Monday, 25 November 2013

Review of Jon Frederickson's 'Co-Creating Change: Effective Dynamic Therapy Techniques'


(Draft of review - European Journal of Psychotherapy and Counselling, Vol 16, Iss 1, January 2014, pages 90-93.)

Jon Frederickson

With this book Jon Frederickson provides the most comprehensive, useful, and best-written overview yet of the techniques of Intensive Short-Term Dynamic Psychotherapy (ISTDP). The work is organised into three sections. The first outlines the therapy model and considers how to establish an effective therapeutic focus and procedure. The second allays anxieties that ISTDP can be too intensive with four chapters on building capacity in fragile patients. The third discusses how to help those (highly resistant) patients most in need of the intensive methods on offer.

Whilst his model is largely faithful to Davanloo’s ISTDP, we nevertheless hear a lot of Frederickson’s distinctive voice throughout, perhaps best epitomised in his highly active, firm, compassionate yet pleasingly cheeky blocking of his patients’ tactical and projecting defenses. (‘You thought the hospital was persecuting you, but... [it’s] Your self-persecution and self-attack [that’s] making you feel worse. The bad news is this: you are hurting yourself. The good news is that, since you are the one doing it, it could be entirely under your control.’ (p. 326)). A nutshell version of Frederickson’s vision of psychopathology might be: Feelings are the fundamental way we understand the world (ch.1). But feelings can give rise to painful anxiety when their expression is felt to threaten an essential attachment relationship (ch. 2). We therefore automatically and unconsciously deploy defences, keeping inner and outer reality at bay, but then lose our ability to make sense of the world and act freely and adaptively (ch. 3). The therapist’s job is to build tolerance for, attention to, and causal understanding of, feeling and anxiety (ch. 5), and to do this by facilitating a careful focus on the visceral experience of and impulses associated with feelings. The defences to be worked on include both those tactical strategies that keep the therapist (use of cover words, distancing, evasiveness, generalisation, undoing etc.), and the repressive defences that keep feelings, at bay (ch. 4).

For fragile patients – who use splitting, projection onto the therapist, etc. – Frederickson invites us to gradually build their anxiety-tolerance by repeatedly helping them achieve self-understanding, turn against their defences (ch. 8) and challenge backfiring (i.e. anxiogenic) defences (i.e. projection) by promoting reality testing (ch. 7). The patient’s agreement that it is their will to examine their feelings (ch. 6) facilitates the therapist’s job of holding them to the therapeutic task and challenging their resistance. For highly resistant patients he provides a panoply of techniques to defuse the projection of will, block attempts to keep the therapist out, and forcefully yet kindly undermine the patient’s superego pathology (ch. 11). In particular this involves questioning the patient’s identifications with judgemental part-objects which lead to character defences (self-judgement), transference resistance (judging others) and projection of superego (believing that you judge me) (ch. 11).

Here are some themes that I found exemplary and which capture something of Frederickson’s unique voice: i) His ongoing psychodiagnostic focus on the patient’s level of anxiety, enabling him to titrate the dose of therapeutic intervention so that anxiety is neither too low (‘anxiety is a good sign, signalling that unconscious feelings are rising’ (p. 21)) nor overwhelming (ch. 7). ii) His addressing character defenses / superego pathology by pointing out the function, the pathological nature of the self-relation, and the cost, of the associated behaviours (ch. 12). iii) His consistent identifying, clarifying, confronting and blocking of the patient’s defences (e.g. of self-attack or of projection) in the session (‘…defense interruption is an act of compassion toward the patient’ (p. 7)).

iv) The constant reintegrating and mobilising of the resistant patient’s will when they become helpless or project their will to change onto the therapist or when addressing transference (‘There is no law that says you have to reveal yourself to me. You have every right to maintain this wall, but then I will remain another useless person in your life’ (p. 103)). v) His powerful use of mirroring to deactivate projective character defenses, returning resistance to its individual intrapsychic origins and at the same time building the alliance (‘Pt: I’m not totally committed to the therapy. Th: Although [your emotional health] is your goal, you are letting me know you are not that committed to you. And the good news is you can be as committed or as uncommitted as you want to be to yourself.’ (p. 391)). vi) His reminder to not misguidedly do the patient’s work for them, depriving them of the opportunity to develop in their self-agency (‘Frustration in the therapist is often a sign of resistance in the patient’ (p. 440)).

Significant in ISTDP is its focus on repressed anger and guilt towards primary caregivers. Frederickson tells us (ch. 1) he will consider the significance of the range of emotions in psychopathology, but more than 95% of the cases considered involve suppressed anger as the psychopathological culprit. My own view is that this, along with Davanloo’s belief that not just anger but suppressed murderous rage and guilt are usually the real culprits (ch. 14), is psychopathologically unrealistic, but since this involves critique of ISTDP rather than of the book I shan’t develop it here. Another possibly restrictive aspect of the book is, despite its title talk of ‘co-creating change’, its total focus on active therapist-led defense deactivation, rather than on mutual connection or the positive provision of the right soil structure in which personalities can grow beyond their fixations.

The reviewer’s notes for this journal describe its audience as philosophically informed; here then are a few philosophical criticisms. First I fussily note Frederickson’s sometimes impoverished ontology, which appears to have room only for ‘objects’ and ‘concepts’. Several times he tells us that ‘Since the superego is a concept, it cannot act.’ (p. 357). However whilst it is not an object, and whilst we do indeed have a concept of ‘superego’ – and of ‘table’ and ‘agent’ – it is surely not itself a concept, but rather a psychological structure, which is to say, a coordinated set of emotional and behavioural dispositions.

Second I note his insistence that, e.g., ‘Defenses are our conditioning, not our essence.’ (396), or ‘The patient’s resistance is not a “part” of him. It is merely an automatic, habitual pattern of behaviour’ or ‘A defense has as little to do with a person’s being as a leech has to do with the leg it is sucking on’ (286). It is unclear what the logical status of such remarks is supposed to be. Are they intended as empirical facts? If so we might note that the concepts of our being or selfhood are not always thought of as exhausted by our existential freedom, basic feelings and non-habitual actions, but instead as including those diverse conditioned habits of behaviour that constitute character. Alternatively we might settle this by stipulation, i.e. simply rule that defences aren’t here to count as aspects of true character. In that case we should perhaps then also acknowledge that we are in the terrain of a particular psychodynamic value system, not simply reporting facts about psychological functioning.

A related issue, to do with fact versus construction, came up several times for me throughout the book and also from watching Frederickson’s teaching videos. Frederickson talks, say, of helping a patient tease apart their anxiety and their feelings, or defuse from their superegos, or experience real but buried murderous rage. But it wasn’t clear to me how to motivate a reading of the therapeutic techniques as uncovering pre-existing psychological structures or feelings over a reading which takes them to be creating new psychological structures or creating new and helpful (but perhaps not truthful) experiences (e.g. of murderous rage). He advises, for example, that it is useful to ‘Refer to a ‘critical mechanism in her mind’ ‘habit’ ‘thought pattern’… Some wonder if this may be a useful way to talk to the patient but an inaccurate description. I would suggest it is accurate.’ (p. 288). However no criteria are provided for adjudicating between realist and constructivist takes on this. A key feature of ISTDP is its use of imaginary ‘portrayal’ to facilitate access to buried rage. Frederickson quotes himself asking a patient ‘If that impulse went out on him, if you were out of control like a wild animal, how do you picture that impulse going out onto his body?’ (p. 446). My own feeling, for what it’s worth, is that this could be a leading question creating extravagant, rather than de-repressing buried, anger. Of course this may be a matter of me being too English, rather than of Frederickson creating hysteria. The real question, however, is whether Frederickson’s model has the conceptual and practical resources to make the distinction at the psychological level of explanation.

To end let me return to the myriad merits of the book. I am aware of no comparable work offering a real sense of how to embody intensive dynamic therapy. It not only details psychopathological understanding and therapeutic technique but, like the best kind of master class with its own compelling examples, brings both to life within the reader. 

Sunday, 22 September 2013

psychosis: a dynamical systems approach

Today I'm going to outline a template for understanding psychosis using dynamic systems theory. It is not itself a theory, being far too rudimentary. But it is perhaps a scaffold on which a theory could be built.

