Sunday, 30 August 2015

on the intentionality of wish-fulfilling thought and behaviour

In recent work Tamas Pataki tells us that not-quite-so-recent philosophical attempts (Gardner, Brakel, Lear, Hopkins, et al) to rescue and do justice to Freudian wish fulfilment and Kleinian omnipotent phantasy by offering sub-intentional or pre-propositional accounts of such phenomena are often superfluous - since the everyday scheme of intentional, belief-desire, explanations for action will often suffice, so long as it itself is comprehended in its true depths. (Pataki gives us the best account we have of wish-fulfilment; Petocz gives us the best account we have of symbolism: these Australians are really sewing up the whole field... Oh, I ought to note: the following thoughts are based on my reading of Pataki's 2015 paper (in the book edited by Boag, Brakel & Talvitie) rather than of his 2014 monograph.)

As Pataki describes it, wish-fulfilling phantasy (of the sort found in dreams, daydreams, psychotic delusions, hallucinatory gratifications, actualisations in the transference, acting out, etc.) is described by Freud both in terms of the wishful representation of wishes as fulfilled, and as the creation of beliefs that such wishes are fulfilled. The latter is the interesting notion: nobody has ever doubted that we sometimes like to imagine our wishes being fulfilled, but what is motivating both for daydreamers and for neurotics is the possibility of achieving not the frustrating recognition that this is mere imagination but rather a temporary 'substitutive satisfaction' from the fantasising.

As Pataki describes it, the reasons why Gardner et al tend to opt for sub-intentional (non-agential, brutely causal) accounts of dynamic wish-fulfilment cluster around the difficulties allegedly attendant on the idea of unconscious yet purposive action (think: Sartre's regress argument against inner censors who must both know and not know something at the same time). Pataki, however, holds out, with Freud, for an intentionalist explanation of wish-fulfilling phenomena such as masturbatory fantasy, parapraxes, play, art, lucid dreams - by contrast, say, with normal dreaming, infantile wish-fulfilment and some defences. He does so because of the way in which much self-deception is intelligible as a form of self-consolation (i.e. as motivated quelling of psychic pain).

To make the case for the promise of intentionalism Pataki invites us to consider the following case from the Sandlers:
A patient, a successful scientist in his own field, came to analysis because (amongst other things) he had a severe work problem. He could, in fact, produce the work required of him, and had made several notable contributions in his field. He had previously had analysis for some years, and at the beginning of his current analysis it seemed that all the well-known factors causing a work difficulty of the sort he had were present. His need to delay getting down to work till the very last minute was quite clearly an oedipal problem, in which he could not allow himself to feel that he had satisfied oedipal sexual and aggressive wishes by working well. It was also seen to be part of an anal-retentive tendency, which had persisted for most of his life, and so on. Analysis of his fear of success, of his need to hold on until the last moment, and of many other elements that were clearly related to his work problems did not do more than give him greater insight ... Eventually ... the significant function of his symptom became clear. By allowing himself to get into a state of anxiety, and by creating a feeling of great internal pressure as the time passed and his work was not done, he could recreate, to a degree which was almost hallucinatory in intensity, the feeling of being nagged at and even screamed at by his mother. It became clear that he used his symptom to re-experience an object-relationship, one in which a wished-for sado-masochistic relationship with his mother was actualised. However, what was present was more than the simple sexualisation of anxiety, but a real need to feel secure by re-experiencing the earlier relationship to the mother, even though he had to pay a rather painful price for this. (Sandler & Sandler, 1978, pp. 290–291) 
Of this patient he says:
There is, we may assume, good reason why he wants to experience mother’s presence, painful to be sure, but satisfying the patient’s overriding need for security or attachment. Can this wish-fulfilling end—that it be for the scientist as if mother were present—be achieved non-intentionally?
Notice that the panic that the scientist manufactures is not the product of a single stroke. What we would find is endless procrastination, strolling, eating; a veritable programme of postponement. In other words, the strategy invades more or less every corner of his life and intentional projects: a thousand intentional acts pointing in the same direction.
In response to this I find myself thinking that, yes, if we accept along with the Sandlers that their patient is intentionally making himself excitedly anxious then the argument goes through rather well. But the question of whether we find unconscious intentional explanation satisfactory in general will also affect the kind of motivational meaning we're disposed to ascribe to the particular case. Thus some chap may experience the idea of fluent success as anxiogenic, since it threatens the perversely comforting identification with the punitive mother - risking her wrath, as it were, if he branches out on his own into accomplished action. This anxiety could however then simply (i.e. non-intentionally) cause the diverse procrastinatory self-soothing, anxiety-discharging, behaviours. It may not be, that is, that the diverse procrastinations are themselves intended as ways to secure professional failure, but rather that they all provide momentary relief from the fear that the thought of success engenders. What knits them together is perhaps, then, not the unity of a singular purpose but the unity of that fear which causes them. (On re-reading this I wonder if I'm here influenced by Jonathan Lear's thinking on repetition compulsion: not, he says, a compulsion to repeat, as if the repetitiveness and the effects of it as such are themselves desired, but a repetition merely caused by a failure to overcome a problem for which the same old failing solution is, in the absence of others, endlessly attempted.)

