Monday, 26 December 2016

psychotherapy as ethics: the case of depression

In a month or so I’m to give a talk on‘psychotherapy as ethics’. The phenomena I wish to cover include making confession, calling someone out, calling someone to courage, therapeutic love, withdrawing projections of blame, and offering recognition. My guiding thought is that effective psychotherapy is therapy conducted precisely as what I call ‘an ethical relationship’. By this I don’t at all mean psychotherapy conducted in accordance with ethical practice guidelines. I also don’t mean psychotherapy conducted through moralizing – something against which, when met with in both self-directed and other-directed forms, psychotherapy has provided considerable bulwark. What I mean is psychotherapy which draws more from the understandings of what it is to be a human being living a human life we find in ethics than from what we find in psychology. What matters, I suggest, are the demands of love, the significance of accountability and responsibility, the value of truthfulness and sincerity, the meaningfulness of repentance and forgiveness.

In this post I want to explore a small part of the above - namely an important symbiosis of model and therapeutic practice (I hesitate to talk of technique) in the theory of depression, and how this alters significantly – including ethically - depending on the therapeutic approach. (I hesitate because, as I see it, such talk belongs more naturally to an instrumental conception of therapeutic action, and I should like here to take a stand against the impersonality of instrumentalism. However ‘technique’ may perhaps mean something different, and hence rather more valuable, within the context of ethical relationship.)

As the cognitive theory has it, depression is maintained by depressive beliefs, thinking habits, and passivity in life. I may for example think of others as untrustworthy, and so not engage with them, and thereby become isolated and lonely. Or I may imagine that whatever I do, nothing good will come of it. Perhaps this stems from aversive early experience. When I meet with others perhaps I habitually, maybe only semi-consciously, rehearse to myself what I imagine they really think of me, how they would like to treat me, etc. I am radically biased toward the negative in my views of self, situation and future (Beck’s cognitive triad). Furthermore, because I become inactive I no longer generate meaning, sense of efficacy, hope. As a consequence life becomes meaningless and depression becomes entrenched.

To combat depression the CBT therapist, in line with the cognitive theory, helps his depressed patient become better at spotting and defusing from or challenging their depressive assumptions, and to take action to generate meaning rather than passively wait for meaning to first appear before taking acting. (The ethic guiding this approach is, I believe, when all things go well, that of unpretentious accuracy and of collaboration in the therapeutic task. And so far so good – I hope we (therapists) all sometimes engage in such tacks and embody such an ethic.) But a difficulty is that depression often tends to relapse, and constantly challenging one’s own thoughts is itself tiring and demoralizing. And the depressive thoughts just seem so natural to the patient – they seem to flow effortlessly from the personality itself, and so questioning them seems to go against the grain, feels as if it itself manifests a lack of self-acceptance, courting further depression.

The psychodynamic theorist has a partly different model of depression. According to her there is within the personality a deeper psychological wellspring of depressive cognition than either core beliefs or the learning experiences from which, it is alleged, they sprung. And according to her this wellspring is motivational in character and hence characterological in instantiation: whilst the patient is (one imagines) honest about his suffering, and sincere in his conscious opinions and in his wish to not be depressed, there is yet within him something like an unconscious wish to be depressed. Not, normally, anything like a wish to suffer (contra the absurd-when-over-extended depressive masochism hypothesis), but rather a wish to avoid the challenges which not being depressed would present. I’m talking of the life-challenges of: allowing oneself to be constructively angry with someone who has wronged one, taking a strong and courageous stand for oneself; admitting one’s guilt and taking reparative action; facing the fear relating to uncertainty and living with existential courage; allowing oneself to truly mourn one’s losses and actually take one’s leave from people and ambitions who have taken their leave of you. Depression, as the psychodynamic theorist has it, is a narcissistic phenomenon: rather than face the unknowns and possible painful disappointments of Beck’s triad - the unknowns of whether one will be accepted by others, the unknowns of how the future will go, the unknowns of the opportunities or disappointments immanent within one’s situation – the depressive individual pre-empts fate and gets in there first. They trust in their own dismal appraisal far more than remain open to a world and a fate and an other beyond the safe horizon of their own mind. They choose to dwell in their own self-ratifying delusion-like ideas and thereby justify their withdrawal from the world. (Contrast the manic patient who more profoundly refuses to stay open to reality in its unknownness, instead choosing to refashion it according to his desire.)