Here are some central ideas from dynamic systems theory. First, a dynamic system is one that keeps itself in balance. It self-regulates - like our home heating systems with their thermostats linked directly to the boilers to turn them on and off. Second, it does this in response to the demands put on it by the local environment. In hot weather the body sweats more to cool down; when it cools down enough, it stops sweating. The internal milieu is thereby maintained. Third, complex systems are autopoetic: the systems are self-creating, not simply maintaining a pre-existing structure within certain homeostatic limits, but rather organising and repairing their own structure. Fourth, such systems can operate at different levels of equilibrium. We do not have to do with a single mode of functioning that is maintained despite the pressures it is under. Rather we have to do with a system that, when maintaining its equilibrium in one configuration becomes highly challenged and too difficult, can jump to different forms of organisation that cope better with the particular challenges now encountered. Quite different orders emerge out of the same ingredients through saltatory steps.

And here is the application to psychosis. First, that everyday perception and cognition which is amenable to 'reality testing' involves one mode of organisation, which is maximally adaptive to the demands of the situation. At its best this mode promotes maximal engagement and maximal self- and other-understanding. However it leaves one vulnerable to hurt, rejection and to needs not being met. Second, that psychosis involves a step into a quite different mode of organisation, a mode which shortcuts reality testing. At this simpler level of functioning, fantasy and reality collapse into one another. Wish and fear are not now separate from real experience: the system is no longer expending energy to keep the two functions of fantasy and reality separate. Third, that the system moves into this mode of functioning when the emotional stressors on it are, for the domain in question (reality testing is not a global cognitive faculty; it operates in many different domains, and a person only becomes out of touch with reality in a limited range of these domains: patients are not usually globally psychotic), too great to handle. Fourth, that anxiety is a perturbation, an instability, in the dynamics of the system - a perturbation enough to invite a transition from a normal into a paranoid mode.

Fifth, It takes energy to separate reality from fantasy. Making the self-other distinction takes effort. Drawing the line between you and I in the right place involves a relaxed flexibility. Tiredness and overwhelm get in the way. We are normally sustained in our reality-contact by healthy relationships and by 'internalisations' of healthy relationships. By the latter is meant: we have developed forms of complex stability-promoting reality-contact through early relationships, and these sediment out a reliable re-usable structure within the self, a capacity to now enter adaptably into new relationships and maintain the stable but flexible give-and-take that constitutes real relating.

So, the main point of the dynamic systems framework for thinking about psychosis is the way it helps us think about the relation between psychotic and non-psychotic modes of function. One of the clinician's therapeutic tasks is to help a local system to change its total form, to find the small nudges that will enable a quite different order of world-relation to emerge. The framework also helps us to not focus on the content of delusional beliefs (although such content may provide important clues) but instead to think about the embedding system and its mode of function. Given that the different systems (psychotic and non-psychotic) are enactive in character, involving different perceptuo-motor cycles for example, the stabilisation of a transition into a non-psychotic world could be aided by particular forms of self-world engagement. 


Another way in which the dynamic systems framework is, I hope, relevant is that it is not intended as a metaphor for a psychological theory. The difficulty I am imagining, for the system which is finding itself unable to continue to self-organise in a reality-contact-oriented manner, and which therefore makes a saltation to a psychotic mode of function. The details of the delusional world are the result of such a saltation. The very form of mind consequent on the saltation is quite different. It is not that we have to do with psychological steps - rational, emotional, or otherwise psychologically intelligible steps - within a mode of function.

I say: not a psychological theory - but of course what does and doesn't count as psychological is not a hard and fast fixed concern. One theory which we might want to call 'psychological', and which I believe is compatible with the outline I'm offering here, is Bion's idea of a breakdown in what he calls 'alpha function' in psychosis. The idea is that it is the processes which lead to the genesis of normal mindedness which itself becomes unbearable and unfeasible in psychosis - i.e. that it is not processes which occur within already formed minds which are in trouble. 

To take just one possible example, imagine if a personality, rather than being able to body forth into a psychologically unified single sexual identity, tried to do justice to its own proto-sexual libidinal drives by sedimenting now or then in two different gendered directions, neither of which had space within it for the articulated mind-creating forms of the routes of instinctual satisfaction of the other. An unstable oscillation could result if normal repressive mechanisms did not suffice to cut off the identity which another dominant identity could not accommodate. The mind would be torn apart, and psychosis would result when conflict at a purely psychological level became unmanageable. The result is a shift to a different level of neurological self-organisation in which the very project of reality-contact - i.e. the project of allowing desire and perception to organise a stable self-world distinction and interaction - would in this domain be abandoned. 

The psychotherapeutic task would here be one of trying to create a broader identity to accommodate all of these instinctual consolidations - and I think it important to note that this task is not best understood as one of merely developing a bisexual self-conception, but rather one of the lived body itself somehow developing a hitherto missing libidinal flexibility. 

Monday, 2 September 2013

un-un-un-understandability

So here's my notes for a forthcoming talk to form part of the academic afternoon on 'Philosophy and Psychiatry: 100 Years after Jaspers'General Psychopathology at St Bart's Hospital London this Wednesday.

Introduction

The understandability or otherwise of belief is often presented as all of a single sort. Jaspers, the clinical psychologists (e.g. Richard Bentall, John Read, Jim Geekie) tell us, was too pessimistic in telling us that the irruptive, bizarre and out-of-character character of primary delusional beliefs renders them unintelligible. Whilst those evil psychiatrists are busy writing off the delusional subject as empathically unreachable in their delusion, we valiant psychological knights can show just how the content of the delusions is linked to the patient's sense of self and bring them back within the fold of humane understanding. Hmmm...

In what follows I will sketch out a more nuanced view of what I will urge are the quite different forms of understanding that we can and can't bring to bear on the schizophrenic subject in his or her delusion, and suggest that these can sometimes be disjunctive. Moreover some forms of understanding - such as those offered us by psychoanalysis - are complex in character, requiring that we grasp the causal underpinnings, the state of mind, and the dynamic (motivational) function of the delusions all together. Schizophrenic-type delusions are, I suggest, rightly understood as unintelligible in terms of the modes of intelligibility we characteristically bring to bear on one another as part of ordinary social life. However quite different modes or forms of understanding can be brought to bear on them in an intercalated manner.

The right answer to the question of whether we can understand schizophrenic delusion is therefore 'yes and no'. Moreover it would be out of place of us to attempt to deploy those modes of understanding that do find some footing with the schizophrenic person in their delusion were it not the case that they were ununderstandable in the more ordinary sense.

Below I focus mainly on the forms of understanding offered us by psychoanalysis and phenomenology. The four forms of intelligibility of belief I look at are: a) empathically achieved everyday social and individual contextualisation; b) grasp of the causal structure and processes underlying the belief formation; c) fathoming of the embedding form of subjectivity - the state of mind - the mode of being-in-the-world - in which these beliefs arise (both static and diachronic); d) uncovering the motivational (defensive) dynamics driving the belief formation and maintenance.

a) Everyday Intelligibility

How do we ordinarily understand why people believe what they do? Well, we might consider how they are aligned with the good,  the true and the rational. So for example we might say: 'He believes that he should go and help her because it is the right thing to do'. We may also make sense of why people believe what they do in terms of their direct exposure to certain situations or to testimony from others about these situations. There is nothing particularly psychological about such forms of understanding: they do not make reference to the personality, to the emotional needs of the individuals, to interferences with reason, etc. Instead the intelligibility comes just from the person being normatively aligned with the interpersonally available standards for situationally apt thought.

The delusionality of delusional beliefs, I believe, is partly - but only partly (see c) below) - a function of precisely their unintelligibility in this fashion.


b) Causal Structures and Processes Underlying Belief Formation and Maintenance

What supports and what disrupts our processes of belief formation? One philosophically informed cognitive neuropsychological project of understanding delusion views it as a failure of belief formation and maintenance. This seems unlikely to me for reasons elaborated elsewhere. (Delusions, I believe, are disturbed beliefs - but they are not disturbances of belief (formation/maintenance). The disturbance which shows itself in schizophrenic delusions is not a disturbance in thinking but in what in psychiatry we call 'reality contact', the nature of which contact requires careful specification. A quick analogy should help here: Imagine that we find that a cog within a threshing machine is spinning in an unusual manner. We might for a while, if we imagine that the normal context of threshing is all in place, investigate local failures in the mechanism surrounding this cog. But delusion, it seems to me, is more akin to the threshing machine no longer being deployed in a field of corn, but instead being towed along the road. Whatever unusual spinning we notice in the cog is a function not of the local mechanics but of the different terrain.) But nevertheless there are of course various processes and structures within and without the brain which enable us to form and maintain all sorts of beliefs. We need to be neurologically healthy, and to live in a social environment where discursive practices facilitate the relaxed formation, rehearsal, interrogation and elaboration of our beliefs. So it is surely possible to tell a causal account of normal belief formation, even if delusion is not intelligibly understood as resulting from a disturbance within such mechanisms.