[post-script: Tamas responded to me with this nice question: but why does the Sanders' patient choose just these ways of procrastinating? He is suggesting that we can only understand the patient's choice of these kinds of behaviour if we take into account his understanding of the consequences of acting thus. My counter would be: Yes, if we do start by taking these procrastinatory behaviours as chosen, then we will want to know, as we rightly do for choices, why they were chosen, and yes, a psychoanalytic account does here give us a good way of answering that question. But, I suggest, maybe they are (properly described as being) done without (yet being properly described as) being chosen. One can't always ask for what purposes behaviour is done like this rather than like that - much behaviour is a function of our morphology, training, identifications, classical conditioning, etc. And every behaviour that is chosen is itself performed in ways which are themselves not always best thought of as chosen. Really the question is: how deep do purposes go? I follow the general hermeneutic tack of thinking that we best serve psychoanalytic thinking by never ascribing more intentionality than absolutely necessary (but, well, it goes without saying that I do think it is much more often necessary than, say, the CBT pundit is inclined to think!). ... I think there's another interesting point here. Let's accept with the Sandlers and Pataki that the procrastinatory behaviour has the effect not merely of quelling anxiety but is also itself positively rewarding (e.g. it itself enacts a comforting if perverse object relation). Even so, rather than thinking here of unconscious choice and motivation, might we not serve ourselves well enough here with the mere concept of conditioning? The person ends up doing the behaviour more because of the reinforcement contingencies that are operative, rather than because they are aiming at and achieving a goal...? ... Thinking about it, it's a really interesting (and, I suggest, non-factive) question - when do we feel the need for, and when do we lose patience with, a notion like 'unconscious choice'?]

At any rate, I am straying a little from my original purpose in writing this post which was instead to think first of the importance, when entering into such debates, of becoming as clear as possible about the marks of intendedness - before, that is, considering whether or not unconsciously motivated action is intended. Rather than start with an assumption that we confidently know without having to reflectively specify what it is for an action to be intentional, and so can straight up consider the question of whether or not there can be unconscious intentional activity, I want to look to the prior question of what it means to talk of intentionality.

There seem to me to be two typical marks of intentionality. The first is the way in which someone's diverse behaviour coheres around a telos, can be seen as answering to their desire, etc. Geoff gets up and walks to the fridge, picking out a beer, and sits back down. Here much of our grasp of his action's defining telos - i.e. of its intentionality - is given simply by our appreciation of its shape. In fact it would be odd to suggest that any smoothly performed temporally extended action were non-intentional - it is not a matter of our having to provide evidence for its intendedness but rather of our needing to provide specific defeating conditions (e.g. someone is in a trance) if an ascription of intendedness is not to go through automatically.  The second is what someone says when you ask them why they did something. As Anscombe puts it:
What distinguishes actions that are intentional from those which are not? The answer that I shall suggest is that they are the actions to which a certain sense of the question “Why?” is given application; the sense is of course that in which the answer, if positive, gives a reason for acting. (Intention: p. 9.) [The answers in question are those provided by the agent on being asked 'so why did you do that?']
It is a fact about human beings, one that conditions the shape that our discourse on intention takes, that these two marks tend to hang together rather consistently, at least much of the time. This may perhaps be partly explicable in terms of innate wiring, but I rather suspect that it mainly comes from the ways in which enculturation and development inculcate just such binding structure in us, as we are nudged, through our initiation in the diverse discourses regarding accountability, towards being implicitly governed by a constitutive and constituting ideal of coherence between avowal and action (probably I'm plagiarising Julia Tanney here).

However when philosophers talk about whether intentions are conscious or unconscious the way they tend to take this question is in terms of whether someone is aware of having the intention in question. The idea seems to be that I am able to avow my intentions, when I am, because I am inwardly conscious of them. (This of course automatically contradicts what I claimed above was actually one of the two marks of intentionality - namely what someone says in response to a 'why' question. ... Yeah yeah, these philosophers would probably claim I am a logical behaviourist; I on the other hand claim they are hyperbolic mentalists. Like Ryle, at least, I'm not trying to reduce (by specifying sufficient conditions) mind to behaviour, so it's really just odd to call us logical behaviourists.) This whole idea of inner awareness, however, seems to me to make a big mess of things. There is simply no reason that I can possibly imagine (but can you? ... really?) why we should typically construe avowals of intentions or desires along the lines of quasi-perceptual judgements that we have such and such desires or intentions. Judgements, after all, are avowals of beliefs - vide the looming infinite regress. (Or: if I can avow my belief straight up, why can't I avow my desire or intention straight up?) No, there is no phenomenological evidence, and much grammatical counter-evidence, to support construing avowals of desires and intentions as reportative, as based on an epistemic appraisal, right or wrong, of how things stand with us. The whole idea is so radically self-alienated that it beggars belief. After all, when I tell you my desire or my intention, what I typically do is not speak about, but rather speak directly from, my desire or intention.

What is interesting to us as depth psychologists is our sometime inability to speak from that which, on the basis of the shape of my dispositions to otherwise express and act, otherwise appears as a warrantably ascribable desire or intention. These are the cases that we call cases of 'unconscious' desire or intention. It is, I suggest, simply a fact that people sometimes go on in this disjunctive manner, simply a fact that there is no guarantee, metaphysical or neurological, of any perfect match-up here between their talking and their walking. (From this perspective, Libet et al's observation that directed action can temporally outrun avowal seems not so very interesting - and the idea that our will is illusory to itself be an illusion caused by foisting onto the discourse of intention an epistemic apparatus (of introspection) which has rather little to do with it.) (In all of this I am, I think, hugely influenced by John Hyman's paper on blindsight.) By saying that this is itself 'simply a fact', what I am denying is that there is some further fact of the matter - the alleged fact of whether or not the person actually has a standard-issue intention which has just got partially put out of reach. Instead what I am suggesting is that we here encounter an ontological rather than any alleged epistemic feature of that which we call 'unconscious intention' - that the 'being', as the existential phenomenologist would put it, of an unconscious intention is a different being than that of a regular intention - that unconscious intentions are marked by the peculiar absence of avowal in a creature which (unlike an infant) is perfectly capable of such avowals in other non-complex-related instances. 

