Friday, 17 June 2011

Review

John Heaton: The Talking Cure: Wittgenstein’s Therapeutic Method for Psychotherapy - Draft of a review for the British Wittgenstein Society

 Wittgenstein, Philosophy, and Psychotherapy

In considering Wittgenstein and psychotherapy in the same breath, our first thoughts naturally go to Wittgenstein’s use of the metaphors of (mental) ‘illness’ and its ‘therapy’ or ‘treatment’ to characterise the intent and manner of his engagement with philosophical questions. The central idea of the analogy is by now clear (thanks to Fann, Cavell, Fischer, Petermann et al.). Unbeknownst to himself the metaphysician is held captive by a ‘picture’ which unconsciously influences and thereby distorts his thinking. He then consciously attempts to articulate the resultant perplexities and doubts into clear questions; the hope is that such perplexities and doubts can be relieved by developing theories and explanations which answer the questions. In doing so, Wittgenstein contends, he is much less like a scientist providing us with global or foundational knowledge, and much more like a neurotic, than he realises.


The obsessional neurotic, for example, struggles to habituate to her underlying anxieties and accept her losses; instead they are deflected by being articulated into obsessional questions or forged into intentions. The underlying anxieties may then be quelled when the questions and intentions are compulsively answered or acted on. But because the questions and intentions do not truthfully articulate the underlying anxiety, the resolution of the anxiety is only temporary and it soon rears its head again. Thus the obsessional often presents to her doctor hoping for a better, more conclusive, answer to her doubts.


So too the epistemologist wants a better, more conclusive, explanation of ‘the mind’s’ relation to the ‘external world’; the ontologist wants a better account of the fundamental nature of ‘reality’; the metaphysician wants to develop a comprehensive theory explaining how mental events ‘cause’ bodily movements. In each case the Wittgensteinian treatment is the same: rather than trying to answer our philosophical questions and develop more secure knowledge, we are to unearth, clarify and undo the underlying deflections. Whether such philosophical deflections are best grasped i) cognitively – as resulting passively from the distorting influence on thought of tacit conceptual metaphors (Fischer), or ii) psychoanalytically or existentially - as actively if unconsciously motivated by a wish to avoid intolerable anxieties (Cavell) – is still a matter of debate. What is shared by all sides, however, is the idea that we do well to direct our interrogation not to philosophical answers but to the philosophical questions themselves.


Considered against the backdrop of this debate, John Heaton has written a surprising book. Rather than enter into the debate, or pursue distinctly philosophical scholarship of any sort, he instead takes back Wittgenstein’s distinctive clarificatory methods for psychotherapy. The form of therapy which results – which is clearly the method Heaton himself espouses – gets called the ‘talking cure’. Along the way he provides what I found to be a fascinating and really rather compelling account of emotional disturbance and the therapeutic resolution provided for it by the ‘talking cure’, and a somewhat uncharitable and less compelling critique of psychoanalysis, cognitive therapy, and psychiatry. I will now consider the therapy and the critique in turn.


The Talking Cure


Heaton’s vision of psychotherapy is modelled on Wittgenstein’s practice, but its value does not consist in its faithfulness to Wittgenstein’s philosophy (how could it?), nor in the evidence gathered for it (for how does one evidence a vision?). It consists rather in its capacity to make clear to the clinician what she already tacitly knows, to open up new insights, and to provide a sometimes radically alternative articulation of the character and goals of therapy, all in a form uncontaminated by pre-existing theories and their over-theorisations of the phenomenological facts of therapeutic interaction, misleading analogies and unhelpful ideologies. If I were to locate him on a pre-existing map I might describe Heaton as an unusually tough-minded, psychodynamically-inflected practitioner of Rogers’ Person Centred Counselling, or as a rather sophisticated exponent of Hobson and Meares’ Conversational Model. The transformative power of an honest and thoughtful encounter between two people is held up as important, rather than the doctor doing something (e.g. applying expert knowledge) to a patient.


