Tuesday, 24 August 2010

OC and OCD

evocative image borrowed with thanks from http://www.addictionrecov.org/paradigm/P_PR_F99/piacentini.htm
Ludwig Wittgenstein
Wittgenstein's On Certainty contains a wealth of references to the 'madness' or 'insanity' or 'dementia' one would have to suffer from in order to not insincerely come out with the kinds of things that otherwise only the philosophical sceptic wants to say. Within the text the appeal is made from an intuitive understanding of what it would be to be 'mad' to an explication of the logic of the non-epistemic foundations of our negotiations (epistemic and otherwise) with others and with our environments. Perhaps that serves well the philosopher's purposes but, from a psychopathologist's point of view, what is more interesting and more illuminating is the tracking of the phenomenological implications in the reverse direction. What, that is, does the account of the character of our 'lived certainties' - which it makes no sense to talk of doubting or believing or justifying (or perhaps even 'knowing') - tell us about the foundations of our sanity? And what, by implication, does it tell us about the primitive location of the deficit in psychosis: a disturbance not in inference making (and in this sense not in rationality), nor in 'mistaken' perception, but rather in our embodied, embedded, (logically, not developmentally, speaking) pre-rational and pre-reflective coping and comportment. (See Rhodes & Gipps (2008) and Gipps & Rhodes (2008 & 2011) for development of this idea.)

In this post, however, I want to start to explore another way in which On Certainty provides rich phenomenological pickings for the psychopathologist. This time my focus is not on psychosis but on obsessive compulsive disorder. Whereas in delusion and psychosis the focus is on what is believed, here the focus will be on what is doubted.

Cognitive models of OCD (see e.g. chapter 9 of Wells' Cognitive Therapy of Anxiety Disorders) would have us believe that the psychopathological action is to be located in the character of the patient's meta-cognitive relationship with their intrusive thoughts. To take a typical example: Mary finds thoughts of her son being run over coming unbidden into her head. She also worries that the having of such thoughts betrays a wish she has, or in some other way may magically bring about the feared outcome. Delighting as they do in reinventing the psychoanalytical wheel, cognitive theorists since Rachman have relabelled 'magical thinking' as 'thought-action fusion'. The relevant confusion in the mind of the OCD patient that 'thought-action fusion' betokens is thought to be a meta-cognitive one:  thoughts are meta-cognitively taken to cause actions or events and/or to signify the likelihood of having actually performed the terrible action which the thought is taken to betoken.

This location of the mental disturbance at a 'meta' level fits well with the 'You're alright Jack' normalising ambitions of the practice of cognitive therapy. "There's nothing wrong with your thoughts themselves - everyone has lots of strange or unpleasant thoughts all the time don't you know. The problem lies only with how you are appraising these thoughts. That's why you think you're going mad, etc. You are taking yourself to be responsible for the having of your thoughts, whereas in fact the mind just likes to churn them out; the only difference between you and someone without OCD is that they don't take much notice of their similar thoughts since they don't assume that they betoken intentions or veridical memories." The cognitive theory is, one might say, almost a direct inversion of the psychoanalytical one - the latter viewing the obsessions as expressions of intolerable and ambivalent wishes which, because of their intolerable nature to the patient, are expeirenced as foreign and intrusive - and because they cannot be assimilated and the ambivalence tolerated, retain such constant anxiogenic power. Whereas the cognitive practitioner tells the young mother 'Of course you don't really want to stab your baby; you are probably only having this intrusive thought because it is the worst thing you can think of and because you are trying not to think of it' ( - like trying not to think about a pink elephant, you're just onto a loser with such attempts at mind-control, especially if you think that there's something intrinsically evil or dangerous about thinking about pink elephants), the psychoanalytic practitioner wants to explore the possibility that it might be quite natural for the young mother to sometimes want to stab her baby, and to pursue the thought that perhaps such anger is better assimilated rather than split off (none of which is to say that she is any more likely than normal to actually stab her baby).

Now I have no wish to bluntly undo the 'you're not mad' message of the cognitive therapist for the OCD patient. (In fact we don't need the normalising theory to achieve this, since it is usually already contained in that which differentiates OCD from psychosis: namely the patient's own insight-ful and at-least-occasional appraisal of their own thoughts - and of their own compulsive rituals which are designed to reassure them and alleviate the anxiety caused by the obsessions - as irrational. 'I am performing this compulsion mainly to reduce my anxiety, regardless of whether the obsession is actually true'.) Therapeutically, however, normalising can come at quite a cost - when it tacitly indicates an unwillingness in the clinician to tolerate and contain the 'mad' parts of the patient. But, therapy aside, it is the viability of the psychopathological theory which concerns me here.

Here are the questions I wish to ask: 1) Is it the case that the patient with obsessive rumination is best understood as having normal first-order thoughts which are being meta-appraised in an irrational way through the lens of a hyper-responsible attitude? Or is it the case that what we have are rather first-order thoughts which, as part of their very own form, encourage an elision of the distinction between the real and the imagined? What could help us decide between these two formulations? 2) Further, if we opt for the latter, what are the key characteristics of the obsessional mind?

