Monday, 23 December 2019

trans dignity

Maya Forstater, a tax expert, was a visiting fellow at the Centre for Global Development (CGD), a thinktank campaigning against poverty and inequality. Her contract wasn't renewed in March this year after she made (amongst other statements) the claim on twitter that 
What I am so surprised at is that smart people who I admire, who are absolutely pro-science in other areas, and who champion human rights and women’s rights, are tying themselves in knots to avoid saying the truth that men cannot change into women (because that might hurt men’s feelings).
This the CGD deemed “offensive and exclusionary”. At a tribunal hearing Forstater affirmed her view further:
I don’t think it’s possible for someone to change their sex … [although] it’s possible to change it on a birth certificate ... I don’t think people could literally change sex. 



Judge J. Tayler, a UK employment judge, ruled against her
I conclude from … the totality of the evidence, that [Forstater] is absolutist in her view of sex and it is a core component of her belief that she will refer to a person by the sex she considered appropriate even if it violates their dignity and/or creates an intimidating, hostile, degrading, humiliating or offensive environment. The approach is not worthy of respect in a democratic society.
Further, he denied that Forstater's belief that men cannot literally change into women counted as a 'philosophical belief', and his determination that her appeal against dismissal failed - an appeal made on the basis of the claim that her belief was protected since it was philosophical - was made on this basis.

'because that might hurt men's feelings'

So why does Forstater talk here of 'men's feelings' - rather than either 'people's' or 'trans women's' feelings? Is she to be taken to mean that we shouldn't let a concern about hurting the feelings of half the population get in the way of telling the truth? No - since the vast majority of men wouldn't have their feelings hurt if it's said that men cannot change into women. So why talk here in what appears an awkward manner of 'men' rather than of 'trans people' or 'some people'? One reason could be to try to hurt trans women's feelings. Whether we should - if that were the intent - draw any legal implications from it is another matter: if someone's recalcitrant about having said a mean thing (whether or not it's true or false, deliberate or unintended), or hides their animus behind their ideology, when should they not have their contract renewed? This presumably depends on content and context, and will be a matter of judgement. Another reason (that was helpfully pointed out to me by someone who read this post) would be to make a feminist point about the radical difference of order of i) (some of) the (serious) physical threats experienced by (some) women from (some) men and/including (some) trans women and ii) the (mere) emotional hurts experienced by anyone (including of course: men) when spoken to in particular ways. If there's a real issue of a significantly increased actual risk of (and not just an increase in worried feelings about) physical threat from certain trans women relative to that from (other) women - if trans women are allowed into e.g. women's changing facilities, prisons, etc. - then the point stands. (It might be important here to demonstrate how the trans treatment issue differs from, say, the profiling issue arising when police stop and search young black men. These men are, it turns out, on average more likely to be violent (because of their social backgrounds) than young white men on average, yet the social and personal costs of acting on such group-based expectations of violence are generally thought to be high. If one agreed with that anti-profiling perspective, then one might need to show why the greater risk of allowing members of the group of trans women into female facilities is to be taken into account when deciding whether they can use the facilities.) The only further point I want to make here is that we shouldn't just appeal to Forstater's intent (to mean one thing rather than another) here in determining her culpability. It's not just the point that she's trying to make, but the readily appreciable effect of what she says on reasonably minded examplars of those who hear it, that will need to feature in determinations of culpability. 

'violates their dignity'

Does saying that trans people are not actually of the sex with which they identify constitute an affront to their dignity? Well, it presumably should be so counted if we've already decided that self-identification is a proper criterion for sex attribution. For it's always a violation of someone's dignity if one dismisses someone's claims about themselves when: (they're old enough to have mastered the discourse in question, are being sincere, aren't insane, and when) the claims are avowals which as such are to be treated as criterial for that which they avow. It is such claims' status as sovereign self-determinations that makes their contradiction by others a manifestation of that deep disrespect which constitutes the traducing of personal dignity.

Now it's surely far more usual to raise this question when considering matters of gender (something like a role or identity one lives out) rather than sex (more ordinarily thought of as biological) - although, and of course, this distinction is itself complex and contentious (and it's not obvious to me that it readily 'goes straight through' even when it's gender we're thinking of). But here's the nub of the matter as I see it. Forstater claims her belief that literal sex change is impossible to be a 'philosophical belief'. Tayler gives an interesting discussion (see paras 50-58) of the difficulties attendant on individuating a belief as philosophical or not. In the end, though, he claims (para 88) that 'if part of the belief necessarily will result in the violation of the dignity of others' then this in itself 'will be relevant to determining whether the belief is a protected philosophical belief.' And because he considers Forstater's claims to violate the dignity of trans women, he concludes that Forstater's belief is after all not philosophical.

This, I contend, is a peculiar conclusion, since it fails to consider what actually makes for the traducing of dignity. Consider this: if I'm delusional, and believe that I'm the king of England, and you dismiss my claim and tell of the fact that I'm just a lowly psychologist, then I may feel my dignity to be violated. However since dignity isn't a subjective state, this is irrelevant. What has really happened here is that my psychosis has diminished my dignity, and that you're being cruel - but not debasing my dignity - in pointing out the lack of dignity which, known to me or not, I already suffer. If being the king were, like being hungry or annoyed, something partly determined by sincere avowals which themselves function as criteria for one's being that which one avows, then to traduce what I say is to disrespect me as a person - i.e. is to traduce my dignity. But whereas it's within my gift to definitively say whether I'm hungry or annoyed, it's not within my gift to say that I'm the king. To return now to the case of Forstater vs CGD: perhaps the central philosophical question hereabouts is whether or not someone's avowals regarding (not only their gender but also) their sex are properly taken to be criterial of it. From what here I'll just call a 'traditional' perspective, sex is determined biologically; from a feminist perspective, gender is (somewhat or largely) culturally determined; from a certain kind of trans perspective, sex itself is (at least partly) determined by avowal. Which is to say that if I sincerely claim that I'm female, and certain other conditions are met, then I am. From a traditional perspective, to claim that I'm female when biologically I'm not female is to suffer delusion. To refuse to call someone 'she', when that person claims to be female, is not, from that perspective, to traduce their dignity but instead to (in a potentially cruel way, depending on the context) advert a lack of dignity that has already been suffered.