But rather than continue to describe Heaton’s therapeutic method in relation to other therapies, or in terms of his fidelity to Wittgenstein’s philosophical method, it will be more instructive here to let it speak for itself; in this way the reader can arrive at her own judgement. Let us first consider Heaton’s characterisation of the nature and origins of psychopathology. In ‘neurosis and psychosis’, he writes, ‘there is an inability to speak of experiences that were traumatic or important but ‘unspoken’ … The victim [accordingly] is … not able to understand the reasons for her unhappiness …’. (ix) Misleading ‘pictures and analogies … hold our thinking in a cramp and stand in the way of our recognising the extraordinariness of the ordinary. The particular pictures that we fix on are rooted in our human way of life and culture, and therefore connected to our desires, fears and aspirations. They may be the expression of a wish to control the seemingly arbitrary world, especially if our childhood experiences were chaotic and unjust.’ (10)


It is part of Heaton’s understanding that the ways clinicians try to explain mental conflict often renders them ‘caught in a confusion whose character is not transparent to us. We are driven by a wish to find an explanation for the conflict, as if that will enable us to cure it. But this search for an answer is also the driving force in the conflict; we need to be liberated from the persistent inclination to seek answers to all questions. It is the conditions in which conflicts emerge, and the confusions which arise, that need attention.’ (10) The following provides an example of the kind of confusion Heaton has in mind. Someone ‘gave an account of his childhood, which was a variant of the ‘wicked stepmother’ theme. When he finished he turned to me and said, ‘ I suppose it was all inviteable’. (146). ‘[W]hen he said ‘inviteable’ truthfulness spoke, in that it showed he was trying to live as if the inevitable could be invited – a confused relationship between freedom and necessity, a compulsive attempt to live a life without suffering. He was saying something that cannot be meaningfully said as he was trying to live something that cannot be lived.’ (148)


This vision of what counts as worth attending to in the clinic entails certain goals for the talking cure. If someone is in ‘the grip of a problem’, what matters in therapy ‘depends on his free acknowledgement … If he does not agree with an elucidation, the appropriate expression has not been found. … This contrasts with much psychotherapy which is addressed to the problem as diagnosed by the therapist rather than the grip of the problem on the individual.’ (56). ‘By revealing themselves to some other person who they trust’, the patient ‘may come to see creative possibilities, differences and similarities they had not seen before. So they may realise that things need not be as they thought they must be, or that things may be as they imagined could not be.’ Elucidating the grip of unconscious pictures, rather than ‘being told what to do, or being interpreted in terms of a theory’ allows the patient to move on ‘spontaneously’ (94). Such elucidation is not to do with correcting mistakes, but with a more fundamental shifting of the way things are seen; it is to do with releasing us from captivity by a picture, rather than replacing one picture with another.


How does this elucidation and freedom to flourish spontaneously proceed? Not by ‘learning new facts, explanations and theories’ but rather through ‘reminders of what we have overlooked’ (ix) and by ‘attending to possibilities’ (209). Pyrrhonian scepticism provides an ideal: ataraxia (peace of mind) is ‘not achieved by cognitive accomplishment, attaining knowledge or insight – but rather by putting down dogmatic beliefs, by ceasing something’ (24). Therapy involves the patient finding their own voice. Free association is used to this end, not (as in psychoanalysis) to allow unconscious determinants come to the fore, but because it breaks up static language use, allows in chance and promotes different ways of seeing (140-1).


The patient’s movement from picture-engendered confusion to authenticity calls for a commensurate ‘response from the therapist… [whose words are] ‘simple, and … ideally spoken without a touch of ill-feeling, contempt, arrogance, bias, frivolity, jargon or word intoxication.’ (31) The therapist is required not just to help us relinquish the grip of pictures, but also to ‘support the [emerging] sense of our own experience. To listen to an expression of despair with a bored, all-knowing expression deprives the words of sense in a person who is unsure of herself. It is the involvement of others in our words that constitutes a condition of their meaningfulness, and which helps to bring order to our confusions.’ (97) The practice of elucidation and the provision of genuine rather than ersatz recognition involves spontaneous action by the therapist ‘and not the application of a theory or technique... Spontaneous action allows the subject to unfold out of itself the richness of meaning.’ (210) The psychotherapy adequate to this task is accordingly ‘a motley of techniques and practices… [using] pictures, analogies, metaphors or humour’ to develop the patient’s thinking (52). The psychotherapist is, unlike (say) the clinical psychologist who styles herself as a ‘scientist practitioner’ applying general scientific knowledge to the particular case, more like the ‘parrhesiastes’ of Ancient Greece: they must possess ‘virtuous knowledge’ – an individual, personal and practical ‘knack for acting’ (15).