Shortly I will draw on Wittgenstein's On Certainty to describe what I take to be (2) some of the key features of obsessionality. But to consider questions (1) first: It is certainly true that the patient is able, in the clinic, at calmer times, to occupy a meta-perspective on their own thoughts - to see that they are being irrational when they are caught up in their anxious rumination and compulsion. Yet, at the time, what seems rather to characterise the obsessional struggle is not so much a being-pulled-between two opposed meta-attitudes (one saying: thoughts are causally inert; the other saying: I am now responsible if what I think happens) to first-order thoughts, but rather amounts to a being-pulled-between a) ordinary propositional attitudes and b) structurally degraded propositional attitudes.

Children sometimes show a form of thought which, especially if it became prevalent in adulthood, would be deemed obsessive-compulsive in character. The idea of the possibility of magic (action at a distance, mind reading, etc.) has not yet been fully overcome; the distinction between what is 'inside' and what is 'outside' the mind has not fully taken form. And this failure occurs in particular when the child is anxious - anxiety destabilising the intentional field (the field within which thought separates off from the world into a domain which can then be said to represent facts which are other than it itself). It can take the reassuring presence of the mind of another to allow the child to gain that composure required for going-on-being in the face of anxiety which otherwise overwhelms and undermines the very possibility of (the essential intentionality of) true thought. (By 'intentionality' I mean: thought's directedness at a world independent of it.)

And, to recap, my thought is here that what the anxiety makes for is not the presence of false meta-cognitive appraisals of first-order thoughts, but rather of structurally degraded first-order thoughts themselves. The child is going into a kind of altered state in which their thought itself is falling apart, failing to cling on to that separation from its objects which gives it the right to its title of 'thought'. In this magical thinking state, which is (more) aptly (than the cognitive theorist realises) called 'thought-action fusion' (since the thought is no longer comprehending itself as such), the child gains (in phantasy!) the ability to magically mend mind-splitting terrors, but also, and terrifyingly, a felt vulnerability to the terrors which their imagination, now failing to maintain its separation from reality-oriented thought, presents as if real. In describing this phantasy-ridden magical thinking state we naturally slip into the vocabulary of thought, imagination, understanding, etc., and find ourselves forced, if we are stick with this vocabulary of the 'propositional attitudes', to describe the patient's obsessional thoughts as such - as thoughts - and then to locate the pathology at what could now only be a metacognitive level. Rather, that is, than acknowledging the glimmering quasi-psychotic character of this aspect of the patient's mental function (which is not to say that, unlike the actually psychotic patient, they are unable to take insightful perspectives onto the contents of this mode of functioning, in particular when disengaged from the fearful phantasy state. I will say a bit more below about what makes OCD non-psychotic).

I want to turn now to the other question (2), namely the core characteristics of the obsessional mind and, here, to begin to make use of OC to theorise OCD. The feature I shall focus on is obsessional doubt. An important strand of On Certainty is Wittgenstein's diagnosis of the way the sceptic, in formulating their doubts, 'sublimes the logic of our language'. Doubts, Wittgenstein notes, are necessarily localised matters, arising as they do within the context of this or that enquiry. As such they presuppose a background framework of certainties. To attempt to raise a doubt outside of such a framework, or regarding the very framework, is precisely to obviate the essential preconditions for, well, for intelligible thought (including doubting thought) itself. By comparison we might imagine someone trying to make the car go faster by pushing on the dashboard, or someone trying to use a lever without a fulcrum (or with only a simulacrum of a fulcrum which nevertheless remains of a piece with the lever or with that which is to be levered), or someone trying to pull themselves up by their own bootstraps. The doubting operation takes place in a particular context and requires the doubter to stand firm on general issues before they can raise an intelligible question regarding some specific detail. (Just as the 'private linguist' in the Investigations (mis)takes themselves to be able to generate genuinely normative distinctions (the 'private' intra-subjective definitions) whilst nevertheless remaining within a domain of subjectivity (which, qua subjective domain, is defined precisely through the absence of normativity); they fail therefore to gain the necessary traction for talk of wrong or right uses of a term to mean anything.)

A second feature of doubt and its relation to certainty that receives treatment in OC is the sceptic's tacit misrepresentation of the character of the certainties we everyday enjoy. For the sceptic these are to be treated as propositional in character: beliefs to which we can rightly feel ourselves entitled, which we can readily justify or which are otherwise self-revealing in their ownmost indubitability. Earlier in OC Wittgenstein introduces the idea of a 'framework' or a 'hinge' proposition: propositional beliefs which are the lynchpins of our whole 'enquiry', propositional foundations for our practices of believing and doubting. Later, however, Wittgenstein stresses the more primarily praxical character of such foundations: the certainties I enjoy are certainties in acting. Well-grounded belief gives out in belief that is not grounded (OC253), which requires no grounds, but which also is not obviously propositional in character. I am certain of what will happen next, of the solidity of the ground under my foot, of the progression of the day into night, that the waves will continue to lap against the shore, that my mind will continue to function, that I will not forget how to speak, that I will be able to understand what people say to me enough of the time. And these certainties consist neither in beliefs which have an actual propositional articulation, nor are derived from their potential propositional articulability, but consists rather in the lived animal dispositional praxical retentive protentive habitual visceral character of my going-on-being.