In short, Tayler decides that Forstater's belief is not philosophical on the basis that her expressions of it traduce the dignity of the trans woman. But he could only have determined that if it wasn't the case that the belief that trans women are women wasn't itself a 'philosophical' belief. But these are precisely the issues in play. (In this connection it's notable that Tayler blankly disagrees with the idea that changing one's sex on one's birth certificate is productive of what we call 'legal fiction' rather than fact. But is that right? Again, surely it's rather the point at issue.)

(A note: presumably the sane trans individual is not going to claim that self-identification is a sufficient condition for sex determination. For that would manifest nothing but an empty Humpty Dumpty narcissism, and in fact would end up being completely empty - since if to be male (or female) is just to proclaim oneself to be male (or female), then what actually is it that one's proclaiming? If to be X is merely to proclaim oneself X, then we're left as yet with a remarkably empty concept of X! Even so, nothing here makes incoherent the idea that self-identification could be one of several criteria which together define being male (or female).)

'absolutist in her view'

In paragraphs 41-45 Tayler provides evidence that not all people fall squarely into a biological category of 'male' or 'female'. Various genetic and hormonal alterations lead to some individuals having the sexual characteristics (typical) of both sexes, or (typical) of the other sex than that to which they have been 'allocated' or with which they 'identify'. (My scare quotes and brackets are to indicate that these are matters of contention, or at least matters that have been contested.)

What he doesn't make clear is how this is relevant to the case. For example, he provides no evidence to say that transgender individuals typically have atypical chromosomes. Nor is it obvious how the presence of a small number of intermediary cases B between A and C sheds any light on whether A can genuinely become C.

In paragraph 83 of his ruling, Tayler considers 'whether the Claimant’s core belief that sex is immutable lacks a level of cogency and cohesion. It is avowedly not religious or metaphysical, but is said to be scientific. Her belief is that a man is a person who, if everything is working, can produce sperm and a woman a person who, if everything is working, can produce eggs. This does not sit easily with her view that even if everything is not, in her words, “working”, and may never have done so, the person can still only be male or female.'

The idea that Forstater's two beliefs do 'not sit easily' with one another is just peculiar. It's a fact that we have a general biological concept of function which concept type enjoys very many instantiations in our language. We say things like 'the function of the liver is to clean the blood'. What's a liver? Well, you have a liver if you have that organ which, if it's working, cleans your blood. You have an eye if you have that organ which, if it's working, affords seeing. Despite its functional definition, there's no problem with the idea of a damaged eye, one out of which you cannot see. So presumably we can - perhaps we even do! - also have a biological conception of sex. You're female if you're a creature who, if your sex organs are working, can produce eggs. If you can't produce eggs but you have the structures which - in those whose structures are working - enable that production to take place, then you're a female. Or something like that. To indicate that here we have to do with a concept of such a form is presumably the whole point of talking of 'if everything is working' in the first place. The key thing to grasp, the thing which Tayler seems to fail to grasp, is the importance of the idea of being a creature who, whether or not its organs are actually working, has such organs which, if they are working, results in such-and-such. 

What such a biological conception of sex doesn't tell us is what to do with cases in which someone doesn't have the underlying chromosomal and anatomical structures. But this is quite normal - very many of our perfectly serviceable concepts are not applicable in absolutely every context. To try, in such contexts, to keep pursuing their application leads to muddle and mayhem. Instead we need to say that in such cases, normal business rules no longer apply. This applies as much to natural kind concepts as to others, and does nothing to undermine their status as natural kind concepts.

Now, so long as Forstader was talking of individuals with such-and-such genetical material, it seems unclear what could be meant by saying that her two beliefs do not sit easily with one another. If however she was including all individuals regardless of their genetic material, then it's not clear what would be meant by her saying that people can be only either male or female - and so it's in turn not clear what Tayler could be meaning by saying that holding a biological functioning-related conception of sex (...you're female if you have organs which, if they're working, have the function or capacity of...) doesn't sit easily with that claim.

(It's also worth noting that just because there are people who don't fit easily into 'male' or 'female' categories doesn't mean that we must acknowledge there to be more than two sexes. For example we don't have to think of, say, a hermaphroditic individual as having a third sex, one that's neither male nor female. I say this because what Forstader most frequently claims is that there are only two sexes, and I want to point out that saying this doesn't entail that one's committed to the claim that everyone must fit into one of these two sexes. To say that there are only two sexes is not to say that every single individual is clearly of just one sex. This would be a bit like saying that the fact that someone is standing still, not moving backwards or forwards, means that must in fact be three directions: forward, backwards, and standing still!)

But in any case, these issues to do with genetic material seem irrelevant to the issue of whether or not it traduces the dignity of a trans person to call them 'she' when they want to be called 'he' (or vice versa). And this is because - I'm assuming - most trans people do not have atypical chromosomal etc. configurations, and because the trans individual surely claims to properly count as male or female on grounds other than their genetics. 