In the above I have let Heaton speak for himself regarding his talking cure. As a vision of therapy I found it, as I said, compelling. What is not so clear to me is that it adequately captures the entire ground or field of either extant psychological distress or of apt psychotherapeutic practice. As I understand it, Heaton conceives of his own practice as a better way of doing therapy than that encouraged by cognitive or psychoanalytical approaches. I shall now therefore turn to his critique of these alternative theories and methods, and spell out some of my misgivings.


The Critique of Psychoanalysis and Cognitive Therapy


Throughout his book Heaton contrasts his talking cure with the theories and practices of psychoanalysis and CBT. He takes these therapies to task for their imposing on us: a vision of our mindedness as the possession of an inner realm of mental entities; a conception of neurosis as a quasi-mechanical disturbance in this realm; a version of the discipline of psychopathology as the causal explanation of such inner disturbances; and an account of therapy as theory-driven intervention in the internal world to undo the disturbances generated there. The question that continually recurred for me was whether it is primarily the therapies Heaton criticises which are to be taken to account for their mechanistic and objectified account of our mental life, or whether instead it is Heaton’s reading of the idioms such therapists deploy in their theoretical work which should be taken to account for its literalism.


As I read it, there are two related aspects of Heaton’s work which contribute to its unpersuasiveness as critique. One is its eschewal of the academic methods of philosophical, psychological or literary scholarship ; another is its running together – despite its oft sensitivity to precisely the same distinction – of matters ‘grammatical’ and empirical.


There are several ways in which the non-scholarly nature of Heaton’s text is a bonus rather than a detraction. In particular it makes for a refreshing directness of communication and a greater expressive force. Nevertheless it also means that there is no significant engagement with other attempts to read psychoanalysis and Wittgenstein together – which engagement, had it occurred, may have provided a better balance to his work. Take, for example, Charles Elder’s book The Grammar of the Unconscious, which makes its way into Heaton’s bibliography, but not into his discussion. The merit of Elder’s curiously disjointed book is its determination to read the intension of psychoanalytic discourse out of its extension – its meaning out of its use, as one might say – rather than out of its explicit (and readily criticisable, naturalistic and scientistic) metapsychological self-understandings. At times one may suspect Elder of an overly liberal application of the principle of interpretative charity. Heaton’s reading of psychoanalytic texts, by contrast, reminds one of the tendency of (say) physicalists to read religious or human science texts as if they were to be judged and understood according to the epistemic and semantic standards of the natural or physical sciences – from which such texts may nevertheless metaphorically extrapolate some of their terms.


I will consider this further in the following section, but first wish to document the other difficulty caused by Heaton’s otherwise pleasing scholastic restraint. This is his offering of unsubstantiated opinion, rather than hermeneutically or empirically evidenced argument, regarding the clinical practice (and not simply the theoretical apparatus) of psychoanalysis and of particular psychoanalysts. I will now – hopefully, thereby, avoiding the charge of hypocrisy – illustrate this with a wide range of examples:


Freud ‘did not distinguish the use of language, on a particular occasion, to describe how things are, from the more therapeutic use of clarifying how expressions are being used.’ (p. 1) [We are not given illustrations.] ‘He treated the patient as an evidence-exhibiting body – rather than a speaking human being.’ [No biographical data are provided.] ‘Psychoanalytic interpretations and CBT … are not based on a fixed truth about reality. [The meaning of the philosophical expression ‘fixed truth about reality’ is not explicated.] The analyst is not in a position to observe reality and put it into words without representing it. Although he should strive to be just, he is not neutral. [No detailing of psychoanalytic discussion about what clinical neutrality might and might not amount to is provided.] ’ (p. 10). In psychoanalysis, the ‘patient is instructed to speak freely but the analyst interprets dogmatically according to a rule. [No evidence of this dogmatic practice is provided.] He assumes that any deviation in free associations is caused by unconscious processes in the mind. [Whether analysts actually practice like this – or whether this is just a working assumption regarding material important for the business of psychoanalysis – is not explored.] He ignores the influence of external and physical factors.’ [No evidence is given.] (19).


