Wednesday, 11 March 2020

depressive theories of depression?

In a recent talk on the phenomenology of depressed mood the following thought occurred to me... But to first set the scene, the talk was on the difference between such phenomenological understandings of depression as stress a mis-attunement, and those which instead understand depression as a dis-attunement, between patient and world. In the former category we had the approaches of Aho, Ratcliffe and Svenaeus; in the latter we have the approaches of Fuchs, Stanghellini and Fernandez. The former see depressed mood as itself a way of being affectively attuned to the world - where the mood of attunement is one of boredom, radical hopelessness, deep guilt etc. And the latter focus on the absence of affective attunement - as found, for example, in an inability to grieve.... Anyway, the thought I had was born of the experience of going straight from the therapy clinic into the lecture. It took the form of a question: might not all such theories of depression themselves rather be partaking of their objects? Might phenomenological theorisations of depression not themselves be depressive?

So the thing is that in the clinic I tend, as I believe many other clinicians do, to work in a zone between the intentional (qua intended) and the non-intentional (the mere happening). The zone is structured not by intention but by motivation; we often refer to it loosely as 'the unconscious'. Take for example Minkowski's schizophrenic patient (cited in Laing's review of La Schizophrénie) who said 'I suppressed all feeling as I suppressed all reality. I dug a moat around myself.' Who knows what actually he meant, but I think it not unlikely that this retrospective report took the form of an acknowledgement, a confession if you like, of agency that was in play yet which at the time of the suppressing and digging would've found no registration in avowal. Agency, that is, in the generation of his anhedonia. Or take pretty much any of the classic psychoanalytic case studies: here we meet again and again not with full-blown intended acts - not the sort of acts the aim of which could be ascertained by asking questions about intention - but nevertheless motivated acts, acts which subserve an affective goal, acts which aim to reduce anxiety, prevent psychic pain, and achieve the ersatz satisfaction of wishes.

In the clinic I often find myself using the language of motivation to describe depressed mood. A patient is facing certain anxious stresses in life; they don't yet have the habits of self-acceptance and self-care necessary to suffer their concerns; their mood consequently drops. Or, well...: drops or is dropped? This is the question I'm here trying to convince my reader to leave open. It's certainly part of the patient's experience of mood - and in truth it's part of our very understanding of mood (we take ourselves to find ourselves in moods; contrast our relation to our feelings into which we are not similarly sunk) - that moods happen to her. But in the clinic, in the greater balm of my solicitude, where the patient's self-understanding - facilitated by an ambiance of acceptance rather than shame - is enhanced, a certain kind of acknowledgement becomes possible. Latent bad faith may now be undone. I might for example gently say 'So when you couldn't face the overwhelm of your difficulties, you dealt with it by flattening yourself, taking the wind out of your own sails?' Or: 'fearful of the possible disappointments that lay ahead, you lowered your own hopes?' And the patient may now say 'Yes, you know I believe I did' - not simply by way of agreement but by way of acknowledging something both to me and to himself. In the process he owns the motivation for the mood.

When I've my clinical hat on, this just is how I (and I suspect many other therapists of a psychodynamic bent) see it: depressed mood presents itself as unmotivated, but this covers over the latent agency at play within it. Mood, if you like, is the collapse of emotion - where by emotion I mean something discrete, something that understands itself, something which has a clear intentional object. And one of the things that makes it depressive is that it takes it that here there's nothing to be understood. 'This is simply something that is happening to me; it's not something done by me'. But when we're doing the phenomenology of mood we needn't speak the language of mood itself. What we might be struck by is precisely what's not being said, what is unusually absent. We might also want to think genetically about it - i.e. to comprehend it in terms of its unfolding, which needn't exclude later avowals which acknowledge such motives as were not apparent at the time. In taking a passive description of mood as the proper description of it, phenomenological psychopathology implicitly invokes a passive understanding of mood itself - one which exscribes agency from the psyche, one which invites us to understand depression as illness rather than dynamism. And that, it seems to me, is to risk colluding in a depressive understanding of depression itself.