There is a way to present the psychodynamic model which keeps it resolutely psychological rather than ethical in character. On such an approach what is avoided by the depressed patient are his feelings and their anxieties. On such a reading – which is what is met with in ‘affect phobia’-type reformulations – the avoided reality is intrapsychic. But such an approach falsifies the phenomenology. For what we encounter in depression is first and foremost someone turning away from the world, from others, from their responsibilities to themselves and to others, from the task of building something and continuing to build it in the future. This in particular is what involves us in an ethical, and not ‘merely’ a psychological, task.

If the psychodynamic theorist is right, then the reason why the depressed person often relapses after CBT treatment is because their changing their mind was not rooted in a change of heart. Challenge your thoughts and your beliefs all you like – but unless you challenge your motivationally-driven narcissistic disposition to form such beliefs in the first place, you’ll be left disposed to relapse. Unless, that is, you challenge yourself. (Challenging your self is ethical in a way that challenging one's beliefs is not.) Come to accept that, despite what you’d understood – i.e. that you were simply a victim of your depression – you are actually its perpetrator, latently motivated to espouse your depressed beliefs – and you have an opportunity for a genuinely existential choice. A choice to live differently. A choice to do better by oneself and others. A decision to make -  to live with more openness, with better grace, with less self-ratification. To take courage. To sow seeds not knowing if the rains will be good. To live according to an ethic of gratitude and risk rather than cautious self-reference.

What does this model inspire by way of therapeutic practice? Well for one thing, therapy now becomes a forum of ethical challenge from the therapist. The therapist’s job is to be collaborative, sure, but also gently, appropriately, respectfully, to challenge. The challenges will be ethical: do better by yourself! Do better with this life you’ve been given! Be courageous! Stop shirking! Don’t be such a scaredy cat! Be kinder to yourself! Be kinder to others! Be more open! Such challenges are a call to conscience. And so the patient has now to make choices, to make decisions. Therapy is no longer practiced in a collaborative fact-finding mode. It becomes an ethically fraught domain. Whilst the patient was unconscious of the motivationally driven character of his depression he had an excuse to not do better by himself and others. But now the therapist has pointed it out, he has no more excuse!

There will also be challenges regarding how the patient is treating the therapist. It’s here that the most potent work can happen. Imagine a psychoanalytic therapist who hid behind her expertise and simply offered descriptive transference interpretations regarding how the patient was treating her. Such a therapy would be a poor, bizarre and alienating thing. No doubt it’s respectful and potentiating to be maximally unintrusive on the patient’s agency – i.e. to ‘allow’ him to make up his own mind, take his own decisions, and thereby achieve a genuine self-possession, rather than having him bow before the expertise of the therapist and passively relinquish his moral authority. (For a patient to act thus would probably mean that he’d got sucked up in a positive idealizing transference – itself perhaps just a way to keep at bay, keep unconscious, a more troublesome negative transference.) But whilst accepting the value of this kind of therapeutic neutrality, imagine the disastrousness of a therapy which performatively took away what descriptively it proffered: i.e. which sapped any degree of emotional and ethical tenor out of the therapeutic relationship at just the same moment that it descriptively drew attention to precisely such dynamics. Which involved a therapist failing to offer any authentic degree of ethical engagement at just the same time she invites the patient to do better by her.

Here is the long and short of it. Patient: A patient has to decide to try to relinquish the negative transference and their other depressive tacit commitments. They have to make a choice – to try to step out of a world of dismal interpersonal expectation, and start to live as if love and meaning were real possibilities. The moment of trust to be taken is in a therapist they can't yet see, a good therapist, waiting off scene, screened by the transference. The patient who first wants reasons to live thus is missing the ethical point. Therapist: A therapist who hides behind a merely collaborative relationship, or who retreats into making de haut en bas interpretative pronouncements, is failing to offer an ethically alive relationship. Failing to meet the patient where he is. A therapy which doesn’t have the patient sometimes being angry and sometimes apologizing is probably no therapy at all. For any genuine challenge to a patient will involve an accusation: that he is actually not, despite what he is inclined to think, doing his best by himself/partner/therapist. And the therapist too will not always do well by her patient, becoming chummy or expert, becoming didactic or passively listening, and so does well to apologise as and when required and to constantly reorient herself to the good.