‘In analytic circles no other self-analysis is authentic if it differs in any significant way from Freud’s ‘discoveries’. It is therefore discouraged. Experts know best.’ [Again, the alleged attitude of un-named psychoanalysts is stated but not evidenced – nor is contrary evidence investigated.] (26). ‘The psychoanalyst has an external relation to her patient. She aims to extract from the individual his inner subjectivity through a particular technique and the subject is supposed to interiorise the norms imposed upon him. … Instead of throwing light on the person’s confusions, it creates theoretical chatter behind their back.’ [We are not told what psychoanalysts would make of this accusation.] The ‘traditional description of speech by analysis breaks it into units that are static, discrete, and context-free. The theory of meaning that underpins psychoanalysis is that these units are combined by a finite set of rules which give structure to our speech.’ [No evidence is given for their being any such underpinning theory of meaning, or for the idea that psychoanalysis even needs a theory of meaning to underpin it.] (45) ‘Much theory in psychotherapy answers questions posed by the theorist rather than the patient. Instead of thinking through the problem together with the patient, the therapist takes the easy way, bypassing the problem by appealing to theories.’ [No evidence is given.] (53).


‘The technical language of psychoanalysis encourages us to believe that we know what we are resistant to, that is, our unconscious sexuality and ‘primitive instincts’. Human vanity and self-deception are not mentioned.’ [Heaton does not investigate what psychoanalysts have to say about narcissism.] (54). Saying ‘to people that they ‘have’ a phobia or depression can cause them to think they have something in them they need to get rid of. It distracts us from the fact that it is they that have become lost, not their mind or brain.’ [The clinical literature on the benefits and the pitfalls of the use of externalisation is not considered.] (139). ‘The not yet expressed is ultimately an expression; however; it is not an object co-existing with the expressed, such as a complex in the unconscious, as Freud’s subjectivist conception of expression would have it. The appeal to the unconscious takes away our responsibility to make sense. It is nihilistic in that it separates freedom from necessity, suffering from living.’ (149) [How this connects with the analytic goal of increasing freedom and responsibility by ‘making the unconscious conscious’ is not considered.] ‘The confusions generated by the picture of the inner world can be illustrated by the Freudian and Kleinian belief that there is a death instinct that is opposed to the life instinct in the inner world … But death is not an entity.’ (170) [Heaton does not give examples of any such curious psychoanalytic texts which presuppose that death is ‘an entity’. The clinical uses of the concept of ‘death drive’ are not discussed, nor is the considerable intra-psychoanalytic controversy regarding the cogency and value of the very idea.]


For this reviewer these hermeneutic deficiencies made for an uncomfortable reading experience. Let me be clear: I sometimes found myself sympathetic to the points of view expressed. Yet the text itself did not show me why I should believe what it claimed, and I found myself thinking that if I had started off with a different point of view I may have become more rather than less reactively entrenched within it by the end of the book.


The Conceptual and the Empirical


Whilst Heaton frequently joins Wittgenstein in urging us to distinguish between the conceptual (or ‘grammatical’) and the empirical orders, a similar conflation seemed to me to crop up when he criticises therapists for not having reflective, conceptual clarity regarding the nature of their and our terms – as if this was a criticism of their theories or practice. That is, he seems to suggest that tacit philosophical beliefs may underpin or underlie (and hence, when the beliefs are confused, undermine) therapeutic practice. Thus the following: ‘differentiating between logical propositions and ordinary empirical ones is vital in psychotherapy but they are often confused. Thus most psychoanalysts and CBT practitioners assume the uniformity of propositions. Their scientism and psychologism lead them to this. Reality as described by science is the only true reality; there is an a priori structure of the world which science describes. The specific features of a person’s language must be reduced to the ‘neutral’ descriptive language of science. Thus expressions of love may be reduced to ‘attachment’, or the sexual instinct, for these lend themselves more easily to empirical explanations.’ (121) And this: ‘The confusion between concepts and objects is endemic to psychoanalysis, CBT and neurosis. Perhaps this is most clearly seen in such notions as that there is an internal world containing internal objects and that thinking occurs in our heads or brain.’ (123).


The alternative suggestion – that psychoanalysts may deploy concepts to perfectly good effect as tools in their clinical work (to organise their intuitions, guide their interventions, and inform their discussions with colleagues), whilst yet often unsurprisingly failing in a separate philosophical task of achieving a second-order clarity in such beliefs as they do have regarding the character of their own concepts – is not pursued.