'legally a woman'

In paragraph 84 Tayler considers that 'if a person has transitioned from male to female and has a Gender Recognition Certificate that person is legally a woman. That is not something that the Claimant is entitled to ignore.' He also considers that a GRC 'provides a right, based on the assessment of the various interrelated convention rights, for a person to transition, in certain circumstances, and thereafter to be treated for all purposes as the being of the sex to which they have transitioned.' In other words, according to Tayler, if someone has a legal certificate which claims they are a man, it is illegal (because it would be harassment) to call them a woman, and free speech rights cannot trump this.

This however is the very point of contention. (Luckily such employment judgements don't provide binding precedent for future legal cases.) Forstater claimed that if someone was biologically and apparently male then it cannot be a crime to call them male, otherwise her right to free speech would be traduced. It's hard to see why this wouldn't - if we assume for a moment the truth of the contentious idea that changing your sex on your birth certificate isn't productive merely of a 'legal fiction' - constitute a simple clash of rights, and hard to see why this wouldn't be precisely the matter that needs legally addressing rather than simply pronouncing on. It's worth noting too that maintaining the sex/gender distinction would here help us out a good deal.

'and/or creates an intimidating, hostile, degrading, humiliating or offensive environment.'

We're now back to where we started. Is it part of Forstader's belief that she will refer to a person by the sex she considers appropriate even if this creates an intimidating, hostile, degrading, humiliating or offensive environment? (These are the legal criteria for harassment.) She clearly professes that she will 'respect anyone’s self-definition of their gender identity in any social and professional context' and that she 'wouldn't try to hurt anyone's feelings'. But there are also behavioural criteria for such beliefs, and I don't know whether Forstader always tries to avoid saying things that risk causing offense. Specifically, it's not obvious to me that standing up for women's rights against the demands of that appalling minority of trans women who appear motivated by a desire to harm or intimidate cis women requires her to say all the things she said. Even so we must make sure we have some way of distinguishing between whether a judgement is offensive and whether someone takes offence at it. 'Snowflakes' will take offence, will perhaps even contrive to take offence, at a vastly greater degree of remarks than would normally be found offensive. Presumably what we require here is a standard like 'what an ordinary rational person would find offensive if they were subject to the alleged harassment'.


Further links: Article in The Guardian about the case.
A defence by Gaby Hinsliff of Tayler's judgement, also in The Guardian.
Forstater's crowdjustice page.
A piece on Tayler's judgement by philosopher Kathleen Stock which also provides links to her work on what it means to talk of changing one's gender.

Saturday, 30 November 2019

the danger of wonder

We're sometimes invited to philosophise in a mood of wonder. Heidegger does this; Wittgenstein occasionally does something similar too. Now I've no wish to dismiss wonder, but I want to express a concern about it, or at least about what can easily be taken for it.

St Augustine
Take Augustine's question "What then is time?" which he follows with "If no one asks me, I know; if I want to explain it to a questioner, I do not know." (Both Heidegger and Wittgenstein were concerned with this remark, and admired, if with reservations, Augustine's treatment of time.)

What I'm imagining is someone taking himself to understand Augustine's words, taking himself to understand the question "What is time?", and agreeing with the idea that, in some sense, he "knows what time is" if nobody asks him but not if they do ask him. If I put myself in this imaginary situation, I find myself starting to wonder at time; "How extraordinary!" I interject. It now seems utterly mysterious what it is. A simple philosophical question seems to take something we all rather took for granted, something into which we're all unreflectively sunk, something which our thought and action rely upon - and turns it into a thematic object of investigation. And a sense of something at least rather like wonder is surely attendant on this. "Time!" we gasp, wondering at it, stunned that this marvel which seems to outstrip our reflective comprehension was all along under our noses.

But what concerns me here is that Philosophy ( - in what follows I shall pretend that 'Philosophy' is the name of the person drawn to making the philosophical move I wish to expose - ) has mistaken its own capacity to confuse itself for the extraordinariness of nature. For Philosophy here takes a question - "What is X?" - a question which we know how to handle in various contexts ("What is the atomic number of mercury?", "What is a dodecahedron?", "What is a carburettor?") and now substituted for "X" (not "mercury", "dodecahedron" or "carburettor" but) "time". After it has done this, Philosophy takes itself to be asking a genuine question with "What is time?" There being no ready answer, a sense of something like marvel or wonder springs up. "Time: how extraordinary!"

Yet what Philosophy has done nothing to show is the intelligibility of its own question. After all, why on earth should we expect to get a sensible question out of "What is X?" regardless of whichever noun we substitute for "X"? Why should that be a good question in more than a certain range of cases? Why should it be any more prima facie intelligible what is being asked when someone says "What is time?" than when, taking "Y" not as standing for "a piece of string" but rather for "a prime number" or "the colour yellow" they say "How onerous is Y?"? 

The "What is X?" question certainly has a clear role in articulating a certain kind of puzzle about certain substances and (what we might cautiously call) various abstract phenomena (insolvency, arrogance, woke culture, aluminium, plate glass); it works for the whole range of ordinary objects too if we put an 'a' or an 'an' in it too. But so far as I can tell it just isn't obvious what's being asked by "What is time?" To believe that a question has nevertheless been raised, albeit one that is as yet obscure, is so far as I can tell an unwarranted, or at least an unearned, and to me an uncompelling, presumption.