Tuesday, 10 March 2020

doctors should be shamans
and perhaps they are

Placebo studies needs a theory of symbolic efficacy. How are unconscious expectancies and unconscious meaning-responses mobilised and how do they take their effect? What is it that enables Lévi-Strauss's Cuna mother-to-be to finally give birth only when the shaman has sung to her the long and involving - and consciously inassimilable - incantation about the recapture of her purba from the domain of Muu? I take it that such a theory might be at least partially available and articulable at the subpersonal (physiological) level. (Say: the positive personal-level expectancy involves subpersonal CNS activity which in turn stimulates the HPA axis, vagus nerve, etc., in helpful ways; remoralisation results in improved immune function; and so on.) But I take it too that there's something unhelpfully dualistic about the invocation of such models: they leave rather a chasm between the two (personal and subpersonal) levels of description, one that leaves slack and gappy such explanations as are couched in their terms. For what we were hoping was surely that we truly could appeal to meaning as itself an explanatory factor in our accounts of placebo response - i.e. that the placebo response truly is itself a meaning response in virtue of the meanings at play within it. And not, say, simply that we here have to do with a meaning which is merely functionally/token 'identical' with matters neural/physiological, such that, if we want to understand the causality actually at play, it will be under the physiological, and not the meaningful, description that illumination will come.

Now, in psychoanalysis, and also in existential phenomenology, we have forms of discourse which do seem to occupy something of a 'between' status - i.e. between the subpersonal and the personal levels of description. (The term 'between' I take from Merleau-Ponty.) With Merleau-Ponty we have 'motor intentionality', the 'lived body', and so on - notions neither fully mentalistic nor merely physiological. And with the Kleinian psychoanalysts we have the concepts of 'unconscious phantasy', 'archaic, corporeal symbolisation', etc. As with Merleau-Ponty's notions, they're ascribed to the subject neither on the basis of her explicit avowals nor in line with (a la Davidson) a constitutive ideal of rationality, but instead by reference to the observable character of their lived, affectively charged, sensorimotoric expectancies.

In what follows I start to sketch - and very sketchily sketch - what a theory of placebo efficacy night look like couched in such terms. I'll stick for now to matters psychoanalytic rather than phenomenological. A proper synthesis will have to wait for another day, but I hope its outline will at least here become visible.

the kleinian body

Kleinian psychoanalysts tell us that the mind unconsciously represents itself to itself in bodily form - as the oral, anal and visual taking in and evacuating of good and bad objects and part-objects. This unconscious representation is called 'phantasy', which is sometimes described (originally by Isaacs) as the symbolic registration of instinctual forces.

With such theory the Kleinians are developing something already present in Freud. In his paper on Negation Freud writes: 'Expressed in the language of the oldest - the oral - instinctual impulses, the judgement is 'I should like to eat this' or 'I should like to spit it out'; and, put more generally: 'I should like to take this into myself and to keep that out'. That is to say: 'It shall be inside me' or 'It shall be outside me'. As I have shown elsewhere, the original pleasure-ego wants to introject into itself everything that is good and to eject from itself everything that is bad.'

This primitive scheme is, according to the Kleinians, the fundamental experience of the bodily self on top of which sit other more psychologically developed functions. We breathe in; we eat; we exhale; we cry; we make snot; we shit and piss; we sweat; we vomit. We have pains inside us which can sometimes be ameliorated by taking something good in (mother's milk) or having a relieving shit or puke. Welcome to the first year of your life. A year which, according to the Kleinians, remains alive as a foundation for later thought.

Bion provides one possible version (in his typical, quasi-psychotic register - a bizarre register that hopes to take us closer to the inchoate infantile experience itself): 'Reforming the model to represent the feelings of the infant, we have the following version: the infant, filled with painful lumps of faeces, guilt, fears of impending death, chunks of greed, meanness and urine, evacuates these bad objects into the breast that is not there. As it does so, the good object turns the no-breast (mouth) into a breast, the faeces and urine into milk, the fears of impending death and anxiety into validity and confidence, the greed and meanness into feelings of love and generosity and the infant sucks its bad property, now translated into goodness, back again.'