Here is a causal account of delusion owed to German Berrios (1991): that 'Delusions are likely to be empty speech acts [sic], whose informational content refers to neither world nor self. They are not the symbolic expression of anything. [Their] ‘content’ is but a random fragment of information ‘trapped’ in the very moment the delusion[s] becomes crystallised. The commonality of certain themes can be explained by the fact that informational fragments with high frequency value also have a higher probability of being ‘trapped’.' The causal account - it is not yet an explanation - specifies a neurological process of crystallisation. The content of the delusion is in this perspective an irrelevance; it might tell us about the preoccupations of the subject, but such preoccupations are not part of reason for the crystallisation itself (contrast psychodynamic accounts). 

Or we might look at cognitive neuroscientific accounts of delusional perception. For example, Hemsley and Friston exemplify a popular approach, proposing that a functional disconnection in neural circuitry (perhaps between frontal and temporal regions) leads to a failure in the constraining impact of context upon the processing of perceptual detail. Gestalt perception is disturbed, leaving the subject at the mercy of being captured by incidental details; their sensory input becomes interrogated against a backdrop of now inappropriate frames of references leading to disturbances in perception of significance. Or we can consider the interesting approach of Frith who proposes that a disturbance in corollary discharge leads to passivity experiences and the associated delusions.

Psychiatrists, especially psychoanalytically minded psychiatrists, have also given us an account of specifically delusional thinking. What, they ask, is the character of the mental functioning at work when delusions crystallise? Inspiration has primarily been taken from Lucien Lévy-Bruhl's notion of 'pre-symbolic magic participations' (symbolic equations / condensations). Symbolism proper proceeds along lines governed by convention, and is in the service of communication. With pre-symbolic participations however the subject does not distinguish between the symbol and the symbolised, and the pseudo-symbols are not formed primarily to communicate; instead, they are substitutes produced via displacement (cf Agnes Petocz and Marguerite Sechehaye).

Hanna Segal (1991) suggests that there are ‘two kinds of symbol-formation and symbolic function. In one, which I have called symbolic equation, and which underlies schizophrenic concrete thinking, the symbol is so equated with the object symbolised that the two are felt to be identical. A violin is a penis; playing the violin is masturbating and therefore not to be done in public. In … true symbolism or symbolic representation, the symbol represents the object but is not entirely equated with it.’


Sechehaye: 'Dominique, a young schizophrenic just brought to the clinic, begged her parents 'to restore its head to my doll; it is broken and it will be more and more mangled; you must take it home; it is the only way to set things right again.' (62-3)

The analysts also describe the ways in which projection, projective identification and splitting lead to the creation of delusional perceptions and paranoid thoughts. Here the key idea is that what would once have been located inside the self is now located outside. (Whether this is due to transitivistic confusion (Bleuler) or to motivated projection (Klein) or to both is unclear - cf later.) Thus paranoia has been theorised as due to a boomerang effect of intolerable aspects of the self projected out into the environment.


The psychoanalytic characterisation of the nature of delusional thinking shows the distinctive type of thinking that it is. This is different from the cognitive psychological account of delusion as a breakdown of belief formation. The delusional mind as the psychoanalyst characterises it is a mind in a particular ('primitive') mode or form of functioning. It is not a matter of there being a failure in certain of the reasoning procedures - 'rational mechanisms' as it were - by which beliefs are normally formed. 

c) Autism / Forms of Mindedness / Disembeddedness

But what is the kind of mind that embeds and informs such delusional thinking? One of Bleuler's 4 'A's characteristic of schizophrenia was autism (the others being association, affect, and ambivalence). The schizophrenic mind is autistic, he claimed - meaning that it operates in its own sphere, disengaged from reality contact, taking its own phantasms for realities. R D Laing writes of one of his early patients (Divided Self p. 221): ‘Reality did not cast its shadow or its light over any wish or fear.’ ‘Every wish met with instantaneous phantom fulfilment and every dread likewise instantaneously came to pass in a phantom way.’ Psychoanalytic authors today, by the way, tend to talk not of autism but of a 'psychotic part of the mind'.

The clinicians who have best elaborated the character of schizophrenic autism are the phenomenologists (e.g. Blankenbourg, Minkowski, Bovet, Parnas, Sass, Stanghellini, Mishara, Fuchs, Gallagher, Maggini, Raballo). A key feature of their re-theorisation of the autistic vulnerability in schizophrenia is their recasting of it as due to a disturbed pre-reflective attunement to the world, especially to the world of others. 

A key aspect of phenomenological theorisations of delusion is their insistence that delusion be understood in the context of a radical transformation of the subject's being-in-the-world (and not, say, merely in terms of a disturbance in the processes by which beliefs are formed or maintained). They are rooted in different forms of being-in-the-world and may also refer to these different 'worlds' (which explains why they are sometimes not connected with action in the real world in the way one might have anticipated (double bookkeeping etc.)).




World: The automatic habitual character of immersed perceptuo-motor activity that subtends the stable experience of a separated self-in-relation-to-a-world is compromised. The body subject struggles to automatically coordinate, as a living invisible centre, the shifting frames of reference around it. Stable perceptual meaning begins to break down (i.e. delusional atmosphere). 'Something is going on'. The world may appear unreal (derealisation, depersonalisation), a domain of images, pasteboard. As Sass suggests, contrary to the psychoanalytic idea that delusion is a result of the hypercathexis of the imagination (mistaking the imaginary for the real), the real 'trouble generateur' is the loss of automatic certainty which denatures the real rendering it akin to the imaginary. Unable to maintain itself as an invisible centre coordinating diverse frames of reference, and depleted by the terror of living in this disintegrating world (trema), the lived body switches to a new form of intentionality in which the body itself is taken as the frame of reference. The result is that everything experienced seems to relate to the self: this is the autocentric polarisation of the intentional field - (anastrophe) - which provides the fertile soil in which self-referential (paranoid) delusions grow. Metaphysical delusions, abnormal attributions of meaning - apophany - thematise this reshaping of the world. (Cf Conrad.)

Others:  The delusional subject's inability to smoothly coordinate perceptuo-motor frames of reference is particularly acute in the interpersonal domain, so that the subject struggles to locate agency and potency proportionately to self and other. The delusional results which thematise this are delusions of omnipotent power or of enfeebled persecution or nothingness.
Delusions not infrequently emblematise the disturbed reality relation. Thus Sechehaye's patient Renee's Wahnstimmung was expressed as 'A great disaster is on its way; the earth will shake to its foundations and collapse with a horrible noise.' Later she lamented 'The water, the water is rising constantly and coering the world in liquid, icy sheets. Soon there will be nothing but water, a desert of ice water. How can I escape? Help, please, save me'. ... Renee wailed for hours at a time as she imagined herself watching real catastrophes: 'Whole cities are crashing, avalanches of rock come tumbling down with a noise like thunder. Only crumbling, yawning holes, chaos and destruction remain.' 

d) Motivational Dynamics 


Improving self-esteem: Grandiose delusions may function - and the patient may be motivated to form them - to increase self-esteem. 


John Strauss (1991): ‘a young woman who has been severely delusional has not been particularly well educated or had much psychological treatment. She was telling me in one interview how her feelings that people were controlling her were much better now than they had been before. I asked her why, and she said that was easy, that she did not have to be paranoid any more, since she felt so much better about herself.’ 

Roberts (1991) had a patient who had believed he was the Messiah said ‘I liked to imagine it because I felt so useless without it… I still feel inadequate now – it’s as though I don’t know anything. I always felt everything I said was worthless, but as Jesus everything I said was important – it came from God. … I just want to hide away, I don’t feel able to cope with people … I always feel lonely, I don’t know what to say.’ Delusion as wish-fulfilling phantasy. 