On this alternative – and what we might reasonably think of as a more faithfully Wittgensteinian – reading, conceptual confusion shows up in clinical theory and practice not when psychoanalysts unwittingly engage in bad philosophy, or use terms which invite the unwary or uninitiated into asking and attempting to answer misguided questions, but rather when in-itself innocent talk about ‘internal objects’ or ‘mental representations’ or ‘transference’ or ‘projection’ gets recruited to pursue explanatory agendas which only find a clear application regarding the objects of the roots of the metaphors (i.e. only regarding actual physical objects, images of such objects, and the movements of the objects or the images). Whether this muddle based on a conflation of the logic of categories takes place in any given instance cannot, I submit, be assessed at a general level but only at the level of a detailed investigation of particular cases. Heaton, however, talks as if the very ideas of a ‘transitional object’ or of ‘transference’ or of ‘projective identification’ or of a ‘mental apparatus’ are impossibly contaminated by conceptual confusion, and his disagreements with psychoanalysis are accordingly pitched at this (arguably far too abstract) level.


For example, Freud is taken to be radically confused as to the nature of mind and of his own (alleged) discoveries because ‘he thought that we only know of the existence of others by inference … But does the mind consist of things and processes that are present to be discovered by inference?’ (28) This leads the way into a series of claims regarding how psychoanalysis ‘conceals human dignity … removing the personal from itself … removes the dignity of self-understanding’ etc. But these (self-understanding, the recovery of dignity, the acknowledgement and growth of the personal sphere), as any examination of a modern textbook of psychoanalytical psychotherapy will reveal, are precisely the goals of psychoanalysis. Just because psychoanalysis deploys a vocabulary, derived by metaphorical extension, of inner objects in causal interactions, need not mean that we have to read the ‘logic’ or ‘grammar’ of this in terms appropriate to the roots of the metaphors. The misreading, to my mind, appears to be Heaton’s, and not (on the whole) that of psychoanalysts.


To exemplify this consider the following: ‘People having only one perspective that are unable to cope with changes in it have difficulty in placing their feelings and emotions in a context. They have difficulty with propositional attitudes and tend to think in a primitive causal fashion about their feelings and thoughts – ‘that’s to blame’ – instead of being able to reflect on the context and their relations to others that enables propositional attitudes to develop. It is this primitive seeking for an immediate cause that psychoanalysts conceptualise as using mental mechanisms such as projection and introjection. These theorists, however, are as mechanical as the people they seek to understand. They assume that there is an entity, the mind, so there is an inner world and an outer world, and as such beliefs must be either ‘inner’ or ‘outer’, introjected or projected’ (90-91). As can be seen, the actual grammar – the logic of the living use of terms such as ‘projection’ and ‘introjection’ in clinical thought – does not get a look in. It is what we might call this ‘sociological’ aspect of Wittgenstein’s project – investigating the uses to which terms are actually put in diverse clinical language games – that receives the barest attention by Heaton.


As a final example, consider this: ‘[The] theoretical concept of transference is confused due to false analogies and a language myth… It assumes that there is a speech circuit that involves the transfer of the speaker’s thoughts and feelings across to the hearer. … Meaning is thought of as some kind of entity which we can take into ourselves, by introjection, and then discharge it, by projection, into other people. … This is a muddle. In transference the person is not introjecting a thought or projecting one; thoughts and meanings are not entities in the mind or head that can be transferred.’ (176) Once again the living meaning of ‘transference’ – in particular, its use to describe the rich undertow of affect in the therapeutic encounter, or its more nuanced use to describe the ways in which a patient may unconsciously re-enact past relationships in the present – is neglected, the unsubstantiated argument instead being prosecuted at the level of a putative and general entification of meaning by psychoanalysis. Psychoanalytical language games (of transference, projection and introjection) are described as if they involved subscription to false theory about reality; the nature of the language games remains obscure.


Dogmatism and Dialectics


Throughout his book Heaton tends to deploy various self-coined or Wittgensteinian mantras as if they were transparent condensations of prĂȘt-a-porter arguments to be wielded against the alleged tacit conceptual confusions of psychoanalysts and cognitive therapists. I found the results of this strategy to be mixed. At times it provided a helpful shortcut, but at times I was left either confused or with the impression that an at best optional interpretation of Wittgenstein was simply being foisted onto me.