Having set out my stall above I want to come back to Pataki before deploying my critique. So, in thinking about what it is that is unconsciously intended, Pataki (like Freud) makes reference to the concept of an unconscious belief. The case under consideration is one of Freud's: a girl can't go to sleep at night unless the pillow is not touching the bedstead. Freud's understanding has to do with oedipal jealousy: the girl wants to separate her mother and father, she believes that by separating masculine bedstead and feminine pillow she will separate them, so she separates them. Against this it could be objected that it is, as it were, too mad to believe that one's mother is a pillow and one's father is a bedstead - so mad that the beliefs can't be ascribed whilst still continuing to do their job in helping us make sense of what she does. But Pataki rightly insists that this identity proposition is not the content of the unconscious belief, which is rather something like 'if I separate the pillow and bedstead then I will have separated my parents'.
Believing this proposition is not the same as, nor does it presuppose, believing that her parents were identical with the furniture. The sorcerer who sticks pins into an effigy doesn’t believe that the effigy is his enemy. The distinction underlying the difference here is between one thing operationally symbolising another and that thing being believed to be identical with the other. And both of these circumstances can be distinguished from a third, where one thing is functionally equated with another: where there is a Segalian symbolic equation. 
So we have identity beliefs, symbolism proper, and symbolic equation. If I understand him right, Pataki is saying that whilst there may be an 'as if' stage in the middle of 'I wish to separate my parents - by doing X it is as if I can achieve that - now that I have done X I believe that my wish is fulfilled', this does not affect the cogency of the ascription of the final belief (although presumably it does affect the cogency of the belief!). I will come back to this.

The next point that Pataki makes is that, following Freud, hallucinatory wish-fulfilment succeeds because it regressively draws on primary process thought in the following way: by withdrawing attention from reality nothing contradicts the hallucinated fulfilment of the wish, and so the belief in the reality of the hallucination 'goes straight through' as it were.

For the sake of the discussion let us accept that there is something right about Freud's account of the girl's oedipal anxieties causing her obsession about her pillow. (I myself find it perfectly plausible, and think that those who baulk at it tend to be simply rather unacquainted with the shape, presence and character of unconscious phantasy - it does after all take a long time and patience and the working through of several defences to start to get one's eye in to this dimension of human life. Unless one does this then one's appreciation of the Freudian account will probably just be bogus - based on a merely theoretical, and emotionally dishonest and idealising, grasp of it.) Now, here's the difference, as I see it, between myself and Pataki. We are both uncomfortable with attributing a belief in the identity of pillow and mother to the girl, but he is more comfortable with attributing to her the belief that her wish that mother and father be kept separate is in some sense satisfied, whereas I am not. I feel no less uncomfortable with the latter than with the former.

Here is my basic gripe. It seems to me that there isn't any obvious fact of the matter as to whether the girl believes that by separating the pillow and the headboard she is effecting a separation between her parents. Thus if you ask her this, she may well say either 'no I don't believe that could work' or, 'oh goodness, yes it was as if I was somehow dreaming or believing that' or 'I did think that yes'. In some sense she did believe that (to summarise it glibly:) the voodoo would work, in other senses she didn't. The closer we get to thinking of belief, as we sometimes rightly do, as governed by a constitutive principle of rationality (a la Davidson), the further we get from wanting to speak of the girl believing that her action could satisfy her wish, or believing that her wish is temporarily satisfied. The closer we get to a conception of belief that has to do with emotional and bodily action tendencies, or to our not asking certain questions of ourselves or of our situation or of others, then the closer we get to wanting to talk here of belief. And the more we allow ourselves to play with partitive ideas of selfhood, the more we are disposed to save for the rationality and thereby, to the extent that the rationality constraint is speaking to us, save the belief. But I just don't see that there is anything that could make me think that some of these proximities make for greater respectful accuracy in playing the language-game of belief ascription. Rather, surely, they just reflect the kind of indeterminacy that obtains in that game itself.

In truth I think the best answer from the girl would be something like 'oh yes, I did kind of think that', a bit like she was reporting something that she dreamed she believed. (When someone says 'In my dream I thought...' they are, I believe, not telling us that they actually thought something, but that they dreamt that they thought something... cf Malcolm on Dreaming.) This is an important point, it seems to me, about the grammar of dreaming and of phantasising. The very moment we give it propositional articulation is (unless one is psychotic or delirious) also the moment of insight, release, and mental structuration: the past tense ('I did kind of think that') is obligatory. (And note, the psychotic never avows beliefs as such - they tell us that the CIA is after them, not that they believe that the CIA is after them.)

I want to avoid a misunderstanding. Someone might say of me 'oh, you're just an anti-realist about beliefs - you're a coherentist or some-such, taking the reality of the belief to consist merely in the explanatory work that positing it can achieve' (think Dennett). Well, no, that's not what I'm saying. In pointing to the ways in which the criteria for belief can come apart I'm both, in pointing to the diverse criteria, actually (unlike those who just take for granted that we intuitively know this so don't have to think about it) specifying what the reality of belief consists in, and in pointing to the disjuncts, noting the somewhat exceptional indeterminate cases. Further, let us imagine someone trying to keep separate two allegedly different scenarios. In the first the girl really does believe that her wish has been effected - this is how she can allow herself to go to sleep. In the second it is somewhat as if the girl believes that her wish has been effected - this is why she can go to sleep. Well: how would we tell these cases apart? I don't mean that question in an epistemic spirit - I mean, rather: what does the putative difference actually consist in? And look, I don't want you to now give me a story about separate selves or what have you -  that, at this point, would just be to be doing metaphysics in the disreputable sense of that term. What I want is to know the practical difference in ascription conditions.