Jung's patient: The patient was a poor dressmaker who ‘fell ill in 1886 in her 39th year – on the threshold of the age when so many dreams are brought to naught’. She has sat ‘like an “imbecile” for twenty years in her workroom, mechanically darning her linen and occasionally mumbling a few meaningless phrases which nobody had been able to understand. Jung records the following fixed delusions: At night the spinal marrow is torn out of her; pains in the back are caused by substances going through the walls covered with magnetism. The monopoly establishes the pains that do not stick in the body and do not fly about in the air. Extracts are made by an inhalation of chemistry and legions perish of death by suffocation. … The patient styled herself “The Banknote Monopoly, Queen of the Orphans, Proprietress of Burghölzli Asylum.’ ‘Naples and I must supply the whole world with macaroni’. … She was Socrates…. ‘I am the finest professorship and the finest world of art.’ ‘I am the Lorelei … Switzerland … a crane … Schiller’s Bell … Hufeland … the master-key …’ She is the owner of a distant island with silver mines, ‘the mightiest silver island in the world’… the ‘greatest orator’ possessing the ‘highest eloquence’. … she is not only the honoured earthly queens Mary Stuart and Louise of Prussia, she is also the Queen of Heaven, the Mother of God, and at the same time the Godhead. … she chose three husbands from the best families in the town and her fourth was the Emperor Francis. From these marriages sprouted two phantom children, a little boy and a little girl. (Jung, 1907/1991, pp. 173-177). 

Sechehaye: delusions as positive wish-fulfilling substitutes for disappointments. 69 ‘a young man, neglected by his mother because of a congenital physical malformation, who sought tenderness in young girls. Unfortunately, the rejection of his tentative amorous advances reactivated the initial privation and precipitated a psychosis. After a short agitated phase, he fell into a long dream-like state offering everything hitherto denied by reality. During a period of improvement, questioning revealed that he had at last found happiness, as he believed himself the son of a powerful royal couple who adored him and granted his every request. He was an Arabian prince, handsome and fabulously rich, living in a harem surrounded by a bevy of women, each more beautiful than the other, who fought for his favour. His conquests were numberless; he was a veritable Don Juan. The shame, the bitterness and distress of his mother’s neglect and his amorous disappointments had disappeared, to be replaced by an exuberance of power and pride, unhappily at the expense of mental equilibrium.’

Renee’s compensatory phantasies: (p. 69 of ‘a new psychotherapy in schizophrenia’) ‘She imagined herself queen of Tibet but… she had neither court nor palace nor riches at her disposal. To be queen of Tibet was to live alone in a distant land, away from everyone. Yet this poor fantasy compensated for her intolerable insecurity, realizing her desire to return to her infancy when her parents lived in material comfort and especially to the maternal body. “Tibet”, she explained, “is the loneliest, most inaccessible country in the world. Entrance is forbidden. Once one leaves there is no going back. But I succeeded because I am nine centuries old [the nine months of the gestation period]. I forced the doors and now I am protected by high walls and hidden from the eyes of everyone. … I am absolutely alone. No one may enter; it is closed on all sides except for a narrow and dangerous pass obstructed by prickly trees.” To one accustomed to psychoanalytic symbolism, this response is obvious, referring to the anatomy of the female body.’ symbolic translations of frustrated fundamental needs.

Reducing dissonance: Delusions thematise and thereby may function to reduce dissonance - relief through rationalisation; a return of a sense of meaning (trema resolving into apophany). Freud: delusion formation as restorative: ‘like a patch where originally a rent had appeared in the ego’s relation to the external world.’ (Freud 1924 p. 151.: Neurosis and psychosis. In SE 19 (149-153)). Self-functioning may be restored as fragmentation is no longer experienced within the self. Arieti (1964): ‘indefinite feelings become finite, the imperceptible becomes perceptible, the vague menace is transformed into a specific threat… the sense of suspiciousness becomes the conviction… Things that appear confusing and obscure have a meaning and purpose.’

Projection: To the extent that transitivism (attribution to others of aspects of self) is dynamically driven (intolerable aspects of self-representation are projected into the other-representation), projection (and splitting and projective identification) are intelligible teleologically as defensive functions. Of course it could be that non-dynamically formed self-other confusions provide the perfect terrain for projection to take root - the dynamic defense exploiting the non-dynamically-generated disturbance in the stable enaction of self-in-relation-to-other.


Bringing a), b), c) and d) Together


To recap: The account of specifically schizophrenic delusion offered to us by psychodynamic psychiatry involves the following four elements:

a. The idea that delusions are not best understood as beliefs expressing and aiming at the everyday consensual world.

b. The idea that they instead arise in, and reference, an 'autistic' or 'psychotic' part of the mind. They speak from and about a form of mental functioning which is not grounded in everyday practical reality-contact, but which instead fuses wish or fear into the fabric of the new world of meaning inhabited by the delusional subject. That delusions sometimes simply thematise this world. 

c. That in this domain the primary processes rule, such that quasi-metaphorical, quasi-symbolic links are made instead of representational thought which keeps subject and object separate. 

d. That delusions can be motivated - they may express the phantastic meeting of needs - for love, nurture, recognition, integrity, self-esteem, power, nurture.

The psychoanalytic understanding of delusion brings these four elements together: The patient, in an altered state of mind (in which reality contact is lost), is motivated to form delusional beliefs (by the need to bind anxiety, to symbolise their emotional distress, or to wish-fulfillingly phantasise the meeting of as yet unmet primary needs, or to disavow painful or shameful feelings), and symbolic equations and projection are, in this state of mind, the means by which this can happens. In particular, the symbolic equations allow the mind to both avow (express in modified form) and disavow (not straightforwardly acknowledge) its intolerable emotions and needs 

For example, Sechehaye talks p. 72 of how ‘The constant intervention of defensive factors rarely permits meeting the direct expression of the frustrated need. Among the numerous schizophrenic signs, however, certain symbolizations do reveal the demands, the pleas, and the disguised attempts to obtain assuagement of a disappointed vital desire.’ ‘The schizophrenic finds the possibilities of expressing his fundamental need most readily in such archaic modes of expression as regression, progression onto allowed models ... and pre-symbolic magic participation where the symbol is confused with the symbolized object. … [T]he need’s symptoms are displayed under two different guises: a positive one, the desire for satisfaction, and a negative one, the anxiety reproducing the initial trauma. The symbols on which the patient projects his affects present one or the other of these aspects and often both together. This double projection was striking in Renee’s case. At the beginning of the regressive phase she regularly projected her wish to return to the nursling stage on a rag doll she called “Moses”. “Moses” she said “doesn’t have to eat. He is always fed and it isn’t necessary to give him anything”, while about her monkey she complained fearfully “The little monkey is going to die of hunger; no one is giving him anything to eat”. She herself had no right to eat; the “system”, the “punishment machine”, forbade it. If she succumbed to the temptation to eat, the “system” would transform her into a starving cat. Here the difference is at once clear between the spontaneous expression of the need (the monkey is hungry, Moses is always nourished) and the reaction to frustrated need (the system forbids me to eat; I will be transformed into a starving cat). The direct expression of the need adopts a primitive, archaic form, utilizing the elementary process of projection, while the reaction to frustration takes a more elaborated, more intellectualized form due to the intervention of ego defense mechanisms.’ 


Ordinary and Extraordinary Understanding

Let's return to where we started  with the question of the unintelligibility of schizophrenic delusion. During this talk I have presented 3 different forms of understanding which we can bring to bear on schizophrenic delusion. These are the phenomenological (grasping different disturbances of being-in-the-world and seeing how delusions emerge from these), the causal (for example the operation of primary processes), and the dynamic (the contribution of defenses to the formation of delusions). What I want to point to here is that:

a. None of these make it the case that the delusion is intelligible as beliefs are ordinarily intelligible. To understand the causal forces and the existential situations from and in which beliefs emerge is not at all to grasp them as intrinsically intelligible ways of aligning oneself to the good, the true and the rational. Schizophrenic delusions are the products of a mind which, in its delusionality, is disconnected from the real and the norms of socially and rationally intelligible function. They are, then, precisely not intelligible as ordinary beliefs are intelligible.