A recurrent claim which just confused me was the idea that people cannot be explanatorily subsumed within their own theories. Example: Psychoanalysts or cognitive therapists tend to assume that phantasies or cognitive schemas drive pathology. But both ‘forget that in any empirical theory the one who makes the theory is necessarily outside it. We … make theories for various purposes but we cannot be subsumed under them. Whenever there is a representation of the world in propositions, there is a subject who is in a position to say ‘I think…’ This applies as much to the patient as to the therapist. Everyone measures the world. To subsume a particular group of people under a theory is to impose a measure on them, to fail to recognise their humanity and to fail to have an unconstrained relation to them.’ (96). The idea sounds intriguing, but further developments of it fail to shed further light on its possible content. Thus the next page has it that the idea of an inner world standing in a representational, mirroring, relation to an external, independent a-priori-ordered-and-structured reality ‘is a functionalism that has thinking as irrelevant to what is thought.’ This is said to be ‘based on the confused notion that there are facts, ‘external and internal reality’, which serve as a standard against which we judge whether our propositions make sense. … We make theories for various purposes; to identify with a theory results in our being used by it, acting as if it were true.’ (97).


Those familiar with Wittgenstein will recall his frequent insistence on not conflating empirical and grammatical statements or, to put it in other words, on not conflating representations with rules for the deployment of representations. We may also recall his diagnosis of the confusion of conceptual ‘sublimation’: when we take a term like ‘real’ which has respectable deployment within various linguistic practices (e.g. real versus fake money or paintings, real versus imaginary scenarios or numbers, real versus pretend smiles or love) and then hold it over and above such discourses, with an ambition – diagnosed by Wittgenstein as disreputable – of asking if they themselves correspond to anything ‘beyond’ them ‘in reality’. It may be something like this which Heaton is aiming at in the above, but his use of phrases such as ‘thinking as relevant to what is thought’ or ‘identifying with a theory’ was to me more confusing than clarificatory.


Furthermore, Heaton himself often lapses into dressing such grammatical insights in a troublingly epistemic garb – that is, in a manner which has recently received much critical attention from Wittgenstein scholars. What in particular I have in mind is the critical attention which the very idea of limits or bounds of sense of thought has received from recent Wittgenstein scholars (e.g. Kuusela). On one understanding, our rules of grammar which as a set constitute the domain of the thinkable, act as some kind of constraint on our thought, or mark out certain ideas as unthinkable, at least for us. Against this idea the New Wittgensteinians in particular have urged the function of grammatical rules as ruling in, rather than ruling out, certain uses of sentential forms. The problem for particular usages of English, including those which pepper the pages of many philosophy books, is not that they contravene what can be thought, but that they are tacitly undetermined or unstably vacillating in their applications. Nonsense characterises words without a use, not words with, as it were, an inadmissible sense (cf Diamond).


Heaton, however, appears to me both to sublimate and to lapse back into the idea of limits of thought, when he offers us such sentences as: ‘The [pyrrhonian] sceptic relies on what seems to him to be the case, while he suspends judgement on how things are ‘in reality’, that is, the fantasy that we can know the essence of things beyond what can be expressed in human language.’ (24) ‘Much of Wittgenstein’s writing was concerned with studying our limits and showing the incoherence of attempts to describe anything beyond them.’ (28) ‘For Wittgenstein, therapy should help us to see that the world does not present itself as a collection of objects to be known, possessed or rejected. We have no direct access to the world. For us humans, thinking involves language.’ (60) ‘Both the Tractatus and Philosophical Investigations were crafted by him at length and painfully to convey the limits of knowledge and the limitations of language for expressing the world.’ (49) On the contrary, as the ‘New Wittgensteinians’ frequently urge, both the Tractatus and the Philosophical Investigations were designed precisely to deconstruct the very idea of limits or limitations of knowledge and language.


The final point I wish to make concerns dogmatism. Heaton tells us that ‘The most important and difficult task of elucidation is that it must avoid all dogmatism for this rarely has any therapeutic action other than that of suggestion.’ (99). Several times he describes the work of therapy as the patient working through of individual, idiosyncratic confusions and troubles. This in part is what riles him about the general theories of psychoanalysis and CBT which he sees, not as providing us with some helpful bearings and moorings whilst we tackle the distress of the individual, but as all too often functioning dogmatically to obscure the individuality of the patient. I feel sure that every honest clinician could recall of examples of this happening in both his own and his rivals’ practice.