Someone might reply "Well talk of Augustine's knowing what time is so long as nobody asks him must just be another way of saying that he knows how to tell the time, knows how to use the word 'time' in sentences like 'The time is 3.30pm', etc." OK. I'm fine with that. But I don't see a way to preserve the sense of wonder generated by "What is time?" if it is taken to mean "How is the word 'time' used?" For the answer to that question is not in any sense mysterious. It involves pointing to clocks and stopwatches, rehearsing the tenses, explaining how the day is divided into hours and minutes and seconds, etc. etc.

Now I've no wish to deprive anyone of genuine wonder. All I wish to point out here is that we're capable of generating apparent senses of awe and wonder by asking questions the sense of which is unclear when this unclarity goes unrecognised by us. We ask "What is time?" and then rather than continue with "Hang on, what am I even asking here?" instead go on with "How amazing, I talk about it unreflectively every day, but it radically outstrips my reflective purchase and I simply don't know what it is!" That, I suggest, is not a sense of wonder worth having, and philosophy pursued under its sign is nothing but arrogant hubris - the arrogance here being the presumptuous opinion that the putative question on Philosophy's lips had any meaning in the first place.

Rather than wonder, then, the affective sign under which we most often do well to pursue philosophy is, I suggest, humility.

Saturday, 21 September 2019

psychotherapy as internal relation

(notes for a talk at Confer, 21st Sep 2019)

Abstract 

Describing psychotherapy as a method of treatment is expedient in healthcare settings, but it would take a tin ear to not baulk at it as a characterisation of the therapeutic experience. To unpack our intuition that ‘treatment’ talk fails us, we may use Wittgenstein’s distinction between internal (constitutive) and external (two-part) relations. Psychotherapeutic work embodies, and develops the patient’s capacity to enter trustingly into, mutually implicating (i.e. internal) relations with others – whereas treatment requires only that people are merely externally related. Then again, psychotherapy is also in the business of helping patients separate out from others. This togetherness-in-difference has a name: it’s what we call ‘love’.


Introduction - Grammatical Notes

The question I was invited to address by the organisers of this conference was 'Is psychotherapy a treatment or a relationship?'

Now I take it that this isn't a straightforward question like 'Is animal X a cat or a dog?' For there's as yet too little context, around the mere question, for us to have a sense that the two terms (treatment and relationship) are being used in a sense which excludes one another. Thus perhaps we should want, and do well, to say that psychotherapy is both a relationship and a treatment.

Now there's a trivial sense in which 'psychotherapy' can't easily be taken as the name of a relationship, since psychotherapy is - like 'treatment' but not 'cure' - the name of an activity, and activities are not relationships even when they're done together with someone else. 

And there's also a trivial sense in which nobody shall deny that psychotherapy involves relationship, since even those behaviourists who think of the therapeutic relationship in merely instrumental terms - i.e. merely as a means to an end - as merely a delivery mechanism if you like - will not deny that it involves two or more individuals in cooperative interaction. A pizza (the end, as it were) is delivered by a delivery man (the means, as it were). The delivery man himself, though, is not the dinner (unless you’re a murderous cannibal).

Having got these trivia out the way let's move straight on to examine the key issues.

Instrumental vs Non-Instrumental Understandings, and Versions, of Psychotherapeutic Relationships

Now, what contrasts with a merely instrumental conception of the psychotherapeutic relationship is one in which it is in the relating itself that therapeutic change is taken to occur.

Consider that Judith Beck tried to take a stand against those who accuse cognitive therapists of ignoring the importance of the therapeutic relationship by insisting that 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.

To this the psychoanalytical psychotherapist Jonathan Shedler responded 

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.

Against this response I only note that Shedler’s optimism regarding his barber or estate agent perhaps warrants some of what a CBT therapist would call 'cognitive restructuring' - although maybe here we meet also with the different cultural expectations and practices of the two sides of the North Atlantic...

Now, working 'in the transference', as they say, provides a good example of what I'm here calling a non-instrumental use of the therapeutic relationship. Let's now spell this out using a comparison of, rather than a remark on the disanalogy between, behaviour therapy and psychoanalytic therapy. (I probably got this analogy from Leigh McCullough's work on 'affect phobia'.)

So consider first that in behaviour therapy it isn't imagined that one shall overcome one's dog phobia, say, merely by talking about dogs. Instead, real encounters with dogs must be suffered, and a 'response prevention' (i.e. evasion prevention) protocol be implemented. In this way one learns - or is re-conditioned - directly from within a transformative experience (of a non-devouring dog).

Similarly when it comes to reconditioning our fundamental, conscious and unconscious, affectively charged expectations of how others will treat us: what's important is not that we (I’m here the therapist, you the patient) simply talk about what happened to you in your childhood, or about what's currently going on at home, but rather that the fearful expectations are directly met with within, because they've been activated bythe intimacy of the therapeutic relationship itself

When the transference is activated and these fearful expectations are alive between us, we now stand a chance of truly learning the difference between the malevolent pit bull (in the negative transference) or the impossibly ideal golden retriever (in the positive transference) the therapist is imagined to be - and the, say, slightly up tight but nevertheless caring and discerning labradoodle he really is (in the real relationship).

As well as this transference work we also have the fundamental work of therapy to install a 'good internal object' and challenge self-criticism, which process we may think of as an internalisation of the therapeutic relationship. Here too the good therapeutic relationship is not merely instrumental – it’s not merely a precondition for the effective deployment of this or that technique, not merely a way to make someone receptive to the actual treatment - but it is itself the substance of the therapeutic process.

We might sum up these reflections by saying that, far from treatment and relationship being antithetical, meaningful therapeutic treatment will itself take the form of a relationship.