(It might be said: Well, both delusions and everyday 'theories' serve to reduce dissonance by bringing order to experience. However ordinary theories primarily serve a truth-seeking function; their good psychological effects are secondary to this; they are therefore not simply rationalisations. Making ourselves feel better and genuinely understanding something are, clearly, two separate things!)

b.  Furthermore, if a belief is intelligible in the ordinary way we do, I suggest, have little business in offering phenomenological or causal or dynamic explanations of it. The kinds of understanding we can mobilise regarding delusions are in fact antithetical to the kinds of understanding involved in everyday sense-making.

c. The view that psychological understanding is a way of welcoming the delusional subject back into the fold of intelligible humanity is deeply misguided. First, psychological forms of understanding are needed precisely when rational intelligibility breaks down. Delusions constitute, one might say, not rationally intelligible responses, but rather psychological reactions, to situations and predicaments. Second, it encourages us to overlook the ways in which the delusional person is suffering - not merely from painful thoughts and feelings, but from terrifying fragmentations of selfhood which at times challenge their very standing as en-worlded subjects. The cost of holding out the promise of overturning Jaspers' allegedly pessimistic doctrine of ununderstandability is that one misses the sometimes shattering music at the heart of the schizophrenic condition and trivialises the depths of their distress.

Friday, 30 August 2013

on how we know what we think

About once or twice a day I receive an automated email from one Anastasia Friel Gutting supplying the latest Notre Dame Philosophical Reviews review. This is a fantastic service, although it's a bit dispiriting just how many philosophy books there are being published these days, and it's not possible to read even the reviews of more than a small portion. (It's also a bit dispiriting how chronically professionalised the whole business of academic philosophy has become. Reviews also often end, a bit like those legion self-serving empirical psychology papers, with some 'clearly this is very important work but there are still some flaws and so lots more work [and presumably lots of funding please too for this ever so important task] is now needed'. About which only: UGH!!!) At any rate, here's one that just came in and caught my attention - a review by Lauren Ashwell of Jordi Fernández' Transparent Minds: A Study of Self-Knowledge (Oxford University Press, 2013). It caught my attention because of a strikingly baffling premise inexplicitly built into it from the get-go, a premise I will question here.

Ashwell talks of how Fernández is interested in 'how we introspect' our beliefs and desires. But we're not told what is meant by 'introspect'. Whether, for example, it is something which happens very often. Whether it is something that is supposed to happen when you ask what I believe or feel and I am able to tell you. Now it might be said that it is the name for whatever the means is by which we come to know what we believe and desire. What I want to point out here though is just how un-innocent the assumption is that there is any 'how', any means or method, at all to something here being called our 'knowing' what we believe. That seems like a massive assumption, and I can't for the life of me think what motivates it - unless I saddle the philosopher promoting it with a prior commitment to an extremely alienated conception of the self (I'll say more of what I mean by this below).


Thus we are told that 'Fernández's account of introspection, like many others, takes its inspiration from Gareth Evans' remarks about introspection -- roughly, that in order to find out whether you believe that p, you simply ask whether p is true.' With this assumption in place from the start - the assumption that it makes straightforward sense to talk of finding out whether I myself believe that p - we then are treated to the inevitable causal theory:  'that when you ask whether p, you are looking for whether you are in a state that normally causes you to believe that p. The normal cause of M [Fernández] labels the ground for M. He calls his model of introspection the "bypass" model; you "bypass" looking for the mental state directly, and look for whether you are in a state that would be a normal cause of that mental state.' The discussion that follows in the book and the review will then treat of the various cases that can and cannot be accommodated by the causal theory in question. A whole host of complex philosophical theorising ensues...


But, really, why should we accept that there is any such thing as finding out whether I believe that p? What work is the concept of coming to know doing here, what discriminations does it afford in this context? There is in ordinary discourse at least one context in which we do talk of finding out what we think about p: it is when we haven't made up our minds yet, and we think it over and thereby arrive at a belief. But there's no reason at all that I can see why this would be called 'introspection'. Instead it is an active process of belief construction.


When you ask me what I believe or feel, and I tell you, what I normally do (...but you tell me what you do if it's interestingly different...) is to speak from my belief or from my feeling. I'm not normally speaking from somewhere else inside me, some other vantage point from which I must now try to access some other portion of myself (where the belief or feeling is, as it were, stored away). To ape Wittgenstein: you can often enough find out what I think or feel by asking me; I however do not need to find out what I think or feel. I do not need to find this out because my being and my believing are not two separate things. Therefore there is, it seems to me, typically no 'introspecting' and no question of a 'how' to be answered by any theory whatsoever; there is no access required.


'I know what I believe!'; 'I know what I feel!'. Sure, I can imagine uses for those phrases - such as when you question or interpret me and I self-righteously resist your usurping of my first-person authority. In pointing this out I am not trying to use an ordinary language philosophy approach to disappear the issue on the philosophical table, but only inviting the philosopher to now actually say what they do mean, since they clearly don't mean what we ordinarily mean, by the notion under consideration. It's not that they can't use words in news ways - in fact, bring it on! - but we need to be told what the work is that these notions - of 'coming to know what I feel' - are to be doing.


So, yes, why might someone come to think that there was some 'how' to be answered as to 'how I know what I believe or feel'? Here's the only way I can think myself into that epistemologised self-predicament. First I imagine myself not as living immanently within my understandings and feelings, but as residing somehow behind or set back from them. And now it really will be the case that I seem to require access of some sort to them. Now I need to find out what I believe or feel. If I really want to entrench this alienated philosophical disposition further in me, then I keep hold of such an epistemologised conception of my capacity to avow or express my beliefs and feelings, and point out just how magical the idea of, as we would now put it, 'just knowing' is. Perhaps it smacks of some Cartesian immediacy of self-presence: the mind that knows itself glowingly and gloriously in its own automatic reflexive glaze and glare. That is surely something we must do away with by wheeling out a thoroughly naturalistic alternative account. Or perhaps I can entrench it further by thinking about those cases where indeed we do all want to talk of failures of self-knowledge (cases drawn from psychoanalysis, perhaps), and then just assert without further ado that in the normal case what therefore we must have to do with are success stories. Other methods of auto-entrenchment may also be available.


What none of these options yet do, however, is to get the epistemologising project - the project of legitimating the idea that there is some knowing, some success, some access, some achievement, some arriving, some how, some means, involved in my everyday ability to state what I feel and think - off the ground. Sure, give me some examples of the communicational work that can be done by the notion of knowing what I believe or think - work that doesn't collapse into those readily available notions of strong-mindedness or interpersonal resistance or of overcoming internal repressive forces - and I'll be the first to concede that there is a need for a theory of 'how we know what' we think and feel. Until then: thanks, but let's hold the causal theory.


Sunday, 11 August 2013


pop-individualist-stoic-schematics

Here's a recent BBC article which presents us with another undelightful concoction of CBT pop-philosophy. 'CBT', we are told, 'is based on the idea that problems aren't caused by situations themselves, but by how we interpret them in our thoughts. These can then affect our feelings and actions.' There follows the obligatory schematic of situations and an individual's thoughts and feelings and actions linked up with bidirectional arrows (we're not told what the arrows represent - causal relations? intentional relations? rational relations? who knows...).

There's something rather helpful about this presentation of the now widespread Pop Individualist Stoic Schematics (henceforth I'll just use the acronym), in that it does rather lay bare to the passingly critical mind some of the confusions at the heart of this vision of the human condition which, being second to none in its triteness and banality, remains such a constant embarrassment to the discipline of psychology.

Let's take the PISS notion of 'situations' (also often glossed as 'things') for starters. For the contrast (not by the situations themselves, but by our interpretations of these situations) to get off the ground we presumably need to have access to a concept of 'situation' which doesn't already have built into it too much by way of meaning-laden-ness - so as not to approach too closely (and obviate) the 'interpretation' which we are told mediates our emotional reactions or 'problems'. At an extreme we might perhaps take 'situations' to be intrinsically devoid of meaning, dead as it were, all the meaning being supplied by the individual's interpretative responses to, or overlay on, them. (This perhaps-pre-requisite deadening of the lifeworld is perhaps also why the stoic adage is often rendered in terms of mere 'things': 'not by things but by our interpretations of things...')

And then on the other hand we're going to have to be careful with our concept of 'interpretation' - weaving a course away from something which risks reconstruction in terms like 'meaning-sensitivity', 'uptake', 'grasp [of meaning]', 'getting [the sense of]' (since if we get too close to meaning-finding and too far from meaning-making we will lose the sense of the contrast (not by situations but by interpretations of situations...)), but which doesn't in the process take us too close to something implausibly intellectualist. By the latter I have in mind anything too literally interpretative - i.e. as when we aid our understanding by substituting the initially unperspicuous words of a text for certain other phrases which, for certain ends in a given context, can be taken as less opaque.