Friday, 23 December 2016

antidepressants

The best antidepressants are compounds; take the ingredients separately and the results are less powerful. The two I'm thinking of are:

i. Courage: What are you afraid of? Discover it and face it. Remember that courage is existential in the sense that it can be taken. You don't have to passively wait for it to grown inside you; you don't need to first not feel anxious. Courage is about stepping up.

ii. Self-Acceptance: What are you feeling? Accept your feelings without judging yourself for having them. Whether you're sad or angry or envious or excited: smile on this. If you're sad then, well, that's what you're feeling.

Sometimes we're encouraged to challenge negativistic or ruminatory thought. But perhaps it accurately reflects your underlying feelings. 

What may need challenging is not your thoughts but you yourself. Take courage in your life! Go on! Accept your feelings graciously; act on your world courageously!

where did bleuler's autism go?

When Eugen Bleuler coined 'autism' for us he propounded it as the central explicatory feature of 'schizophrenia' (another of his coinages). (Thirty years later Kanner and Asperger famously took it up as the name for a developmental condition - but the difference between infantile and schizophrenic autism was that the former involved a failure to enter the affectively-constituted, meaning-stabilising, intersubjective world, the latter involved a dropping away from it into private fantasy and unaccountable trains of thought.) Bleuler's concept of autism was multi-faceted. The schizophrenic psychoses, he declared, are


characterised by a very peculiar alteration of the relation between the patient’s inner life and the external world. The inner life assumes pathological predominance (autism). The most severe schizophrenics, who have no more contact with the outside world, live in a world of their own. They have encased themselves with their desire and wishes (which they consider fulfilled) or occupy themselves with the trials and tribulations of their persecutory ideas; they have cut themselves off as much as possible from the any contact with the external world. … This detachment from reality, together with the relative and absolute predominance of the inner life, we term autism.


Bleuler explains that his term is nearly coterminous with Freud’s autoerotism but that he chose a new term because Freud’s greatly expanded sense of eros/libido can be misleading. He also explains that unlike what he saw as Janet’s quite general concept of ‘loss of the sense of reality’ (diminished ‘fonction du réel’) , he considers autism to characterise the patient’s reality relation only in the ambit of her complexes. Autism for Bleuler means a circumscribed withdrawal from reality - into what today we might call a ‘psychic retreat’ (Steiner) or ‘autistic enclave’ (Tustin) - which withdrawal provides the condition of possibility for the flourishing of delusional experience and thought.

A key aspect of Bleuler's autism is its psychodynamic intention. There are three central aspects of this. First, the autism Bleuler describes involves a world of private fantasy in which wishes and fears are considered realised. This indicates a form of mentality which Freud described as no longer subject to the so-called reality principle but instead governed by the so-called pleasure principle. Second, Bleuler's autism involved a motivated retreat to this world - i.e. away from an interpersonal world that was overwhelming, and towards a private substitutive domain. Third, central to Bleuler's autism, and a key reason why he was not happy to go along with Janet's conception of a generally diminished fonction du réel is that he saw autism as only affecting the patient in the ambit of her complexes. Someone may be perfectly in touch with reality when this reality is not challenging to her sense of self-worth, when it doesn't remind her of her failures or unmet desires or shame. But trigger such complexes in someone with a schizotaxic disposition and autism supervenes; it is not that the patient retreats to their own delusional and idiosyncratic solipsistic domain. 

This essentially dynamic conception of autism is lost in the contemporary formulations of Sass, Parnas, Stanghellini et al. Marvellous and hugely illuminating as their descriptions of autism are, they typically deny that psychodynamic matters enter into the heart of the autistic condition itself. At best they are conceived of as secondary withdrawal reactions to a primary disturbance in general pre-reflective attunement. But were autism really a deficit merely in vital contact with reality then Bleuler would never have coined the term - instead he'd have made do after all with what Janet's take on diminished reality contact (l'abaissement du niveau mental - due to loss of psychological tension and lost vital contact with reality. 