So it seems to me that there is a good dialectical reason why we ought with Hopkins opt to talk of 'pacification' rather than the 'fulfilment' of an unconscious wish. The reason is this: that the act of hallucinatory wish-fulfilment is not just an abrogation of reality-testing in that kind of way we might (by falsely reporting, or by creating illusions) mess with someone else's head. It is rather a (benignly intended, sure) assault on the structure of the ego itself which temporarily damages the integrity of the wish, the perception of the object, and the relation to reality. Hallucinatory wish fulfilment and unconscious phantasy are simultaneously fudges on satisfaction and fudges on the intentionality of the wish: the cost of substitutive satisfaction is the simultaneous degrading of the intentional character of the desire. Speaking purely from an ontological point of view, a wank is never as good as a fuck, and the hallucinatory kingdom of Yeats' faeries is definitively lacking in life and soul. It won't do to say that the desire still 'aims at' something (e.g. the breast) outside the mind, but the baby (e.g.) has fooled himself that he truly is at the breast and this is why he is now pacified. The pacification is as much a degradation as a satisfaction of the wish. My challenge to anyone who thinks otherwise is: convince me what here would even make for a substantive difference between the two.

One other thing struck me about Pataki's chapter. He tells us in it that we needn't think of wish-fulfilling self-deception as 'mad', and this because it yet aims at self-solicitude. Here however I think I want to draw a distinction between solicitude on the one hand and fobbing off or hypnosis on the other. It seems to me that fooling someone that their desires have been realised is not much of an act of solicitude, and there's something even shabbier and ego-degrading about fooling oneself. Part of what makes me think of it as, precisely, itself making for madness is the way in which it damages reality-contact: it un-hinges the mind from the world and leaves it without that grounding animal bedrock of world-embeddedness. But it is not just that the mind's feet are pulled up into it and out from under it by wish fulfilling phantasy, but that the mind's necessarily non-reality-oriented faculty of imagination is simultaneously bent out of shape. The mind most becomes itself when it comes to entertain what it acknowledges as not the case; undoing this makes not for satisfaction or solicitude but for the undoing of imagination itself.

To return to the beginning: how do we distinguish between mere wishing, wishing that is satisfied, and wishing that is 'fulfilled in phantasy'? I think we ought to acknowledge that the last is a term of art, that it relates to a set of tendencies in human beings to achieve lulling through gulling, but where the gulling in question no more amounts to the satisfaction than to the regressive dismantling of the wish.

Thursday, 27 August 2015

does cognitive therapy rest on a mistake?

...first draft of a psychological critique of CBT to complement the philosophical one I produced a couple of years ago for the OUP Philosophy and Psychiatry Handbook ... this one to be submitted to BJ Psych Bulletin after I've improved it... The title, by the way, is me riffing on John Heil's (1981) excellent Mind paper 'Does cognitive psychology rest on a mistake?'.



Summary



The theory and practice of cognitive therapy grew out of Aaron Beck's dissatisfactions with psychoanalysis in the 1950s and 60s. He replaced an understanding of depression as motivationally driven by an avoidance of anger with one of it as incidentally maintained by negative automatic thoughts. Along the way the aim of therapy also shifted - from the restoration of self-possession to the achievement of self-management. In this paper I argue: that Beck's scientific reasons for abandoning psychoanalysis were mistaken; that his clinical reasons are best formulated psychoanalytically rather than cognitively - in terms of the transference relationship; and that cognitive therapy’s limited understanding of that relationship risks it delivering an under-powered therapy.



Introduction



Aaron Beck, the founder of cognitive therapy (CT), was a psychoanalytically-minded psychiatrist who became disaffected with the psychoanalytic theory and therapy of depression popular in mid-twentieth-century America. On reading and listening to his descriptions of his own standard-issue thinking and practice as a psychoanalytical psychotherapist we readily understand his disaffection. The psychoanalytic theory of depression he describes appears emotionally remote and intellectually recondite. Rather than being meaningfully grounded in and constrained by a living, phenomenologically sensitive, emotional connection with patients’ inner worlds, it is brought to bear on them from without, as if it were merely an independently intelligible psychological hypothesis being used to causally explain some experiential data. The therapeutic procedures he describes also sound disengaged; we hear nothing of his own emotional experience of being with the patient, and little comes across of the quality of his patients’ inner struggles, conflicts and evasions. Over time Beck courageously challenged the validity of his own deeply held psychoanalytic theory and practice. But rather than go on to challenge the adequacy of his epistemological framework to frame a more meaningful and sensitive encounter with the dynamics of his patients’ inner worlds, he instead jettisons the very idea of the latter’s significance. Therapy now becomes just about attentional training and intellectual disputation; occurrent emotional connection and disconnection become not means to understand and refigure the inner world, but matters of merely facilitative or obstructive significance to the cognitive training. In what follows I trace one theoretical and one clinical track from Beck’s rejection of psychoanalysis to his invention of CT and highlight the losses to clinical theory and practice that accrue along the way.