Now neither of these extreme readings - of 'situations', of 'interpretation' - is presumably going to find many supporters in an even slightly reflective psychological milieu. For on the 'external' side the very idea of a situation, especially as we encounter it in sociology, is of an event or context which is already run through with socially specified norms which pre-specify a range of correct, incorrect, apt, inappropriate, dismal or hopeful or what-have-you responses. And, on the 'internal' side the idea that our finding or discerning or imputing meaning in our situations is a function of anything as cognitively rich as something akin to genuine interpretation can hardly seem anything other than hyperbolic.

So on both the 'situation' and the 'interpretation' side we are, on reflective appreciation of what we could allow ourselves to sensibly mean by our talk of such matters, likely to want to slide towards the middle - taking situations as already to some degree meaningful without individual help from us readers of them, and taking what is being referred to here as 'interpretation' as to some degree a matter of sensitivity rather than of idiosyncratic and reflective making-something-particular-out-of-ness  (the 'how we interpret them in our thoughts' bit). But then, I want to ask, are we still really confident that we know exactly what we are talking about when we say now that psychological 'problems' are a function of interpretation rather than of situation? Can we really hold these two far apart from one another in an obvious and reliable way without them jostling up against / collapsing into one another in the middle? Can we avoid the defunct dualistic conception of the human as split into a meaningful interior which inhabits a meaningless exterior, and instead bring ourselves home to the embodiment of our dasein, the fleshliness of the social, whilst yet still holding out any hope that the PISS formulation can do anything for us?

Unemployment and social isolation are what social psychiatry identifies as amongst the most powerful causes of depression. Is it really a helpful take on this to come from family home into one's job in the clinic and say to one's patient 'but you're just caught up in an unhelpful take on your predicament me old mate'? 'Look at it this way: you have no commitments or responsibilities to anyone, you have a lot of free time to yourself; you're just taking a perfectly innocuous situation in which you happen to not be in frequent geometric proximity to others and laying on top of it all of this unhelpful interpretative paintwork by construing it evaluatively in terms like 'isolation', 'loneliness' etc.' Now of course no-one really thinks this, and I should probably stop taking the PISS so seriously. To talk in that way is just as absurd as to suppose that the causal effects of unemployment and isolation are brute de re facts akin to the causal effects on mood of, say, low serotonin (or what have you).

But my point, recall, is not in any way to try and position the causality underlying emotional problems as either meaning-involving or brute, or anywhere in between, but instead to put pressure on the idea that we really know what we're talking about when we say things like 'not due to situations, but due to our readings of them.' For the fact seems to be: that some, perhaps many, readings are a matter of uptake and not of (non-dynamic) projection; that some of the emotionally significant meaning is there to be found and not to be made; that the concept of a 'situation' is typically of something necessarily already meaningful - already woven through with trans-individual emotionally salient senses of significance; that both problems and joys (both our access to reality and impairments of that access) arise naturally and equally through an admixture of meanings found and imposed; that often problems emerge not from our interpretations of our situations but from the thought-and-feeling-and-understanding-numbing consequences of an instinctual defensive recoil away from those painful feelings that we avoid; that the 'interpretations' which we meet with in the patient are often enough the result of the distorting effect of defenses operating on feelings rather than something driving the problems-in-feeling under their own steam; etc. (To say nothing of the fact that, surely, some problems are somewhat brute - take the unwanted side-effects of certain psychiatric medications for example, or the impact of damage to this or that part of the brain.)

In fact, to get nearer to the psychopathological truth it seems to me that we have to become much more specific and phenomenologically acute about what we mean by our 'interpretations' of our situations. And at the end of this process, I submit, we might look around and find ourselves a million miles away from anything like the nice breezy PISS formulation and allied boxological models of the human condition. (We ultimately arrive, I would submit, at something which looks a lot more like the primitive embodied unconscious phantasies described by the psychoanalysts - phantasies that much more beset us than are entertained by us, phantasies which pay little respect to the laws of rational sense-making - than at anything that naturally invites us to engage in talk of 'interpreting'. But I won't try to make that case here! In any case, to imagine that one could promote the grasp, through a bare schematic assertion of the psychodynamic and phenomenological facts, of what is what here really would amount to the analytic kettle calling the PISS pot black.)

Read the PISS in as interpretatively charitable a way as possible and we arrive at something which one would have to be pretty much insane to deny. But also, I suggest, at something which will either need to be so vaguely broad, or so idiosyncratically finessed, that one would also have to be pretty much insane to imagine that its articulation in the clothes it normally wears could serve any fathomable human purpose.

Friday, 12 July 2013

mindfulness as patch

I've been wanting for a while to give some time to get clear in my thinking about why the current vogue for mindfulness meditation bugs me in the rant-inducing way it does. I think I've finally got somewhere with it, and in what follows I lay bare my objection.

Here is the first objection, which isn't very sophisticated! But honestly, as it seems to me: mindfulness meditation is boring. It can not only be boring to do. But it risks cultivating a kind of pervasive inner banality, a cucumber-coolness, in the practitioner. Here's a second objection: It is banalising in part because it risks entering into an unhealthy alliance with the massively banalising instrumentalist Gestell of our time. I should probably say what I mean by this...

But first of all here's something rather good about mindfulness: It takes us out, for a moment, of the endless for-the-sake-of-ness of too much of our everyday life. For a moment we have to stop. We might do mindfulness meditation because we've been told its good for our physical or mental health. But in the practicing of it the goal is a kind of goal-less-ness, the 'aim' is to simply be in the moment, in the in-and-out of the breath, in the present. And when the mind wanders off into the future or the past, in that particularly neurotic form of temporality in which we start endlessly ruminating, problem-solving, worrying - and when whatever is being done right now is only ever done for-the-sake-of what comes next - then the mindfulness practitioner gently and forgivingly brings it back to the present moment in which there is in the (non)activity, as it is practiced right now, no for-the-sake-of-ness. (I will now temporarily follow convention and summarise a) activities pursued within neurotic temporality versus b) engaged for-its-own-sake action with the labels a) 'doing' and b) 'being', although these terms are clearly not at all up to the task.)

Yet here's the rub: In doing this, we can easily end up i) spending our being-time in a state of just-sitting, or just-walking, or inwardness. And also then ii) carry on as usual in doing mode in the rest of our life. When surely, if we are living our life in an existentially alive and authentic manner, we will be living each and every active moment of it in a spirit of 'being'. So: Now I am doing therapy which has its own intrinsic values around human connecting, relating, loving, sharing, caring. Now I am playing my guitar and singing. Why? Well maybe sometimes it is 'to practice for a gig'. Maybe sometimes it is 'to relax' bla bla bla. But, well, most of the time, there it is, I want to play it, it calls to me from its stand in the corner of the room. And now I am making some good food, going for a run, working out, writing this blog post, laughing with my friends. Again sometimes there is instrumental value to be discerned in these (for example, if running was unhealthy as opposed to mental and physical health-promoting I probably would not want to be doing it). But on the whole they are sui generis goods done for sui generis ends. Or, if we prefer, they can be described as end-less.

So my worry about mindfulness is that it risks becoming a kind of technology of mental or physical good health that, far from unseating today's terrible instrumentalisation, the 'technological Gestell' as Heidegger called it, becomes something done as a piece of self-care so that the rest of the time we and our societies and our bosses and our workplaces can carry on exploiting us, inviting us to work for money, to 'work in order to live' instead of one's work being 'a living'. (Isn't it terrible, as an aside, to note how the very idea of 'a living' has become understood in financial terms.)

Now I know full well - well, I think I know this well enough - that I am a financially well-off well-educated middle-class person who is lucky in his work and friendships and general social set up etc. I have what many would see as a luxury of being able to 'be' in my various projects. It is all very well, Richard, criticising mindfulness as a kind of being which, in as much as it is not itself the form that our projects take - in as much as it is not only a kind of being-ness, but is also a form of project-less-ness - is but a poor cousin of that form of genuine being-for-itself-ness which informs living projects. But, Richard, you must remember that most of the tasks of the average working person are, well, really rather dull, necessarily instrumental, etc etc. They are ego-depleting, and this is why we need mindfulness as an adjunct to everyday life.

But, ok, yes, BUT! This is such a politically lame line to take, and also so massively existentially complacent. I know several very admirable fairly poor people who live existentially alive lives, who haven't got swept up into the whole house/car/mortgage/passive consumerist nonsense; who engage fully in what we might call 'DIY culture'; who are alive in their cooking and playing and relationships and parenting and also, often enough, in the way they undertake their work and in the work they do. It's just way too easy to suppose that alienated labour and consumer culture are the only options available for most people; and there are plenty of studies available now showing the false economy, in terms of real over-all quality of life, of working hard at depleting banalising alienating jobs in order to earn money to pay for holidays and other tonics.