Disanalogies

I now wish to turn to ways in which talk of a 'psychotherapeutic treatment' may be considered oxymoronic - or, in other words, to think about what it is in our concept of 'treatment' that can strike a bum note when we're thinking of applying it to the case of psychodynamic and person-centred psychotherapy. And I think the bum note rings out most clearly when we consider such uses of the word 'treatment' as 'Dr Gipps was treating Megan for her depression' - i.e. when the treatment is something done by one person (the therapist) to the other (the patient). This is the sort of thing which may be useful to write on an insurance report or in an NHS case file, but the 'treatment' concept does, I think, risk doing an justice to our sense of the therapeutic process.

To get at this I will borrow a concept from Wittgenstein's philosophy - that of an 'internal relation'. We might define this abstractly - as a conceptual or a constitutive relation - rather than a relationship between discrete, separable, entities - but I think that what it is will come out more readily with an example.

So, imagine first a child's toy in which various shapes (stars, squares, circles, etc) are to be posted through variously shaped holes. Here the holes and the shapes are two separate phenomena. We can say what they are without referring to the other. We can tell a meaningful story about what allowed the one to fit so well through the other (it was made to the same specifications, the craftsman was very skilled, etc). Here we meet with phenomena that are externally related one to the other: they don’t each take their shape from the other.



And now imagine that we meet instead only with a circle drawn on a piece of paper. Someone may come along and ask 'How is it that the white disc in the middle fits so well into the black circle around it?' But now we'd have to explain to the person that they’ve made a mistake. These are not really two separate phenomena, but just one phenomenon. The outside of the white disc is defined by its black perimeter, so there can be no question of one thing fitting another. The white disc and the black circle are internally related to one another: they take their shape from one another.


O

Now what I propose is that talk of 'treatment' is best understood as talk of something that's done by one individual to another separate individual. As such it is a paradigm of an external, causal relationship between discrete beings. 

The individuals in question may of course be very intimate, but the idea of a treatment going on does not in itself presuppose this intimacy. And it is because treatment talk has these external connotations that we should reject it for an apt description of the work of psychotherapy if we want to understand what psychotherapy essentially is. (You and the pizza delivery man may be lovers, but the pizza he brings is (presumably) extrinsic to your lovemaking.)

The question remains, though, as to what it means to describe what are after all the two separately identifiable participants in a therapeutic relationship as 'internally related'? And clearly the answer will be that, to the extent that the relationship stands a chance of being therapeutic, there is some sense in which the participants cannot be considered entirely separate. And yet clearly the last thing we want from a therapeutic relationship is that the participants become somehow merged with one another. Indeed it may be because of problems with her ego boundaries, or because she suffers a want of self-possession, that the patient comes to therapy in the first place. 

In what follows I shall look first at the internal relatedness required in a truly therapeutic relationship and then consider the significance of our human recognition of separateness, finally tying both of these points to the bum note struck by 'treatment' talk.

Internal Relations

The predicament we're often in when we go to therapy may I think be put like this. (I'm now going to tell you some things that I hope you'll agree we both already know.) So (you’re the patient again): you've suffered a partial developmental failure. You're unclear or doubtful in your heart about whether you're truly lovable as you are and about whether other people are truly to be trusted. To manage these concerns you erect a set of defences and develop a pseudo-adult carapace or persona through which you now engage with the world.

Certain others you do 'let in'. Even here however this goes smoother if first you idealise, have a 'love-in' with, identify with, these others, doing your best to overlook or 'forgive' (which is not real forgiveness) their all-too-human sides, all this happening under the aegis of a positive transference. All the other others, however, you 'keep out'; you engage in politeness, decorum, and all the panoply of those forms of latent human shunning or failures of openness that go to make up 'civilised life’. But whilst these defences help manage your anxiety they also create what we call 'symptoms' and thwart your development. Why is this?

They thwart development because it's only when we let others in that we can grow. The child needs a trusting intimate connection with others in order to get anywhere in life. Before he can become a separate being with a character which is more than a congeries of defences, he must be able to find his sense of himself in his relations with trusted others. Only out of this togetherness may true individuation proceed. I think that the quality of this experience of the child is best summed up by the Christian use of the word 'parrhesia', which in the Catechism is described as "straightforward simplicity, filial trust, joyous assurance, humble boldness, the certainty of being loved".

So: when I trust you, and let you in, I take your reaction to me as a true indicator of how I really am in myself. I cannot, despite the seductive illusions of omnipotent narcissism, truly achieve this calibration for myself. I can only achievemy self-esteem andcalibratemy moral sensibility (i.e. my conscience) through a close trusting relation with you. I find myself in you.

In such trust I allow myself to be calibrated by you - this is the sense in which a close trusting relationship, especially of a parent-child sort, involves a relationship that is partly internal. My self-becoming and your sense of me are not now two quite separate matters.

Now - not globally but at this specific juncture of our connection - we're related not as two separately-shaped phenomena which happen to coincide, but instead as the edge of the white disc to the inside of the black circle which defines it.

My self-esteem - which is simply the confident untrammelled bodying-forth of myself - can now grow. It grows, in particular, to the extent that I get a sense (now I’m the patient or child, you’re the therapist or adult) that you love me - by which here I mean, you want the best for me- with the stress both on 'the best for'and on the 'me'I can now grow as I step forward confidently into my life. My sense of forgivableness - my sense that I shan't be sent into exile when I make mistakes - and my sense of the valuedness of my own love - is also now increased. Because of all this I can allow myself to form valuable and close relationships with others.