I just used the phrase 'vital contact with reality' which belongs to Eugene Minkowski. Today's phenomenologists view Minkowski's work on schizophrenia (in La Schizophrénie (1927) and other works) as the profoundest exploration of that topic yet. Sadly my French is terrible and his book hasn't been translated, but from what I've read of the other works it seems clear that the general assessment of Minkowski's phenomenology is right. Here we meet with no crass psychologising of schizophrenic psychopathology, but a deep exploration of the disturbances in intersubjectivity and temporality and spatiality which we meet with in the existential foundations - rather than the psychological upper storeys - of the schizophrenic mind. But what strikes me about such of Minkowski's work as I have read is its peculiarly delibidinised quality. Matters of sexuality are given a secondary place in the structure and function of the human psyche. They are not - by contrast, say, with the phenomenologist Maurice Merleau-Ponty (or others today, such as Jonathan Lear) - seen as ontologically central in the being of the human. Instead they are seen, as it were, as 'merely' psychological. The matter of our conflicted struggling with bodying-forth in our bio-motivational drives is relegated to a kind of disturbance of mental content rather than to a disturbance in the unfolding of mental form. I'm not going to try to make the case for all of that here, but instead turn to an example from an essay by Minkowski on the 'interrogative attitude'. The case he cites is that of Paul C, a socially withdrawn 17 year old schoolboy. Here I borrow the abstract provided by Louis Sass:
Paul C. had long been overly logical and precise in his style of thinking. An acute disturbance began with mental fatigue along with apparent obsessive symptoms (e.g., extreme monitoring of his own actions) to the point that simple, everyday actions became very time-consuming; he also developed a tendency to ask endless questions even about trivial phenomena. However, unlike those of the true obsessive, Paul's monitoring, doubting, and querying seemed to lack any emotional or personal element; he was not anxious but, rather, apathetic. Also, Paul lacked real curiosity: To him, everything had the same level of importance, and his attention was not directed by any precise or personal goal.
This paper argues that Paul's interrogative attitude was actually a form of autistic-schizophrenic thinking characterized by "pragmatic weakening" and a loss of vital contact with reality, which are consequences of a weakening of the "élan vital" with its "vital propulsion toward the future." Such patients retain their intellectual powers but do not use these powers in accord with the requirements of reality. The interrogative attitude can be seen as a compensation mechanism—a way to maintain some minimal contact with the world. The paper ends with psychotherapeutic recommendations.
The paper provides a brilliant description of Paul's diminished élan vital - a Bergsonian concept (although nb Bergson developed various of his concepts out of his reading of Pierre Janet's book on neurasthenia - Bergson's 'attention to life' being somewhat synonymous with Janet's 'reality function' - (cf Pete Gunter's interesting essay on Bergson and Jung)) - but provides scant information about his inner emotional life. Early on we are told that the beginning of this seventeen year old boy's condition 'goes back approximately nine months. Paul started complaining about a lack of energy and mental fatigue. Some time before this, he seems to have been preoccupied with questions of a sexual nature; he would question his father and ask him for explanations, revealing a complete ignorance of the subject.' This is the last we hear of any explicit mention of sexual preoccupations; later Minkowski opines that  The sexual curiosity that appears at the outset of the illness, which could be considered for that reason a point of departure, can only be a precursory sign of the interrogative attitude that takes a firm hold afterwards. In any case, it is this attitude that must be rectified before attending to anything else.’  But, well: why on earth can it only be considered that?! How odd that the central preoccupation of a (of any!) seventeen year old boy should just be lost from view in this way!