Ok, ok, so this, you are telling me, isn't the fault of mindfulness. You're being ridiculous Richard! If anything mindfulness invites us to step back from the rat race, regain a little being in our lives that are so over-run by doing. Well, but my problem isn't with living mindfully per se (although if anyone invites me to suppose to simply 'wash the dishes when washing the dishes' or to 'tune into the taste and texture of every morsel of food in your mouth' as supposedly emotionally healthy aptitudes, I do want to invite them to mindfully pay attention to the feel of my boot on their backside), if by 'living mindfully' is meant: living in a largely non-instrumental manner. My problem is with the whole individualist, de-politicised, radically non-existential, conservative, tranquil-not-radical, nature of something which is so often now sold as a practice to enhance wellbeing. I want to encourage everyone to forget about mindfulness meditation practice, and instead to start living non-instrumentally in all aspects of their life. This might mean engaging mindfully (which does not mean: with a rather self-aware, very-slightly-smug, oh-so-equipoised, serenity-mongering, demeanour) in all of one's life projects. In other words, living fully, living out of one's 'id' (in Groddeck's, not Freud's sense - i.e. out of one's Being and not out of one's reflective self-consciousness), owning what one is doing, not using existential anaesthetics (capitalist-era defences like: slumping in front of the tv), etc. If mindfulness meditation becomes a name for passionate engaged non-self-conscious non-instrumental being-in-doing that characterises all of life then, yes, I'm all for it. But if it's something to be packaged at a workshop for those caught up in the stressy lives we all live today, then, well, forget it.

Friday, 31 May 2013

thinking about suicide

At the university counselling service I work in we sometimes have to be mindful of the impact of the deaths by self-killing of some students on others of the university members. To this end the manager of the service must announce these deaths - which are only occasional, and not in greater number than would be expected for this age group nationally - to the staff group. When this happens we don't seem to know what to do with what we are told. I recently tried to explain why I thought this was to my colleagues, but did so in a rather desperately unhelpful manner. So I now want to get some clarity on this here.

Here is the feeling I encounter in the meeting: that the fact of the death of a student sits there like a huge dead fish in the middle of the meeting, with us all staring at it in its gloaming palor, not knowing what to do with it. It sits there like a kind of inert body. We all know, in some way, that it is an unspeakable tragedy. But our lack of speaking does not reflect this unspeakableness. Rather it reflects a kind of stuckness.

And here is my diagnosis of the stuckness: It is hard to think about, we get stuck, because we live in a world largely dominated by a particular Gestell or episteme or enframing. We know that death is hard to think about, but this, I want to say, is because it is hard for us to know how to think about the significance or meaning of a death - that meaning being of course the meaning/s of the life that preceded it. And why is it hard to think about the meanings of a life? Heidegger's idea is that we are enframed by something he articulated in terms of technology, but which has more to do with a splitting of the living of a life into two components: our actions themselves, and the meanings of them which are now unhelpfully located in a future beyond the actions themselves. All has become instrumentalised, everything done for the sake of something else, the meaning of things always being located supposedly outside of and in front of them.

Examples of this, I think, are all around us. They infect my profession when it gets sucked into a utilitarian ethics in which therapy or mindfulness or whathaveyou is done for the sake of increasing the sense of wellbeing of the patient. They affect the workplace, where we end up 'working in order to live', or in order to play, or in order to earn money to go on holiday with - rather than working for working's sake, rather than work itself being a spontaneous playful intrinsically meaningful rewarding activity. We start to take it for granted that alienation from our labour will always be status quo. Rather than the meaning or purpose of activities being inside themselves, they are located elsewhere. We therapists are alienated too from the means of production - and sometimes unwittingly end up working to meet the agendas of the government's latest thinking about mental health, or the suggestions of NICE, or to meet the needs of the service or our boss, or to meet our own needs. We find ourselves talking too in nonsensical ways about 'suicidal ideation', 'cognitive restructuring', 'positive and negative thinking', 'managing your anxieties' and so on. These terms aren't describing the living of a life, the meaning and value immanent within it - they are technologised and alienated descriptions of a life lived at odds with itself.

The result of this, I suggest, is a kind of splitting of the living organism - the now inert body on the one hand, leached of its value and meaning, and on the other the now imponderable meanings of its life endlessly deferred into a future (into 'happiness', into 'holidays', into 'my salary / my pension', into 'quality of life' defined in hedonistic ways). We then get brought up against a fact of self-killing, and find ourselves blundering about almost not really knowing what to say - and start thinking in platitudinous terms like 'well they will get through this and then they'll be so grateful they didn't do it because now they're enjoying their life again', or what have you. We go mute at biological death because we're already muted and capitulated to existential death - the death of self-becoming, of living loving connecting intrinsically valuable relating open raw fragile vulnerable passionate frightened bold courageous quivering humanity. We capitulated thus by our unwittingly being caught up within the 'technological' Gestell, within the instrumentalised world in which value is located outside of the current moment of self-becoming. And we disguise from ourselves our awareness of our own existentially impoverished grasp of the meanings of dying and living through letting ourselves be taken up primarily with the trivial anxieties du jour - with the loft conversion, with the difficult colleague or neighbour who raises our hackles or ruffles our feathers, with the totally unfair rate at which we're paid, with the difficulties of managing risk, with the waiting list and reports to be written, and so on.

What do we do about this? Well, what do we do with the suicidal patient? Do we get caught up in trying to manage their risk? Perhaps a little of this is sometimes a good thing. But what we mainly need to do, surely, is good old fashioned psychotherapy, which attends to the felt and true risks of being - and of not being - existentially alive, rather than to the distracting risks of self-killing. Which attends for example to intolerable hatred 'turned against' the self; which itself takes the risk of making real, vulnerable, contact with the patient in their emotionality - contact between the patient and with who one is in oneself, that is, and not between the patient and some model or theory or technique or instruction we've inserted between us. The real risk, after all, is that our patient never comes alive - that we collude with their inner death through ourselves getting caught up in being nice or safe or jolly or banal - and not that they kill themselves. Existential suicide and infanticide are all around us; we are run through with it. What are we going to do about it?

Thursday, 30 May 2013

even if it's sunday may i be wrong

Consider e e cummings' passionate prayer:
e e cummings
may my heart always be open to little
birds who are the secrets of living
whatever they sing is better than to know
and if men should not hear them men are old

   
may my mind stroll about hungry
and fearless and thirsty and supple
and even if it's sunday may i be wrong
for whenever men are right they are not young
 
and may myself do nothing usefully
and love yourself so more than truly
there's never been quite such a fool who could fail
pulling all the sky over him with one smile

Here a hungry and supple loving openness to living the spontaneous song of life is pitted against something called 'knowledge', pitted against something to do with 'being right', religiosity, utilitarianism.

So what's the pitting? Is it fair; are the contrasts meaningful? Considered as conveying psychological wisdom the poem's message is perhaps apt, yet basically dull: May I be without fear, flexibly minded, not get caught up with needing to be right, not cleaving too firmly to received beliefs, etc.... Right, but poetically boring. And also, for such a reading we have the question: What's all that stuff about age, singing versus knowing, not being useful, pulling the sky over oneself with a smile? Have we just caught the most always romantic e e cummings in one of his more exuberant soppy moments?

So instead let's have a look through a philosophical lens. The one I'm shuffling into my scope right now is perhaps borrowed from Heidegger, but let's not be fussed with Heidegger exegesis here (this is just a blog post, ok). Here's a distinction to get us going: between originary discourse, in which the 'being' of things is disclosed to us, and representational discourse, in which a grasp of 'being' which has already been disclosed is now simply redeployed in a description.

A function of poetry on the one hand is to reveal things in their sui generic being to us. The poet intones 'A' and brings the being of A alive for us; the A-ness of A is evoked by her words; metaphors used here will be live ones. Poetic thought, furthermore, is thought to no purpose beyond itself. Poetry which descends into point-making, like some conceptual art which serves only to convey ideas which could equally be expressed in language, denatures itself as art.