One way we might articulate all this is by distinguishing two different senses of 'recognition'. In the one – let’s call it ‘empirical recognition’, as when I recognise that bird over there as a green woodpecker - we meet with something that may intelligibly be described as correct or incorrect. In the other – let’s call it ethical recognition, as when recognition is what you offer me - you affirm me in my essential character. This is what Rogers called 'unconditional[,] positive regard' - which, incidentally has got nothing to do with a regard that is unconditionally positive (since otherwise how could it begin to cohere with anyone but the sappiest therapist's congruence), but everything to do with being treated as an 'end in oneself', to borrow the Kantian terminology. You welcome me in; you show an openness to me as I am. When I trust in this recognition, then I and you are one, not simply in the coincidence of the content of our beliefs, but in a moment in which who we are is jointly enacted and thereby constituted. Now, just at the meeting point between us, we are one another, just as the white disk and the black circumference are of a piece - although, and of course, there are myriad other junctures of our lives where we are not so mutually implicated.

Now this, I think, is what it is to be internally related to one another in psychotherapy. It is only by presupposing a relationship with such a feature that, say, meaningful work in the transference can ever occur - otherwise why should I – I’m still the patient - ever trust your interpretations? It is this quality of the work, this inner involvement and implication, that - I think - explains why talk of ‘treatment’ just doesn't cut the therapeutic mustard. 

And, for that matter, it is this intimate recognition which is rightly described in terms of love, and which prompts the observation that decent psychotherapy is necessarily informed by love.

Separateness

Having described our togetherness in a meaningful love-structured therapeutic relationship, I now turn to the equally important matter of our separateness and the recognition of it. The important question here is how to think both of these together. 

In a paper called 'The Sublime and the Good', Iris Murdoch writes:

Love is the perception of individuals. Love is the extremely difficult realisation that something other than oneself is real. Love ... is the discovery of reality. ... the apprehension of something else, something particular, as existing outside us. The enemies... of love...are... social convention and neurosis. ... Freedom is exercised in the confrontation by each other, in the context of an infinitely extensible work of imaginative understanding, of two irreducibly dissimilar individuals. Love is the … respect for, this otherness.

I present this here because with its talk of recognising otherness it can seem to give us a very different picture of what intimate connection is than the conception of self and other as internally related provides. 

And I take it too that a lot of therapy is about helping the patient separate out from, and recognise the independence from him of, his significant others. 

Therapy is partly - and it's an important part - about the growth of self-possession. In psychodynamic psychotherapy this occurs, we believe, partly through the interpretation, and thereby the dismantling of, the transference. A precondition of this is that the therapist can offer that unconditional positive regard to the patient which itself stems from a recognition of his independence from her. But what we were talking about before was the need for patient and therapist to join together in a moment of internal relatedness, mutual implication, or conjoint constitution. And this seems now to put us inquirers at theoretically odds with ourselves, to have us searching for both identity and disunity at the same time.

The answer to this puzzle is that that recognition which makes for an internal relation between self and other isn’t a kind of identity. What you offer recognition to is: me in my distinctive selfhood. In my particular character. This particular character is thereby acknowledged as an intrinsically valid way of being human. This is what it is to offer me positive, unconditional, regard. And I gain my sense of myself and the comfort to body forth as myself under your loving gaze. Despite how different I am from you, you recognise my character as a viable form of human selfhood. By loving me you acknowledge me in my utter otherness to you, as Murdoch states. Yet when I in my self-understanding meet you in your recognition of me, there we are at one, and there I can flourish.

Individuality, Psychotherapy and Treatment


Now it’s sometimes said, by psychoanalytic psychotherapists seeking a quick-and-easy response to the challenges of empirical research pundits, that it's wrong to make use of intrinsically generalist evidence-based treatment research because patients are all individuals.

If what this means is that patients all have different characters, then it's obviously wrong to some degree, and right to some degree. In some ways we are really rather like one another, and psychoanalysis has even contributed to our understanding of this. Whether or not one patient with, say, OCD, is sufficiently similar to another to make a research-derived psychotherapy protocol viable is, we might then think, surely an empirical matter, not something to be pronounced on from an armchair.

But this all makes me wonder whether there might not be another way to take what the psychoanalytic psychotherapist says from her armchair by way of reply to the scientist practitioner. And the way I suggest is what’s already been offered above: we're to treat our patient as an individual not in the sense that he has a unique character profile, but in the sense that he has a way of being human that (underneath the destructive defences he deploys) is to be accepted as is

It’s in his way of being human that we offer him recognition. This is not about our empirically recognising his characterological distinctness, but ethically recognising him in his distinctness. (And so we use his name and not a number; we treat him as an intelligible object of love; if he dies we don't treat him either as a dead animal or as a piece of rubbish, and when we grieve him we grieve not our loss but him. If we wrong him then we feel bad - not for having broken some moral law, but because we've hurt him

So the reason why it may not be apt to apply an evidence-based protocol to our patient, then, is not because he has a rare character profile, but because in a therapeutic relationship we specifically encounter him under the description 'human being' rather than, say, ‘homo sapiens’. This requires recognition - not of the empirical but of the ethical, offered, sort. The point isn’t that he’s not an instance of a type (presumably he is) - but rather that a relationship structured by that idea could never itself be a therapeutic one. 

To suppose that it is would make no more sense than someone saying 'I love my husband because he's 6 foot tall, has a handlebar moustache, is a clever clogs, and has large biceps'. One may certainly 'love' (qua greatly enjoy) those things about him, but truly loving him has no because - or, if you enjoy circular explanations, has no ‘because’ other than that in 'I love him simply 'because he is he''. Our patient has struggled with receiving recognition, has erected defences against being met with as a person, may have been judged in his core being, may have been projected into or neglected or used or smothered or spoiled or indulged by those who were instead supposed to care for him by honouring him, offering him recognition, treating him as a moral subject, one capable of wronging and being wronged. This is what we must undo, as we now express our willingness to meet him as a human being.