And how to theorise OCD in such terms? Well, first we note that the person with OCD has some degree of weakness within particular aspects of their praxical bedrock of lived certainty. This I believe, admittedly without compelling research grounds for doing so, often stems from an insecure attachment relationship in childhood, sometimes along with over-protective forms of parenting. (The point being that the child does not internalise enough certainty that the world and their mind will continue to function as anticipated, and that they will be able to cope with such variation as there is.) This weakness is not as radical as in psychosis, and certainly does not prompt the reorganisation of the substructure of the intentional field that we find in the neurological systems of persons, systems which solve for foundational anxieties by radically restructuring the structure of the world. Furthermore, the diathesis often remains largely unactivated due to absence of significant stressors.

Second, when the diathesis is activated, the obsessional person is disposed to use reason to attempt to solve for their uncertainty. They try to find reasons for believing in the health of their body and mind. They attempt to justify to themselves their actions. They attempt to check, verify, double-check, prove, logically ascertain their veracity in their belief that their doubts are unfounded. Yet, whilst temporary relief may be obtained by such methods, the underlying pre-reflective doubt - in particular, the diathesis - remains intact. Once it has been unhelpfully raised to the level of a reflective question, the way it invites its own repose is by means of attempts at reflective answering. And these may indeed settle the question for a time. But because the foundations of our certainty are pre-epistemic, not themselves well-founded (or ill-founded, for that matter - but rather, non-founded and in principle not intelligibly founded at all), the questions which arise regarding their validity can only really be silenced rather than answered. Sometimes the entire charade of question and answer will bubble up and settle down, anxious certainty replacing anxious doubt for a while, until the next tranche of worries rises to the surface. Wittgenstein's text helps us understand why obsessional strategies of resolving obsessional doubt are doomed to failure. Once doubt has arisen at bedrock and cracked it, it will not help us to attempt to dig below bedrock in order to found it: the digging exercise will, in the end, only unseat us further.

What does this imply about the therapy of OCD? Well, first that CBT therapy is on the right lines, despite the inadequacy of its theory. For what it encourages in its behavioural component is an exposure and extinction (through response-prevention) attitude to obsessional anxieties - and it explicitly proscribes reassurance provision. And second - if my aetiological speculations are right - that the therapeutic action will take place at the pre-reflective level, whereby the therapist provides, in and through the manner of their own comportment in relation to the patient's worry, a reassuring pre-reflective sense that going-on-being is possible, that the world and the mind are enduring and stable enough to be born, that they will survive.

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On Certainty
246. "Here I have arrived at a foundation of all my beliefs." "This position I will hold!" But isn't that, precisely, only because I am completely convinced of it? - What is 'being completely convinced' like?


247. What would it be like to doubt now whether I have two hands? Why can't I imagine it at all? What would I believe if I didn't believe that? So far I have no system at all within which this doubt might exist.

248. I have arrived at the rock bottom of my convictions. And one might almost say that these foundation-walls are carried by the whole house.

249. One gives oneself a false picture of doubt.

250. My having two hands is, in normal circumstances, as certain as anything that I could produce in evidence for it. That is why I am not in a position to take the sight of my hand as evidence for it.

251. Doesn't this mean: I shall proceed according to this belief unconditionally, and not let anything confuse me?

252. But it isn't just that I believe in this way that I have two hands, but that every reasonable person does.

253. At the foundation of well-founded belief lies belief that is not founded.

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Postscript.

I notice another nice parallel reverse use of Wittgenstein's intuitive reaching towards psychopathological forms of life to explicate philosophical points in 433 of the Philosophical Investigations:

When we give an order, it can look as if the ultimate thing sought by the order has to remain unexpressed, as there is always a gulf between an order and its execution. Say I want someone to make a particular movement, say to raise his arm. To make it quite clear, I do the movement. This picture seems quite unambiguous until we ask: how does he know that he is to make that movement? How does he know at all what use he is to make of the signs I give him, whatever they are? Perhaps I shall now try to supplement the order by means of further signs, by pointing from myself to him, making encouraging gestures, etc. Here it looks as if the order were beginning to stammer.
OCD is to thought partly what stammering is to utterance. Embarked on a regress, thought or language splinter and fall apart. The stammerer struggles to speak - instead they are left caught up in trying to speak. They are separated from their own life-with-spoken-language, standing outside of it, trying to instantiate it. How can they once again become linguistic beings?