There are however some clues as to the possibly psychosexual significance of Paul C's symptomatology. Thus of two significant symptoms we find that one involves taking more than an hour to put the handkerchief under the bolster before going to sleep (don't ask me why these dudes were putting handkerchiefs under their bolsters in the first place). When asked for explanation Paul said that 'he wants to make sure that the handkerchief does not hang out anywhere beyond the bolster under which it is placed.' (Freud would have a field day!) Another symptom is spending hours in the bathroom. When asked for explanation all we get is the description of what Minkowski calls his 'morbid rationalism' - i.e. perseverative non-instinctual unstructured hyper-reflective devitalised thought and action. Why all this should happen particularly in the bathroom and bedroom, and what drives it all in the first place, is missing. When it comes to cure, Minkowski provides Paul with work on copying and translation. The occupational cure gets him somewhat engaged with reality again, but we can hardly imagine a less nocturnal (i.e. delibidinised) activity. We are left in the dark as to whether he has managed to integrate his instinctual life, we are left in the dark too as to why his soul is dirempting itself in the manner described. The meaning of Paul's initial attempts to put his struggles into words (his questions to his father about sex) are simply ignored. (Witness the fate of many a schizophrenic mind?)



Bovet & Parnas tell us that they think Bleuler's autism got lost because of his unhelpful psychodynamicism - and that if we just stuck to a Minkowski/Blankeburg line in our phenomenology we can develop a psychopathology that maps more neatly onto the biogenetic neurological drivers of the condition. I don't disagree with the significance of the neurological and the genetic to the development of schizophrenic pathology, but why our conception of the  biological should be thought to exclude the motivational and dynamic in this way is beyond me. Surely one can't get more neurobiological than instinctual matters such as the libidinal drive. Poor Paul C, it occurs to me, may well not seem to have managed its integration at all. (Let's face it, it's hard enough for the saner amongst us.) A properly psychoanalytic account is an account of the vicissitudes of the drives - that is, of such structures as are of their nature at once motivational and biological. For whatever largely constitutional, or perhaps sometimes also environmental-developmental, reasons, an inability to integrate the interests of the drive within the developing personality leads - so the theory goes - to massive defence formations, the creation of autistic retreats and delusional worlds, etc. ... 


Far from the psychodynamics being unhelpful, it seems to me to be key in understanding why it is that schizophrenia tends to develop in late adolescence - with the psycho-socio-sexual challenges of that time. But what it also does is allow us to understand a key further part of Bleuler's concept of autism - that it precisely doesn't stand either for some quite general abaissement du niveau mental or for a quite general loss of vitality, but instead refers to a state of mind only sometimes in the ascendant. Bleuler's idea is that it is just in the ambit of their complexes that the schizophrenia sufferer partakes of a way of being which pulls the inner and the outer worlds apart so destructively. A basal deficit theory, by contrast, not only provides less hope by way of treatment, but also less by way of understanding of the ebbs and flows of autism in the inner life of the patient. I would like to put it back to Bovet & Parnas: might it not in fact be the loss of the motivated-retreat-from-consensual-reality aspect of Bleuler's autism, and the development of quite general accounts of self-world undoing which treat not at all of matters of personal meaning and motivation, that set the concept of autism back so?



Wednesday, 21 December 2016

on hallucination and fonction du réel

I've said before that a hallucination is a 'negative' of a sensory expectation. I kinda expect you to walk through the door. You don't. And so your 'ghost' walks through.

But what is striking about hallucination is that the expectations aren't cancelled by reality itself. If they were then, after all, we wouldn't hallucinate!

This experience, I've claimed, is like always lurching on stepping onto static escalators. But much of life isn't like that.

Much of the time we manage to get disappointed. We achieve relief. This happens instantly. And so we don't 'see ghosts'.

So we need to understand more about why, sometimes, we don't assimilate to the situation of the thwarted expectation.

I suggest it can be due to a failure of mourning. Sometimes it isn't bearable to assimilate the absence of the beloved. So we hallucinate her.

But sometimes it's due to - let's-call-it - gormlessness. We're not really adequately looped in to reality. We're drifting trancily, hypnopompically, into doolally land, into the land of wish-and-fear-fulfilment.  (This is not a structurally different phenomenon than a failure of mourning.) 

We do this when we're tired and we do it when we're overwhelmed.