Conclusion

I began by getting a clear non-instrumental sense of the therapeutic relationship on the table. I then stressed that we can use the idea of 'internal - mutually implicating - relations' to characterise the kind of relationship we find in a therapeutic relationship. When we are open to one another in such a way as to make ourselves visible to the other's ethical recognition of us, then we are related internally and then the transformative work of therapy may begin. Now we take the other's reactions to us as providing more than information about ourselves. Rather it's in your true pity that I find myself; in your moral challenge to me that I understand my thoughtless selfishness; it's here that I can now become myself. Yet whilst this relationship between us is internal in form, like the black circle to the white disc within, it's not one of identity. Far from it: to be real your loving recognition of me must honour me as truly separate from you - as a being with his own character, own inner life, own needs, own form of experience.

And all this, I suggest, helps us grasp what it is that 'treatment' talk misses by way of an apt characterisation of the essential form of a therapeutic relationship. It tends us toward supposing that we and the patient do well to both direct our attention to something extrinsic to the therapeutic relationship, to something called 'the problem', 'the illness', 'the symptom'. But the very 'symptoms' that bring patients to psychotherapy are a product of a failure of personal being - a failure to receive, or a chronic shying away from receiving, recognition. And it's in providing the requisite recognition that we meet our patient, and its in this recognition that he meets himself and so may now pick up afresh the task of being a person in the world. It is, we might say, precisely in our treating him as a human being that the lie is given to the idea that what he needs is something called treatment.

Monday, 1 July 2019

just published



Previous multi-author collections of English language essays in phenomenological psychopathology include Rollo May, Ernest Angel and Henri Ellenberger (1958) Existence: A New Dimension in Psychiatry and Psychology; John Cutting and Michael Shepherd (1986) The Clinical Roots of the Schizophrenia Concept: Translations of Seminal European Contributions; and Matthew Broome, Robert Harland, Gareth Owen and Argyris Stringaris (2013) The Maudsley Reader in Phenomenological Psychiatry. Unlike the Maudsley Reader, which is the only other collection still in print, the Oxford Handbook of Phenomenological Psychopathology is a 98 chapter collection of newly written essays, covering a wide variety of topics.
  1. The 23 essays in its first section cover the history of phenomenological philosophy (Husserl to Levinas) and phenomenological psychopathology (Jaspers to Laing).
  2. The 7 essays in section two consider the meaning of taking a phenomenological approach and its relation to other approaches.
  3. Section three consists of 12 essays on key concepts of phenomenology such as the self, emotion, and various of what Heidegger called the existentialia (essential dimensions of human existence).
  4. Section four comprises 15 chapters on descriptive psychopathology, chapters which amongst other things consider the psychopathology of the various existentialia.
  5. The 8 chapters of section five look holistically at the different life worlds of persons with different conditions (schizophrenia, mood disorders, hysteria, BPD, addictions, autism, eating disorders).
  6. Section six entitled ‘Clinical Psychopathology’ contains 9 essays on different aspects of (mainly) psychotic experience.
  7. Finally section 7 contains 13 chapters on the relationship between phenomenological psychopathology and other disciplines from neuroscience to psychoanalysis.

1: Introduction, Giovanni Stanghellini, Matthew Broome, Anthony Vincent Fernandez, Paolo Fusar Poli, Andrea Raballo, and René Rosfort

Section One: History


2: Edmund Husserl, Roberta de Monticelli

3: The Role of Psychology According to Edith Stein, Angela Ales Bello
4: Martin Heidegger, Anthony Vincent Fernandez
5: Jean-Paul Sartre, Anthony Hatzimoysis
6: Merleau-Ponty, Phenomenology, and Psychopathology, Maxine Sheets-Johnstone
7: Simone de Beauvoir, Shannon M. Mussett
8: Max Scheler, John Cutting
9: Hans-Georg Gadamer, Andrzej Wiercinski
10: Paul Ricoeur, René Rosfort
11: Emmanuel Levinas, Richard A. Cohen
12: Critiques and Integrations of Phenomenology: Derrida, Foucault, Deleuze, Federico Leoni
13: Karl Jaspers, Matthias Bormuth
14: Eugène Minkowski, Annick Urfer-Parnas
15: Ludwig Binswanger, Klaus Hoffmann and Roman Knorr
16: Medard Boss, Franz Mayr
17: Erwin Straus, Thomas Fuchs
18: Ernst Kretschmer, Mario Rossi Monti
19: Hubertus Tellenbach, Stefano Micali
20: Kimura Bin, James Phillips
21: Wolfgang Blankenburg, Martin Heinze
22: Franco Basaglia, John Foot
23: Frantz Fanon, Lewis R. Gordon
24: R.D. Laing, Allan Beveridge

Section Two: Foundations and Methods


25: On the Subject Matter of Phenomenological Psychopathology, Anthony Vincent Fernandez and Allan Køster

26: The Phenomenological Approach, Dermot Moran
28: Genetic Phenomenology, Anthony Steinbock
29: Phenomenology and Hermeneutics, René Rosfort
31: Phenomenology and Cognitive Science, Shaun Gallagher
32: Phenomenology, Naturalism, and the Neurosciences, Massimiliano Aragona
33: Normality, Sara Heinämaa and Joona Taipale