Depression, Anger and Dreams



An important theme in psychoanalytic psychopathology has depression resulting from the suppression of anger toward valued others. Rather than risk the feared fall-out from expressing his anger, the patient unconsciously depletes himself, trading that sense of self-worth which his angry sense of injustice presupposes for the stability of his relationships. This idea forms but one strand of the complex psychoanalytic conceptualisation of anger's relation to depression (Freud 1917; Busch 2009; Lubbe 2011), but is widespread in both popular and clinical culture for good reason. Clinically we discover, again and again in the more straightforward cases, i) a depressed person who avoids her anger by downgrading her sense of her own value, shutting down her self-assertion, wrongly construing herself as perpetrator rather than victim of a relational injustice, seeing herself as deserving of treatment which neutral others would consider unjust, and denying the significance of her unmet emotional needs. In more complex cases however we find ii) masochistic self-abasement added to this anger-avoiding dynamic: hatred towards another breaks through the attempts at self-suppression and gives rise to intolerable guilt, and this in turn inspires self-punishment where the anger towards the other is 'retroflected' (taken out on the self) leading to further and darker depressive misery. In clinical practice the therapist finds the recovery of energy and mood going hand in hand with the reinstating of apt outer-directed emotional expression, self-esteem and assertiveness as the patient learns to tolerate his hate and guilt and address his relational difficulties in an open, constructive and honest manner. Many effective psychoanalytical psychotherapies base almost their entire therapeutic rationale and method on this psychoanalytical foundation (e.g. Frederickson 2013).



It was as a reaction against the above-described psychoanalytic theory of depression that a young, American, psychoanalytically-minded psychiatrist and dream researcher developed the theory and practice of cognitive therapy. Following a helpful personal experience of psychoanalysis, Aaron Beck treated several patients using standard mid-century psychoanalytic methods, applied (albeit unsuccessfully) for membership of the American Psychoanalytic Institute, and published several papers both on psychoanalytic psychotherapy and on the quantitative investigation of the themes of his depressed patients' dreams (e.g. Beck & Hurvich, 1959; Beck & Ward, 1961). Reading these today we learn in particular of his scientific interest in the increased prevalence of thwarted, deprived, excluded, rejected, injured and ashamed themes in his patients' dreaming lives, and of his clinical interpretation of these along psychoanalytic lines.



Already in these early papers, however, we find a curious feature which presages his later rejection of psychoanalysis: although most of the themes Beck describes (e.g. 'I was in a restaurant but the waiters would not serve me'; 'Everyone was invited to the party but me'; 'My fiancée married someone else') appear interpretable in terms of i) the simple hypothesis of motivated self-depletion, Beck surprisingly interprets them all in terms of ii) the more complex and compounded dynamic of self-hatred: the depressive's misery is always seen as deliberately rather than incidentally self-inflicted - as reflecting a 'need to suffer' (Beck 1967, p. 179). Dreams such as not getting food that is requested, or being rejected - themes which in themselves appear to reflect little more than a need to portray the self as worthless relative to others - are instead counter-intuitively seen as 'the representation of self-punitive tendencies ... the depressed person feels guilt about his ego-alien drives and punishes himself for them.' (Beck & Hurvich, 1959, p. 54). However Beck's later experimental and clinical investigations - including his patients'  negative reactions to interpretations that were overly organised by this prior theory-driven hypothesis -rightly led him to doubt whether many of his patients really were motivated by self-hatred ... but as a result he then threw out the entirety of the baby of the venerable psychoanalytic theory of depression along with the counter-intuitive bathwater of an over-reaching masochism hypothesis. Now the project of providing a psychological explanation as to why the patient is driven to think and feel and act in depressive ways is abandoned; depression collapses into a merely habitual rut of self-maintaining negative thought, feeling and behaviour. The question we must ask today, then, is why Beck was so compelled by ii) the masochism hypothesis that it overrode his recognition of the sufficiency in many cases of i) the simple psychoanalytic hypothesis of depression as motivated self-depletion.



The answer to this is not apparent in the early papers, but Beck's later writings provide an important clue. Here he tells us that what he was actually trying to do in his early research was establish the clinical psychoanalytic theory of depression on a firmer scientific basis by providing quantitatively ascertained psychological evidence of unconscious anger in the dreams of his depressed patients (Clark, Beck & Alford, 1999; Beck & Beck 2012). Although he didn't report it at the time, what he found is what has also been established since (Barrett & Loeffler, 1992): that as a group depressives have fewer themes of anger in their dreams than non-depressed dreamers. This however puzzled him as he had understood the Freudian idea of dreams as the 'royal road to the unconscious' (Freud, 1913) to mean that feelings which were unacceptable to the waking patient ought to show up straightforwardly in their dreams (Clark, Beck & Alford 1999, p. 50). The finding of fewer rather than more angry themes in depressives' dreams therefore appeared to contradict the psychoanalytic hypothesis of depression as resulting from suppressed anger. But by interpreting the very dreaming of all and any miserabilist themes by the dreamer as masochistically motivated, Beck is for a while - until he finds independent evidence of the implausibility of this interpretation - able to save the psychoanalytic theory that in depression we meet with difficulties with anger.




Looking back, the most striking thing in this story is Beck's misunderstanding of a core strand of the psychoanalytic theory of dreaming. According to Freud (1913), dreams serve to protect the dreamer's sleep by helping prevent her anxious recognition of unacceptable emotions, such as anger towards loved ones, which anxiety would otherwise cause waking. Dreaming may be understood as the processing of emotionally significant experiences, especially of the previous day, where by 'processing' is meant the alignment of the meaning of emotional experience with one's (realistic or distorted) sense of self. The wish-fulfilling construction of self-diminishing dreams can then be one way in which a dreamer can manage the anxiety caused by what would otherwise be recognition of the perceived undeservedness of slights and injustices. Accordingly, the 'road' to unconscious emotion provided by dreams may be 'royal' compared with that of a mind filled with the myriad preoccupations of waking life, but hardly so straight as to make for the ready applicability of the theme-counting methods of empirical psychology which, as is well known, Beck went on to make the mainstay of his scientific methodology.