Segal elaborates further: 'When the infant introjects the breast as a container that can perform what Bion calls the alpha function of converting the beta elements into alpha ones, it is a container which can bear anxiety sufficiently not to eject the beta elements as an immediate discharge of discomfort. An identification with a good container capable of performing the alpha function is the basis of a healthy mental apparatus.'

Such quotes give a good flavour of the Kleinian theory, but exceed both what is clearly intelligible and what I want to take from them. (I propose in particular that we drop the confused and confusing notion of the mind representing its own activity to itself. Talk of 'representation' here is altogether de trop.) All that I want to hold onto, here, is the idea that the experience of taking things into and out of the body, and the experience of bad or good things (food, wind, anxiety, disgust and other emotions, etc.) existing inside the body, are fundamental to the way the baby experiences his or her life, and fundamental thereafter in organising our emotionally alive experience of interacting with the world more generally.

bodily metaphorics 

In a creative and helpful paper Jim Hopkins connects together the Kleinian understanding of corporeal phantasy - of good and bad substances going into and out of the body, thereby creating pain and blissful relief - with Lakoff and Johnson's work on conceptual metaphor. These psycholinguisticians focus too on how it comes naturally to us to deploy a whole range of bodily container-and-contained metaphors for thinking of the mind. Think of idiomatic phrases like:
  • can't contain myself / my joy
  • full of feeling
  • keep things in mind, keep in our memories / heart
  • bubble up, well over
  • bottled up
  • let your feelings out
  • venting
  • pressure of feeling
  • feeling as a hot fluid - simmer, agitated, hot under the collar, fuming, anger rising, wells up, boils over, cool down, let off steam, explode with rage, blow your top, flip your lid
  • not an honest bone in his body
  • brimming with vim and vigour
  • overflowing with vitality
  • devoid of energy
  • drained
  • took a lot out of me
  • take in what I am saying
  • what he said left a bad taste in my mouth
  • half-baked ideas
  • warmed over theories
  • I can't swallow what you are saying
  • can't digest all these facts
  • the argument smells bad
  • food for thought
  • meaty part of the paper
  • let the idea jell, ferment
  • crack up, fragment, crushed, shattered, broken, go to pieces
  • give you a piece of my mind
  • good things - girls, babies, dreams, faces, baby animals, melodies, are tasty and sweet - we want to take them in; life is sweet, I could just gobble her up, sugar and spice, honey, sugar, sweetie-pie, etc.
Central here is an idea from work on 'embodied cognition': our experience of being the bodies we are not only provides us with a range of bodily metaphors that can be borrowed to articulate psychological facts, but also constitutively shapes our experience and thought. And experience and its representation here are not to be thought of as two separate affairs: the very form my cognition can take is now to be seen as a function of the bodily experience on which it rides. It is no accident that it comes more naturally to us to talk of 'taking in' or 'digesting' or being 'sickened' by what someone is saying. We feel disgust, for example, not only at rotten food but also at 'rotten' ideas; our moral discourse is permeated quite generally by the ideas of such rot and the feelings they provoke in us.

I'd like to note in passing that the unconscious mind represents itself to itself (in dreams especially) not merely as a body but also, often, as a house (and sometimes also as a vehicle). And houses and vehicles are also containers into which bad things can come (bad spirits, ghosts, robbers, mysterious energies). We mark the thresholds to keep their inhabitants safe (Christus Mansionem Benedicat). The dolls' house, and the motif of 'telling the bees', provide further elaborations of a mapping between psychological and domestic domains. Dream houses are often possessed of additional rooms. Attics and cellars are mysterious places. It's not unheard of for charms and clothing to be hidden up fireplaces and under floorboards. Romantic passions are scratched onto hidden walls. The hearth is a heart (the heart of the home), one that can provide life and warmth - or be chilled and barren.


children, psychotics, occultists... and 'complementary' medicine

I want now to elaborate the above idea of emotional experience taking its form from bodily experience by reference to a diverse set of cases.