Section Three: Key Concepts


34: Self, Dan Zahavi

35: Emotion, René Rosfort
36: The Unconscious in Phenomenology, Roberta Lanfredini
37: Intentionality, Joel Krueger
38: Personhood, René Rosfort
39: Befindlichkeit: Disposition, Francesca Brencio
40: Values and Values-based Practice, KWM (Bill) Fulford and Giovanni Stanghellini
41: Embodiment, Eric Matthews
42: Autonomy, Katerina Deligiorgi
43: Alterity, Søren Overgaard and Mads Gram Henriksen
44: Time, Federico Leoni
45: Conscience, Marcin Moskalewicz
46: Understanding and Explaining, Christoph Hoerl

Section Four: Descriptive Psychopathology


47: Consciousness and its Disorders, Femi Oyebode

48: The Experience of Time and its Disorders, Thomas Fuchs
49: Attention, Concentration, Memory, and their Disorders, Julian C. Hughes
50: Thought, Speech and Language Disorders, John Cutting
51: Affectivity and its Disorders, Kevin Aho
52: Selfhood and its Disorders, Josef Parnas and Mads Gram Henriksen
53: Vital Anxiety, Maria Inés López-Ibor and Dra Julia Picazo Zapinno
54: Hallucinations and Phenomenal Consciousness, Aaron Mishara and Yuliya Zaytseva
55: Bodily Experience and its Disorders, John Cutting
56: The Psychopathological Concept of Catatonia, Gabor S. Ungvari
57: Eating Behavior and its Disorders, Giovanni Castellini and Valdo Ricca
58: The Phenomenological Clarification of Grief and its Relevance for Psychiatry, Matthew Ratcliffe
59: Gender Dysphoria, Giovanni Castellini and Milena Mancini
60: Hysteria, Dissociation, Conversion and Somatisation, Maria Luísa Figueira and Luís Madeira
61: Obsessions and Phobias, Claire Ahern, Daniel B. Fassnacht, and Michael Kyrios
62: Thoughts without Thinkers: Agency, Ownership and the Paradox of Thought Insertion, Clara S. Humpston

Section Five: Life Worlds


63: The Life-World of Persons with Schizophrenia (considered as a Disorder of Basic Self), Louis Sass

64: The Life-World of Persons with Mood Disorders as Disorders of Temporality, Thomas Fuchs
65: The Life-World of the Obsessive-Compulsive Person, Martin Bürgy
66: The Life-World of Persons with Hysteria, Guilherme Messas, Rafaela Zorzanelli, and Melissa Tamelini
67: The Life-World of persons with Borderline Personality Disorder, Giovanni Stanghellini and Milena Mancini
68: The Life-World of Persons with Drug Addictions, G. Di Petta
69: The Life-World of Persons with Autism, Francesco Barale, Davide Broglia, Giulia Zelda De Vidovich, and Stefania Ucelli di Nemi Translated by Martino Rossi Monti
70: Eating Disorders as Disorders of Embodiment and Identity, Giovanni Castellini and Valdo Ricca

Section Six: Clinical Psychopathology


71: First Rank Symptoms of Schizophrenia, Lennart Jansson

72: Schizophrenic Delusion, Arnaldo Ballerini
73: Delusional mood, Mads Gram Henriksen and Josef Parnas
74: Delusion and Mood Disorders, Otto Doerr
75: Paranoia, Paolo Scudellari
76: Auditory Verbal Hallucinations and their Phenomenological Context, Matthew Ratcliffe
77: Affective Temperaments, Andrea Raballo and Lorenzo Pelizza
78: Schizophrenic Autism, Richard Gipps and Sanneke de Haan
79: Dysphoria in Borderline Persons, Mario Rossi Monti and Alessandra D'Agostino
80: Psychosis High Risk States, Luis Madeira, Ilaria Bonoldi, and Barnaby Nelson
81: Psychopathology and Law, Gareth S. Owen
82: Atmospheres and the Clinical Encounter, Cristina Costa, Sergio Carmenates, Luis Madeira, and Giovanni Stanghellini
83: The Psychopathology of Psychopaths, Jerome Englebert
84: A Phenomenological-Contextual, Existential, and Ethical Perspective on Emotional Trauma, Robert D. Stolorow

Section Seven: Phenomenological Psychopathology


85: Phenomenological Psychopathology and Neuroscience, Georg Northoff

86: Phenomenological Psychopathology and Qualitative Research, Massimo Ballerini
87: Phenomenological Psychopathology and Quantitative Research, Julie Nordgaard and Mads Gram Henriksen
88: Phenomenological Psychopathology and Psychotherapy, Giovanni Stanghellini
89: Phenomenological Psychopathology and Psychiatric
90: Phenomenological Psychopathology and America's Social Life-World, Jake Jackson
91: Phenomenological Psychopathology and the Formation of Clinicians, Giovanni Stanghellini
92: Phenomenological Psychopathology and Psychiatric Classification, Anthony Vincent Fernandez
93: Phenomenological Psychopathology and Clinical Decision Making, Eduardo Iacoponi and Harvey Wickham
94: Phenomenological Psychopathology and Psychoanalysis, Federico Leoni
95: Phenomenological Psychopathology and Autobiography, Anna Bortolan
96: Phenomenological Psychopathology, Neuroscience, Psychiatric Disorders and the Intentional Arc, Grant Gillett and Patrick Seniuk
97: The Phenomenology of Neurodiversity, Marco O. Bertelli, Johan De Groef, and Elisa Rondini
98: The Bodily Self in Schizophrenia: From Phenomenology to Neuroscience, Francesca Ferri and Vittorio Gallese