To sum up so far: A central plank of CT's origin myth has it that it developed out of an apparent scientific disconfirmation of the clinical psychoanalytic theory of depression as a motivationally explicable state. But in retrospect what seems most likely to have happened is that an inappropriately simplistic quantitative methodology was deployed to assess an unlikely theory of dreaming; that an implausibly general theory of depressive masochism was developed to save the floundering analytic theory; and that when this general masochism theory was dropped for good reasons the whole idea of inner motivational dynamics - i.e. the whole idea of a depth psychology - was jettisoned. As we will see below, the resultant psychology offers the depressive the hope of release from an allegedly self-maintaining rut of depressive thought and feeling through the effortful achievement of cognitive self-mastery. At the same time it eschews the promise of helping patients find motivational meaning in their suffering, reinstate a relatively effortless self-possession, and enjoy the consequent reversal of self-diminishment.



NATs and the Transference



As described above the development of CT's psychopathological theory rests on its rejection of the prevalent psychoanalytic notion of depression as unconsciously motivated. The development of CT's psychotherapeutic technique, however, rests on its rejection of the centrality for psychotherapeutic practice of what psychoanalysis terms the 'transference relationship'. A curious aspect, then, of Beck's development of CT is that it was actually inspired by his encounter with, and dawning realisation of the clinical significance of, his patients' transferences to him.



First a note on 'transference': A defining preoccupation of psychoanalysis is with how our immersion in relationships which inspire concern and attachment - such as those with psychotherapists, partners, parents, employers etc. - so readily elicits unrealistic fearful and idealising expectations concerning others' views of us. These relentlessly maintained emotionally charged expectations are seen by psychoanalysis as at the root of much psychopathology, and their manifestations are known as negative and positive transferences. They can be easy to attend from, as it were, but powerfully difficult to attend to - i.e. they are often unconscious, and their patterns are typically transferred from one significant other to another over time (Fried, Crits-Christoph & Luborsky 1992; Andersen & Chen 2002). The task of psychoanalytic therapy is the patient's emancipation from distorting transference patterns, a task prosecuted by first facilitating the flourishing and then the subsequent emancipation from the transferences between patient and psychotherapist, an experience that may then generalise to the transferences in the rest of the patient's life. Much of a psychoanalytical psychotherapist's training has to do with cultivating his ability to be emotionally touched, yet not inexorably swept along, by the patient's transference so he can think about, experience, describe, and help liberate the patient from, her unconscious emotional habits.



To return to CT: As Beck tells the story (Beck & Beck 2012), he had a patient who would lie on the couch each session and regale him with lurid tales of her sexual exploits, whilst he sat back and offered somewhat by-the-book psychoanalytic interpretations of the content of whatever it had occurred to her to say. At the end of one session however Beck's humanity got the better of his method and he asked her how she was feeling; she replied 'anxious'. Beck first suggested, in an interpretation focusing only on intra-psychic issues, that conflicts about sex were making her anxious. She responded, however, to the effect that her real worry was not intra-psychic but inter-personal: her worry was that he was bored by her. From this Beck describes how he began to see 'that there's a whole stream of pre-conscious thinking that goes on that the patient doesn't normally communicate to the analyst' (Beck & Beck 2012) - especially pessimistic, biased, black and white, over-general irrational thoughts about what the therapist thinks and feels about the patient. Beck came to call these transference expectations the patient's 'negative automatic thoughts' (NATs) and, drawing on the ‘rational therapy’ of Albert Ellis (1962), went on to develop a significant range of procedures to help the patient attend to and challenge their NATs.



There are several striking things about this narrative. The first is that Beck the psychoanalyst appears to have been practicing a rather remote form of psychotherapy which was more concerned to offer theory-derived hypotheses about the content of what the patient said, than to emotionally engage with how and why she said it or listen out for what she wasn't saying. The result was on the one hand that, despite her clear lack of inhibition in talking about sex, Beck still interpreted her anxiety as due to sexual conflict, and, on the other, that we hear nothing about what it felt like to Beck to engage with this particular patient (his countertransference). The second is that it is when Beck shows a real interest in his patient, actually asking her how she feels, that she is able to acknowledge her transference to him, and they can understand it together. We do not hear whether her anxiety about boring Beck was consonant with her everyday anxieties about what, say, other men thought of her, but we do at least arrive at a moment of emotional connection between the two of them. As the therapeutic relationship is strengthened (by Beck's concerned question about her actual feelings), the emotionally alive experience of the transference (her worries about what Beck thought of her) also begins to be acknowledged and worked through, and remote speculation about intra-psychic conflict is thankfully foregone.



The third striking thing about Beck's narrative, however, is that no sooner is this therapy-potentiating emotional experience of the transferential context encountered, than it is set aside. Anyone who has been in psychotherapy will know how replete it is with holding back acknowledgement of one's thoughts and impulses for fear of the therapist's disapproval, despite such fears speaking right to the heart of the emotional difficulties which brought one to therapy in the first place. Notwithstanding the simplicity of the 'fundamental rule' of psychoanalysis to 'free associate' - i.e. say whatever is actually on our mind - the fact is that no-one can actually follow it (Lear, 2014, p. 83), since we naturally associate away from rather than towards conflictual emotional preoccupations (Frederickson 1999, p. 169). This is why the therapist's job is often to listen not so much to the content of what is said as to performative matters of style, timing and omission. Beck, however, construes NATs as merely incidentally hard for the patient to articulate and challenge - due to a lack of attentional training and rational ability – rather than because of their emotional valence. It is in part because of this that CT risks providing a significantly underpowered therapy - one that substitutes a coaching relationship for an encounter which, by keeping itself on the experiential pulse of emotions alive in the room between patient and therapist, is itself therapeutic.



