of the ongoing enactive structuration through differentiation (here of the mental and the physical) of the bodily source of the intentional field. Not a matter of conversion from mind to body, then, but a matter of a disturbance of the balanced co-emergence of mind and body in the first place.

So, the theoretical claim still sounds fairly mad at the moment, and a little too close to the double aspect theory to boot. What can be done to give it some plausibility and determinacy? First, I want to make it clear that I'm not talking about the body qua physical being mysteriously unfolding from the background id (that would be, like, weird, right?). It is the subject's experience of their bodies on the one hand, and the subject's mindedness on the other, that interests me. (I do think these experiences fold over into the constitution of the lived body, as non-'mentalised' experience becomes sedimented, in the body, in character (bodily habits, frown lines, stoops, a constant quizzical look, etc.) - but that's another issue.)

So for the moment let's just consider bodily and emotional experience. Where the 'of' in 'experience of the body' or 'experience of the emotions' is not to be taken as specifying the intentional object of an experience, but rather the form of the experience itself (bodily, or emotional).

In the posts on self and other I considered whether psychotic forms of identification could be considered as due to a shift in the placement of the 'chiasm' such that the normal existential unfolding of self and world becomes skewed to one side, leading to a hypertrophy or atrophy of the experience of the self (that which is 'inhabited' and so precisely not experienced) or of the other (that which is not inhabited and thus can be genuinely experienced). Here I want to consider whether the same thing may not happen between mind and body, such that there may, in psychosomatic conditions, be a skew in the unfolding of the source of the intentional field such that what normally would find itself taken up into freedom, inhabited as emotional suffering, lived from, becomes instead something of the non-lived body which oppresses the lived body, something one suffers from rather than the suffering.

The notion is familiar from psychoanalysis that the goal of therapy is to help the patient be able to find activity where previously we had but passivity. That is the goal of the interpretation - and it would not be too far stretched to say that, whilst the doctrine is often presented in epistemological terms - as if it were the subject's self-knowledge which is here at stake, the real goal is often a transformation of the self itself, and not merely in its representation. (Rather than it being 'really the case' that we have an emotional feeling disguising itself as a bodily symptom.) We aren't concerned to merely help out patients have a correct perspective on themselves, but to engage more meaningfully with their worlds by increasing their agency, ownership and responsibility for their experience.

So, the idea under play is that our experience of our feelings qua emotions and our experience of our bodies qua patients of their abnormal functioning are constructed as the bodily pole of the intentional field unfolds into mental and bodily experience. In the former we have genuine emotion or thought, and the lived body is in this mode inhabited, pure subject, seen from, and our ongoing emotions or thoughts are the form of this embodiment. In the latter we have a hiatus, an experiencing of one's body which becomes both subject (experiencer) and object (experienced). In the former the lived body suffers, in the latter it is suffered.

It is I believe quite hard to think clearly about whether there is any correct way in which the limits of one's subjectivity, or the limits of the impingement of one's unowned embodiment, should be drawn. We do however have uncodified norms for what amounts to a healthy degree of ownership, and we sometimes feel we know when our patients are experiencing a skew in the existential underpinnings of their agential self - either with the obsessive taking too much responsibility for that which 'really' is just happening to them (in an attempt to make themselves feel less at the mercy of a world which impinges on them, they take on a terrifying amount of responsibility), or with the somatiser taking too little ownership for that which 'really' belongs to their subjecthood.

An example may help. Helen has what to many people would be a traumatic break-up with a partner, and she does not become angry where many of us might. (Furthermore we notice that she is quite alexithymic, and that feelings of anger are experienced by her as quite unbearable whenever they do arise.) Instead she develops a chronically disabling condition which is experienced by her as physical in character. (The doctors don't seem to be able to find anything wrong with her, though, and she ends up with a dustbin diagnosis like CFS.) The idea that her experience is 'all in the mind' rightly infuriates her - she is not imagining her symptoms after all. (A striking feature, I believe, of patients with (what I will continue to misleadingly call) such 'psychosomatic' conditions is that they feel very sure about what is and what isn't psychological - as if their experience itself could be thought to reliably disclose to them its sources. The very idea of a condition being 'psychological' becomes instantly equated with the idea of it being factitious ... which is no less unreasonable than the typical psychological theories of the 'conversion' process.)

Helen experiences as happening to her various physical sensations and disturbances (such as pain, weariness, spasm, paralysis, weakness) which she then describes herself as suffering from. For someone else whose subjectivity was differently constructed (and I'll come back to the word 'constructed' below), these may instead have been constituent components or vehicles of an intentional relation to the ex, where the relation in question is an emotion such as anger or sadness. In the latter case the person would not say 'I feel such and such physical feelings', but rather 'I feel such and such emotions', since they would, as it were, be attending from the physical feelings to their object (the ex). In the former they instead attend from an attenuated body subject to the remainder of their embodiment now experienced as happening to - rather than as constituting - their selfhood.

Finally, a word on 'constructed'. The term is often used to denote a psychological process or the products of one. But here I am not referring to a certain reflectively available understanding or interpretation one may have of oneself. The construction is more existential than psychological - it is the delineation of a transcendental field within which psychological phenomena - emotional and physical experience - can arise. I am unwilling to say that this process does not occur through discourse, nor that it is never a product of interpretation (cf Charles Taylor's conception of humans as self-interpreting animals) - although care would need to be taken over what is meant by 'interpretation' here. What I believe is an unhelpful way of understanding the issue is to posit an undifferentiated experience which then through interpretative acts gets elaborated as either emotional or physical. Nor, I believe, is it helpful to describe us as normally engaged in the business of interpreting our own sensations.

To conclude I want to think about the clinical merits of some such ontological / existential account of 'psychosomatic' conditions. First, we understand the impasse between clinician and patient. Both coming from and presupposing different backgrounds or frameworks of experience, they talk past one another. The clinician may tacitly assume, as it were, the normal placement of the chiasm, and so cannot grasp why the patient cannot understand the connection between their physical experience and their past and present interpersonal situations. The patient cannot understand why their own experience is so often apparently not being respected. Second, we can move beyond potentially unhelpful notions like (the metaphysically inflated) 'psychosomatic conversion' idea, or (the metaphysically deflated) 'mind and body are one' idea (the former pretending to an understanding and referring to a mechanism which remains unknown to it, the latter pretending that the need for understanding can be obviated by a materialistic or dual-aspect metaphysics of dubious coherence). Third, we can begin to grasp how the therapeutic focus must be on the background, on the structuration of the intentional field. Focusing on the symptom may just reinforce the existing background; developing a relationship in which the intentional field - and hence the foundations for the patient's own emotional experience - is mutually structured may be far more helpful. The aim may be, as with delusion, to non-reflectively encourage (i.e. encourage through active spontaneous emotional reinforcement) modes of being-in-the-world within which the symptom will have little place and the preoccupation with the body will simply drop away.