Vital contact with reality - in which sensorimotor expectations are updated through an engaged participation with a reality which we have afforded the opportunity to update us thus - is an essential precondition for non-hallucinatory acclimatisation. Someone who seduces themselves, or is thrown, into the twilight zone of omnipotent wishful and fearful phantasy, does not get auto-updated. So when reality does not conform to their expectation they 'see' or 'hear' the antithesis of their expectation.

This is a very different kind of explanation than the one the psychologists like to give - of 'you hear what you expect to hear'. Their explanation ignores the role of a recalcitrant reality. ... Or at least: this is an explanation of why we might 'see' what we expect to see. It doesn't wander off into pseudo-scientific talk of 'interpreting visual stimuli' etc etc; that is, it remains properly ontological. 

Tuesday, 6 December 2016

what's the point?

Some contexts support the question 'but what's the point?'

Perhaps you go to work only to earn money - you don't much like your job - and then you're told 'Well, you can come in today, but there's no money to pay you.' The question finds ready application here.

Instrumental activity - activity done to some independently specifiable end - always has 'a point'. That's the point of it.

Other contexts don't support the question. You are singing in the shower. Now, what's the point of doing that? (No good answer.)

My point isn't that there's no point; but rather that here we have neither point nor pointlessness.

Or: we might say here 'there's no point to it', but the point I want to make, here, is that the absence of point here is different from the kind of pointlessness which aptly marks other actions. Thus the absence of point here could be called 'ontological' rather than 'ontical'. We meet here with an activity with respect to which point is not aptly sought, rather than with an activity which could rightly be said to fail to achieve something - fail to attain a goal which, were the action at all aptly suited to meeting it, would have given said action a point.

To be sure if someone forced the question on us then we'd most likely find a way to force it to make some or other kind of sense. We might answer 'Well, I was expressing my joy!' Or 'It's my private singing time!' Or 'Duh, it sounds better in here!'.

Suffice it to say that these aren't answers to the same question - the question as individuated by its meaning rather than the words it contains - as asked in the instrumental context. These answers force the question into the shape more naturally filled out by 'Why do you do that there?' or 'What appeals to you about singing in the shower?' or 'What were you expressing in there?'

Depression pretends to us that our life is an instrumental context. It then pretends that we do well to mobilise the question whenever and wherever. Indiscriminately.

'But really, what's the point of any of this?' it asks.

I suspect that depression is able to deploy this conjuring trick because it rests on a prior alienation of a subject from her life. No longer a living bundle of praxis, I look on at my life from the outside. It seems to me, now, that I can always ask why I should engage with this or that. It seems to this disengaged, alienated onlooker, now, that meaning must obtain antecedently to or as the independently specifiable telos of action.

Or I look at the future and wonder why I should go there. What reason do I have for thinking it holds something for me? In fact can't I think of several reasons to doubt that it has much on offer?

So depression tries to lure us into a conversation to be had solely on its terms. We're invited to see all our activity under the rubric of pointfulness or pointlessness, and then to endlessly debate (God, how boring) whether there is or isn't some or other point to doing anything we or others might actually do.

Well: nice one, depression! But you can't fool us so easily these days. We've learned how to fend off scepticism about meaning and knowledge without falling into the trap of answering it (which already concedes far too much). We've learned how to question the presumptuousness of this question-subliming impulse. (Subliming: ripping a concept out of its intelligibility-conferring context and blithely wanging it about überhaupt.) We've learned about the illusory nature of much sceptical doubt. We've appreciated just how very narcissistic it is to arrogate to one's own noddle - rather than to the life already underway - the provision of the requisite intelligibility-conferring context.

Many junctures of living are, I suggest, neither pointless nor pointful. So there's often no point asking 'what's the point?'

Now, how about asking some other questions? The one's that depression has squeezed out. Questions like:
How can I live today in a way which I can feel proud of?
What can I do by way of today making something more beautiful than otherwise?
How can I make someone happy?
How can I further something I value?
What would a courageous approach to this day look like?
How can I body forth as a confident bundle of autochthonous energy, rolling forth into its milieu in such a way that it allows itself to become something, someone, instantiate rather than merely track meaning, create liveliness, create art, write in an idiom which deprecates justification, glow?
Such questions don't resolve the driver of the underlying alienation, but they do at least disrupt its compounding through sceptical, depressive rumination.