Cognitive therapists are often accused of downplaying the importance of the therapeutic relationship, but as psychologist Judith Beck (2010) explains, this is false; cognitive therapy 'requires a good therapeutic relationship. Therapists do many things to build a strong alliance. For example, they work collaboratively with clients ... ask for feedback ... and conduct themselves as genuine, warm, empathic, interested, caring human beings.' However, as psychoanalytical psychotherapist Jonathan Shedler (2015) replies, ‘This is the kind of relationship I would expect from my hair stylist or real estate broker. From a psychotherapist, I expect something else. [Beck appears] to have no concept that the therapy relationship provides a special window into the patient’s inner world, or a relationship laboratory and sanctuary in which lifelong patterns can be recognized and understood, and new ones created.’ Shedler's optimism regarding his hair stylist and estate agent perhaps warrants some cognitive restructuring, but his point about the therapeutic relationship stands. A relationship which is not merely instrumentally useful (as in CT), but itself intended as a unique vehicle of change (as in psychoanalytical therapy), is one which both activates the patient's latent transference fears (that the therapist is untrustworthy, angry, etc.) whilst simultaneously providing enough of a working alliance to challenge such fears in real time. With a merely collaborative and empathic focus the opportunity will be lost for a powerful eliciting in the present of the patient's true emotional preoccupations. The result is rather like trying to conduct a behavioural exposure therapy for a phobia without physically encountering the fearful stimulus, or like a chat between two adults about the difficulties of a child left waiting in the next room. Without the negative transference being activated and understood in the room, the prospect of an intrinsically, rather than merely instrumentally, therapeutic relationship is lost. [footnote: A prevalent myth about psychoanalysis and CT is that the latter focuses on the present whereas psychoanalysis unhelpfully spends an unnecessary amount of time looking at a patient's childhood. The reality, however, is that whilst both therapies attempt at times to understand the present in terms of the past, the focus in CT is often only on what has been happening over the last week, whereas in psychoanalysis it is largely on the patient's here-and-now live emotional experience of the therapist.]



Conclusions: Self-Management and Self-Possession



Therapies of all stripes aim at furthering self-knowledge, but talk of 'self knowledge' is ambiguous. On the one hand, as we find in CT, it can refer to an intellectual achievement: of coming to know such and such facts about our own psychological functioning. Such knowledge can with luck and courage be put to instrumental use: we learn to identify our cognitive pitfalls and - guided by enhanced skills in rational self-challenge, self-care and self-management - reform the unruly mind and free ourselves from psychological ruts. On the other hand, as found in psychoanalytic psychotherapy, it can mean what we could call an ethical achievement: of taking responsibility, mustering authority, cultivating character, and acknowledging - in a moral rather than factual sense - one’s thoughts and feelings. Coming to know one’s own mind, in this sense, is not of instrumental but rather of intrinsic value: it already means not a cognizance, but the relinquishing, of one’s defences, and coming to live as an increasingly self-possessed, integrated subject. The intended result is not that one comes to speak more knowledgeably about one’s thoughts and feelings, nor better control the recalcitrant denizens of the mind, but rather that one can now identify with and speak directly from them; not correctness but truthfulness is its goal.



CT understands itself as a technology to, in the words of a popular self-help CT book, help you ‘manage your mind’ (Butler & Hope, 2007). As a development from a variant of psychoanalysis which offered merely intellectual insight it is surely to be commended. As he describes it, Beck moved away from offering hypotheses about his patient’s unconscious which, whether they were right or wrong, were no match for his taking a real interest in her experience of being herself. Furthermore, intellectual self-knowledge, and the self-management it instrumentally makes for, do have an obvious if limited value, as too do the warmth and honesty of a good therapist (Ablon & Jones 1999), and the behavioural and experiential elements that provide the 'B' in contemporary CBT (Jacobson et al 1996).  The question I have raised in this paper is whether psychotherapy can’t be very much more than this, and whether CT’s dismissal of the psychopathogenic and psychotherapeutic significance of unconscious motivation and of working in the transference might jeopardize its ability to provide that something more. In particular, without the patient coming to recognise, own and relinquish her attempts to defensively avoid her feelings in the relationship with the psychotherapist, the clear risk is of supplementing an already exhausting project of defensively managing intolerable feelings with the further project of cognitively managing their symptomatic products. The result may be temporary symptomatic improvement but the cost is longer-term characterological and developmental stasis.



References



Ablon JS. Jones EE. (1999). Psychotherapy process in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology, 67:64–75.



Andersen, S.M., and Chen, S. (2002). The relational self: An interpersonal social-cognitive theory. Psychological Review, 109, 619-645.



Barrett, Deirdre & Loeffler, M. (1992) Comparison of dream content of depressed vs non-depressed dreamers. Psychological Reports, 70, pp. 403-406.



Beck, A & Beck, J. (2012). Aaron T. Beck, M.D. Interviewed by Judith S. Beck, Ph.D., Beck Institute for Cognitive Behavior Therapy. Available: https://www.youtube.com/watch?v=7BZp7ZiAE3c [accessed 23.8.2015]



Beck, A. T., & Hurvich, M. S. (1959). Psychological correlates of depression: 1. Frequency of “masochistic” dream content in a private practice sample. Psychosomatic Medicine, 21, 50-55.



Beck, A. T. (1967) Depression: Clinical, Experimental, and Theoretical Aspects. Philadelphila: University of Pennsylvania Press.

Beck, A. T., & Ward, C. H. (1961). Dreams of depressed patients: Characteristic themes in manifest content. Archives of General Psychiatry, 5, 462-467. 