What is troubling about Heaton’s book, however, is that his presentation of this very theme is itself dogmatically and non-reflexively pursued. Thus we are frequently simply told what is wrong with psychoanalysis or wrong with CBT in general. The failings of the uses of concepts as wielded by individual theorists on particular occasions recedes into the background. Wittgenstein urged that, in our philosophy, we pursue the process of working through our difficulties with careful attention to the details of how language is being used in particular instances. Here, however, both Wittgenstein’s ideas regarding philosophical therapy, and Heaton’s regarding psychological therapy, are presented in a purely dogmatic form. Wittgensteinian mantras are intoned in lists without explication and without a hint of dialectical handling: ‘The structure of reality cannot be understood as necessarily mirrored in language. We cannot ground propositions with sense in any intrinsic structure of an independent reality. The meaning of a word is not something in the world that is correlated with it.’ (106). Chapter 3 contains an extended discussion of the differences between writing and talking, and constitutes a eulogy to the immediacy and particularity of speech away from the abstractions of the written word. But curiously the chapter presents no self-conscious reflection on the fact that it itself is a piece of writing. Freud’s generalisations are criticised, but Heaton’s own general claims (some of which appear rather extraordinary, such as ‘every oral utterance is unique in respect to its context, pronunciation, and meaning’ (43-4)) remain unsubjected to self-reflective criticism.


Conclusion


Heaton, along with Steve de Shazer, is one of a small handful of psychotherapists who have developed their understanding of therapy through an engagement with Wittgenstein’s philosophy. His enthusiasm for and inspiration by Wittgenstein shine through throughout his text. His own pleasingly a-theoretical explication of the ‘talking cure’ provides a significant addition to the therapy literature. His use of Wittgenstein and his critique of psychoanalysis and CBT is however marred by its non-dialectical dogmatism. Rather than look and see how psychoanalysts use terms in the midst of clinical practice, metaphysical views about the nature of mind and meaning are foisted onto them on the basis of their explicit formulations. In this respect Heaton falls significantly behind Elder’s work on Freud, and the field of modern psychoanalytic psychotherapy still lacks a perspicuous grammatical synopsis.


Wittgenstein is of course not the only 20th century philosopher to have provided inspiration to psychotherapists. Perhaps the greatest influence came from Heidegger, and was felt by the ‘Daseinsanalytic’ and existential therapists who aimed to deploy Heidegger’s insights in the treatment of disturbed forms of ‘being-in-the-world’. Ludwig Binswanger, one of the earliest such proponents, has long been understood, including by his later self, as offering us a ‘creative misunderstanding’ of Heidegger’s philosophy. In short, Binswanger’s patients are presented as embodying pathologically different forms of meaningful world-construction, rather than having partly and in different ways fallen out of that being-in-the-world constitutive of meaningful life itself.


In attempting to bring Heidegger’s philosophy to bear on the psychopathology, matters ontological are tacitly and mistakenly reduced by Binswanger to ‘anthropological’ (empirical) concerns. Heaton, like Binswanger, also aims to set aside what are frequently the dehumanising scientific preoccupations in therapy, replacing them with a welcome focus on people as, or as potentially, free individuals. Like Binswanger, however, and despite his own sometime sensitivity to the key Wittgensteinian distinction between matters ‘grammatical’ and empirical, Heaton too often ends up conflating the two. Mere usages of psychoanalytic terms are described as implying adherence to metaphysical theories; grammatical rules are described as providing limits to the knowable or as mediating our experience; and dogmatism rather than dialectics too frequently ends up ruling the day. Medard Boss and later existential therapists were able to provide some kind of corrective to Binswanger’s creative misunderstandings of Heidegger. Despite Heaton’s considerable creative efforts we still await an interpreter of Wittgenstein comparable to Boss for the psychotherapy community.

Thursday, 16 June 2011

psychotherapy and the relation of theory to practice in clinical psychology

I want to have another go at articulating a fundamental difference between the use of theory in clinical psychology on the one hand, and in psychoanalysis and psychodynamic (and other) psychotherapy on the other. It is, I believe, one which easily gets lost in the way that clinical psychologists - such as myself, too much of the time - articulate the relevance of different models of disorder, or of different formulations, for the treatment.

The psychologist's articulation typically has it that the job of the reflective scientist-practitioner is to formulate an explanation of the patient's difficulties within the terms of the model, and then to guide the therapy by this explanation. You treat the disturbance-as-formulated-by-the-model, and this treatment consists accordingly in the model-guided interventions that you make. The formulation may be in whatever terms seem most appropriate (cognitive, behavioural, phenomenology, psychoanalytical, systemic, narrative, etc.), and the treatment follows from the formulation.