A function of representational and technological thought, on the other hand, is to tell us which, of various already-grasped options, we have to do with in a particular case. The scientist says 'A is a case of F.' Any metaphors deployed here will be essentially dead. Here we have to do with thought not as originary evocation, but instead as a re-presentation of something already cognised. We don't give voice to phenomena, but instead merely talk about them.

An important theme in Heidegger and elsewhere is the way in which the very fact of the prior disclosure of Being in representational discourse is lost on us. The very fact of disclosure itself is lost on us, and because of this we are condemned to tacitly reiterate pre-understandings of Being which are only part of the story of what is, and try then through our metaphysics and epistemology to find ways to accommodate certain of the manifest facts about ourselves to a universe which has been pre-understood in an impoverished way.

Anyway, what about Cummings' poem? Well seen through the lens just offered I think a fuller range of its meanings become immediately available. Anyone who has listened to the song of little birds will, I suggest, find it baffling that they are just singing, that its not obvious that any why can or should be offered as to their singing exactly this, then, now, etc. (Though we can of course offer evolutionary and ecological explanations of their having and manifesting the ability to sing.) They are, as it were, pure expression, pure self-becoming, in their singing. Hearing this singing, being alive to the un-representing spontaneity of their singing, is better than any amount of 'knowing' or representational thought. Being 'right' too is a matter of representational matching. Better to be 'young' - to be close to the evocative pulse of life rather than stifled by unwittingly adopted dead metaphors - than to be one who is 'right'. And utility, too, is a matter of non-poetic thought: A is done for the sake of something outside of itself; it is not true to say of what is 'useful' that it is done 'for its own sake'; we are instead always thinking of doing A to meet end B. The image of 'holy' fools who fail (who are not in the business of representational fitting, success, aiming at extrinsically defined goals, but who instead are just pulsing with love and life) is, finally, one familiar to many of us in religious literature.

Another prayer of Cummings, this time of thanks rather than petition, ends:
(now the ears of my ears awake and
now the eyes of my eyes are opened).
A sui generic sensibility awakens to sui generic stimulation: here there's no danger of closed, old, correct, knowing hearts at all.

Thursday, 23 May 2013

on the compatibility of the different ways of understanding and not understanding schizophrenic delusion

As ought to be well known, psychologists are prone to conflate various different senses of the verb 'understand' when considering the question of the intelligibility of schizophrenic delusions. I'll outline a few forms and then consider their in/compatibility.

Thus we have an ordinary sense of 'understand' where I come to fathom what someone says or does in coming to see their reason for thus saying or doing - the end (Aristotle's 'final cause'), say, at which that speech or activity aims. It is this kind of understanding, surely, which Jaspers has in mind in talking of the un-understandability of the primary delusions of the schizophrenic person. Try as I might I can't make the reasons they proffer my own.

And we have another kind of 'understand' in play when I grasp, if it were as much as possible to do so, what neuropsychological mechanisms had temporarily become disturbed when someone is deluded. Perhaps in offering a causal explanation of this kind I can be said to be fathoming the 'material' or 'formal' causes of the change in psychological functioning that constitutes or underpins delusionality.

A further kind of 'understand' is in play when we think of how, say, a paranoid delusion may bring at least initial relief to its sufferer, by systematising, concentrating and (in an unhelpfully vague use of this term, which is at least a little less misleading than the 'explaining' function which the cognitive psychologist often posits as the cause of delusion formation) 'rationalising' the unbearable antecedent psychotic terror. It isn't exactly obvious to me which level of explanation this form of understanding is best pegged to. For example should we think of it as primarily referencing the subject's motivation - that the subject's forming and maintaining their delusion is motivated by a drive to reduce selfhood-disrupting terror? Or should we think of it in terms of the subpersonal lure of, as it were, an 'attractor basin' in the systemic dynamics of the brain's function - a replacement form of inner equilibrium which can kick in when equilibrium becomes hard to come by in the context of what might normally be those sustaining reality-contact-promoting brain-body-world-other-afferent-and-efferent feedback loops (certain of which have for the delusional subject become radically destabilised) - a replacement form, that is, characterised by an intra-neural short-circuit. Or perhaps those are two different levels of explanation of the same phenomenon?

Another kind of 'understand' is in play when we grasp how the delusion emerges out of prodromal disturbances of selfhood - of the sort that Louis Sass and Josef Parnas and Giovanni Stanghellini - i.e. phenomenologically minded psychiatrists and psychologists - are so good at characterising. Sometimes, as Sass suggests, this emergence may itself thematise aspects of the character of the prodromally psychotic mind - I think that it is following Heidegger (or Merleau-Ponty?) that Sass calls this 'emblematisation' (in the sense of 'emblems of someone's Being' (emblems of their form of Existence / being-in-the-world)).

And then we have yet another kind of 'understand' that comes into play when we grasp the 'symbolic content' of the delusion - in the way that psychoanalysts shed light for us on psychotic aspects of mental function. This, I suspect most important, sense of 'understand' concerns us with a particular mixture of causal and motivational factors that also reference a different ('autistic' or 'psychotic') mode of functioning (i.e. 'formal cause') of part of the self (nb when psychoanalysts talk about 'mind' they refer, it seems to me, to what most psychologists instead refer to by 'self': thus ego, id, superego are parts of the self, not of the information processing mind). Understanding delusions in this sense of 'understand' involves us in 'reading' them according to a certain pattern: as ways the patient is trying to meet their own libidinal / object-relational needs through a kind of surrogate and narcissistic/omnipotent formation. Coming together here, then, are factors about i) a particular (omnipotent/autistic) mode of function, ii) motivational dynamics and the defence mechanisms (projective identification etc.) used in attempts to meet, deny or destroy the emotional needs, and iii) association-governed 'symbolic' connections to provide a substitute content.

There are undoubtedly other forms of understanding too that can be brought to bear on the question of the formation or of the being of delusion. Many of these will be hybrid in character. For example, if I am to grasp the significance of a delusion of world catastrophe, I will first need to understand how aspects of the subject's selfhood and self-experience have become detached from the ('external') world, resulting in an 'autistic' or 'primary narcissistic' or 'omnipotent' mode of being. And then I will need to think of how what has now become the world (i.e. this subjectivised version of worldhood which is all that the schizophrenic person, in the delusional aspects of their being - i.e. in the ambit of their core psychotogenic complexes - has left to them) is experienced as ending. Thus we can say that the delusion of the ending of the world is the emblematisation of the destruction of the self, perhaps projected safely into the future (think of Winnicott on what one fears as already having happened).

But, yes, my main point here is that many of the forms of understanding we bring to bear on delusion are precisely not compatible with the form we started with - with, that is, the kind of understanding which, if I am right, Jaspers is referring to as being impossible with schizophrenic delusion. I cannot grasp a delusion as the product of to-me intelligible-to-hold beliefs and desires (Davidson's so-called 'primary reasons') or in terms of the ends or the facts or purported facts (which are what we normally mean by actual talk of 'reasons') proffered by the delusional person. If I could, then, (the standard interpretation of) Jaspers' story goes, we simply would not here have to do with delusion in any case. But also in the very bringing to bear of some of these other forms of understanding on the delusional beliefs we are, I want to suggest, already consigning them to the category of the un-understandable (in the ordinary, initial, sense). To offer, say, a defensive-motivational understanding of someone's believing what they do is to assert that an ordinary reason-giving explanation will not cut it here. As to which forms of understanding are and are not compatible with maintaining the propriety of the initial everyday-reason-giving form, well, try it out yourself using different examples. Even at the neurological level, whilst it is clear that ordinary believing will necessarily be subtended by any number of diverse neurological processes, if we are looking at accounts of neurological dysfunction, given that such function or dysfunction must itself surely be defined relative to (say) the reality contact or otherwise of the patient, the possibility even of such 'merely causal' forms of explanation will itself, it seems to me, impugn the sane status of the person in their believing what they do when they cleave to what are to be identified as delusions.

And, just in case its not obvious, why am I going on about this here? Well, psychologists are apt to say something like 'oh that terrible Jaspers, he said we couldn't understand delusions, make them intelligible, but this was to give up on the psychotic person and to fail to reach out to them as a sense-making subject'. My point would be that the ways in which we can and do understand delusion in fact precisely also implicate the delusional subject in a form of senselessness, in a failure of everyday meaning. Far from bringing a greater degree of interpretative charity to bear on the psychotic subject, the psychologist just described succeeds merely in muddying the psychopathological waters - as well as in missing the depth of psychotic damage and, one suspects, the terror attendant on it.