Beck, Judith S. (2010) Cognitive Behavior Therapy: Myths and Realities. Huffington Post. Posted 7.11.2010. Retrieved 11.9.2015. http://www.huffingtonpost.com/judith-s-beck-phd/cognitive-behavior-therap_b_638396.html



Fredric N. Busch. 2009. Anger and depression, Advances in Psychiatric Treatment, 15 (4) 271-278.



Butler, Gillian and Hope, Tony. (2007). Manage your mind. 2nd edition. Oxford: Oxford University Press.



Clark, D. A., Beck, A. T. & Alford, B. A. (1999). Scientific foundations of cognitive theory and therapy of depression. New York, NY: John Wiley & Sons.



Albert Ellis (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.

Jon Frederickson, 1999. Psychodynamic Psychotherapy. Philadelphia: Brunner/Mazel.

Jon 

Frederickson. 2013. Co-Creating Change: Effective Dynamic Therapy Techniques. Kansas City: Seven Leaves Press.



Sigmund Freud 1913. The Interpretation of Dreams. New York: Macmillan.



Sigmund Freud 1917 Mourning and Melancholia. SE 14, 239-258.



Fried D; Crits-Christoph P; Luborsky L. (1992). The first empirical demonstration of transference in psychotherapy. The Journal of Nervous and Mental Disease 180 (5), pp. 326-31

Jacobson, N. S., K. S. Dobson, P. A. Truax et al. (1996). A component analysis of cognitive behavioural treatment for depression. Journal of Consulting and Clinical Psychology, 64, 2, 295-304.



Jonathan Lear 2014. Integrating the non-rational soul. Proceedings of the Aristotelian Society, 114, 1, 75-101.

Trevor Lubbe. 2011. Object Relations in Depression: A Return to Theory. Hove: Routledge.



Shedler, Jonathan. 2015. The therapy relationship in psychodynamic therapy versus CBT. Psychologically Minded. Posted 18.3.2015. Retrieved 11.9.2015. https://www.psychologytoday.com/blog/psychologically-minded/201503/the-therapy-relationship-in-psychodynamic-therapy-versus-cbt

Tuesday, 11 August 2015

two suspicions

Which statements, in what we read or hear, we take to require justification or elucidation before their espousal becomes something contemplatable to us depends on our temperament, their clarity, how outré or quotidian they may be, how closely they sail to the winds of something we all already recognise as fantastical. And when we are doing philosophy our interrogations that press for meaningfulness may - I will be claiming - take two forms. I was schooled in the first but, it now seems to me, only the second is intellectually respectable.

In the first I demand something that could properly be called a 'conceptual analysis'. The very idea of analysis carries with it a reductive notion of decomposability, in particular, it carries with it the idea of the legitimacy of pressing for necessary and sufficient conditions. The analysis demands that whatever is now blithely being talked about in certain terms ought with cognitive effort to be able to be further cashed out and captured in other terms. We are, I think, now largely well aware of the futility of the reductionism this mode of inquiry espouses when it turns its attention to, say, 'analysing' the use of ascriptions of so-called 'mental states' in largely non-mental terms: behaviourism and functionalism being the main culprits. But we rarely pause to question the general motivation of this form of suspicion - why it should be, in particular, that everything is urged - on putative otherwise pain of vacuity - to conform to the form of the physical particular. Or perhaps, more simply, why everything is urged to conform to the form of something else - everything that is except the physical particular. Here the motivation seems all too often churlish. Smug and settled in our competence at identifying physical particulars and negotiating questions of their function, we insecurely and narcissistically make irritable demands that other matters conform to their scheme, pressing this with a requirement for necessary and sufficient conditions where the conditions will be found in the domain of the physical. We make demands on the conceptual scheme rather than on ourselves; rather, that is, than ourselves attempting to make genuine accommodations that take the form of cultivating an additional and deeper sensibility to see and receive in a settled way what is autochthonous in artistry, sacredness, motivational depths, permutations of love, moral truth, sartorial prowess, mathematical insight, and political purpose.

In the second I acknowledge that I may just not be attuned to the sui generic character of that, which perplexes me, about which statements are being proffered. But I nevertheless carry with me a suspicion - not that what is being stated cannot be reduced to terms of my choosing, but that it involves a conflation or blunder of some particular sort. My suspicion here is positive - I do not take myself to enjoy intelligibility just whenever I might press for justification - why on earth, after all, should that demand of mine itself be taken to enjoy some universal decontextualised warrantable pass? But I have in mind some distinctive possibility of failing to make proper sense in the judgements that I'm presented with, and on this basis I press for a rebuttal of my charge of tacit hokum.  'Look', I say to the new-agey supernaturalist, 'you are carrying on about 'energies' and 'fields' and other woo-woo but all along you seem to be running together two quite distinct language-games - one to do with physics, the other to do with the psychological. Your slippage is simply a form of symbolic equation, a failure to keep apart the metaphorical and the literal, the symbolic and the real, the imaginary and the perceived.' Or, to the Platonist, 'Look old chap, it seems to me you've got in a muddle about numbers - you've started treating them like they are things located somewhere, things that can be encountered and known by us, and in the process you've lost your reflective grip on the sui generic form of the intelligibility of the mathematical.'

The second form of suspicion is more tempered, it takes the burden off the interrogated subject and puts it back on the philosopher, and it makes a much more congenial bedfellow to that other impulse in philosophy - the drive to awaken our diverse sensibilities, to get our multiple eyes in, to the whole ontological panoply of humanity, nature and the infinite. An impulse, a bedfellow, we may call 'wonder'.