There is perhaps nothing wrong with this way of putting things in and of itself. I think it is a very natural way to describe the relation of CBT theory to CBT practice for example. However it can come to seem just so obvious that it can force out other ways of understanding the relation of theory to practice. The way it does so is, I believe, a clear example of the way in which what we could call the 'ideology' of CBT comes to affect the way that all the therapies are understood and practiced with clinical psychology.

Recently I've been noticing how the very idea of the scientist practitioner, implementing theory-laden understanding in the clinic, can get in the way of my own clinical practice. Let me start by explaining what I am not going on about. Here is one way of reacting against the above-described practice - the practice of the scientist practitioner: 'It is far too non-collaborative; we have an expert clinician thrusting their interventions on the patient. Whereas what would be better would be a collaborative enterprise in which clinician and patient come together to understand the patient's difficulties and figure out what to do about them'.

Now that might sound just lovely, but it really isn't what I'm on about. And the pitfalls of it as a general approach are obvious: it may i) encourage the therapist to eschew the very real expertise they do have, relative to the client, and the way they can be helpful in and through that expertise, and it may ii) encourage us to ignore the way in which the client is unable to grasp what they need (in fact that is why they have come in to start with) because their defences and transferences get in the way of their access to the understanding in question, and it may iii) lead us to ignore the way in which the therapist must beware of getting caught within the re-enacted narrowings of experience, understanding, and relating which the patient brings with him. Further, for me I think it all-too-readily leads to a kind of 'virtual therapy', in which I and the patient discuss together what they would, as it were, need from their therapy (were they to have it!), what new understandings they would need to reach; the 'they' who this is to happen to now comes to seem like someone other than the 'they' who is in the room (explanation-driven approaches to therapy such as CAT (cognitive analytic therapy) seem in particular to run the risk of this) .

But in any case, I now understand, despite the above sometime cul-de-sac in my own thinking and practice, that I'm on about something quite different from this, when I question the rightful hegemony of the reflective scientist practitioner model in the psychotherapies. And here is an alternative - and, I believe, sometimes more fruitful, although my aim here is just to clear some space for it and resist the hegemony of the scientist-practitioner approach - construal of the relation of theory to practice, a construal which draws more on a psychoanalytical, than on a clinical psychological, self-understanding:

That what is curative or restorative for people is the extraordinary ordinariness of everyday empathic conversation, acceptance, love, sharing, connection, being understood and knowing one is understood. That new development, disintegrations and reintegrations, occurs in the context of such relating. That what happens in neurosis is that development, inner movement, becomes blocked. And that the therapist must therefore work to break through defences, work to find room to stand outside of transference and make himself available nonetheless, work to negotiate projections and ally himself with the patient's better self against these forces of inner stasis. This is the 'negative' work of therapy: i.e. it is here that psychological understanding must sometimes be deployed by the therapist to inform their practice of negotiating defences. But the 'positive' work of therapy is just the therapist making themselves available as a new 'object' (a new person who can make possible a new constellation and growth of personal being) through their personal qualities as a human being. That of course is also the work that is done, when it is, by the parent or priest, friend or boss. Their human qualities may outshine some of the best therapists. But the best therapists ought at least to have a good understanding of what gets in the way of psychological transformation - gets in the way of a process which, when unblocked, will happen by itself.

Along the way, then, the therapist will use theory. But this will not typically be to guide an intervention, but to un-derail the therapeutic process. The therapist finds himself thrown out of the healthy use as an 'object' by the patient, in a cul de sac, bored, caught up in a reenactment, stuck. Theory and supervision help him at this juncture. There may or may not be an intervention; what we have instead might be, say, an interpretation. Or some other such utterance which has the function of creating space for the making of meaning once again.

---------------

In an interview in 1998, Jerome Frank put it this way: “Psychotherapy is not applied behavior science. I think that is the wrong model. Because all science is based on facts, but psychotherapy is the world of meanings, which is far from the world of facts. Psychotherapy relies on the fact that human beings react not to the facts or events themselves but to the meanings of the facts as they interpret them. Psychotherapy is the transformation of the meanings that patients attribute to events from negative to positive. I think it should be taught as an art” (Holland and Guerra 1998).