In their games children attempt the sublimation of un-processed shame experiences. Now the experiences become infectious agents - i.e. like cooties - that can be 'passed on'. Tag/It is played to playfully manage the fears and desires aroused around shame, being outcast, etc. The emotional here finds its registration in concrete terms - as generally happens, in fact, when we're dealing with infantile, borderline and psychotic thought.

Schizophrenic persons can experience their body as populated by strange energies and invasions, as a container of foreign objects, etc.

The same vision of the body is offered us by a range of occult depictions of the body - a site of 'energies', spirits, force fields, etc.

Medieval medicine, both Western and Eastern, relies on notions of humors and energies - inner substances or forces which may be imbalanced and which may need removing from or adding to the body.

The intuitively compelling idea of the body as containing bad forces which can be purged appears to underlie the popularity of a range of 'alternative' medical practices. Thus we have the 'dietary therapy' or 'detox' in which 'bad substances' ('toxins') which are supposedly locked up inside you can be purged from the body with the right kind of diet. We have 'super foods' which are special containers of goodness. We have cleansing enemas. We have the idea of the value of drinking many litres of water - perhaps a specially pure mineral water - each day to keep the body healthy. Moxibustion and cupping remove the bad lodged within. Crystals, magnets and electricity provide healing forces; think here of the antics of the animal magnetists (mesmerists).

We have too the cigarette - a basic oral comfort which in phantasy therefore involves taking in a good dose of mother's milk under one's own control (the latte with the disposal lid being a good example of the oh-so-sophisticated nipple substitute), but which has now become a source of bad milk that can (not merely as a matter of phantasy but as a matter of fact) produce the ultimate bad phobic internal object: cancer.

Complementary medicine is usually describes as complementing orthodox medicine. But what it most often complements, it seems to me, are the largely unconscious ways the self represents itself to itself in phantasy.

anthropology

Before turning to synthesis, let's consider one more set of observations - this time the anthropologists' observations of the rituals of healing.

Lévi-Strauss provided us with the beginnings of an anthropological understanding of symbolic efficacy - but as Kirmayer has argued 'the process of healing seems under-theorized and the mechanisms involved remain unclear'. Even so, let's consider: the terrified pregnant Cuna mother with congested parturition is given a long incantation in which the shaman and she must go and rescue her purba (soul) from the domain of Muu (the embryogenic force). They must make their way through a passage, replete with demons etc., right into the interior domain of Muu. They then recapture her purba and beat their retreat after exchanging what turns out to be respectful and hopeful goodbye's with Muu. Or: Quesalid the once-debunking shaman conducts a ritual in which he claims to remove the illness (a 'bloody worm') from the patient's body - but this illness is in fact a feather that he has earlier secreted in his mouth and which he covers in blood by biting his tongue. The patient is relieved on seeing the 'bloody worm'.

Lévi-Strauss offers us this:  'The patient is all passivity and self-alienation, just as inexpressibility is the disease of the mind. The sorcerer is activity and self-projection, just as affectivity is the source of symbolism. The cure interrelates these opposite poles, facilitating the transition from one to the other, and demonstrates, within a total experience, the coherence of the psychic universe, itself a projection of the social universe.' One wants to say: 'Yes... but .... how?' Kirmayer takes us closer in his work, but one still feels that just where one wanted to understand something, we get something like a disparate collective of sociological descriptions.

Or consider the
story of an Alabama man, 80 years ago, who was cursed with voodoo. By the time the unfortunate patient was seen by a doctor, Drayton Doherty, he was emaciated and apparently close to death. Concluding that nothing he could say would shift the patient's unshakeable belief that he was about to die, Doherty resorted to trickery. With the family's consent, he gave the man a strong emetic then slyly produced a green lizard from his bag, pretending it had come out of the man's body. The witchdoctor had magically hatched the lizard inside him, Doherty told his patient. Now that the evil animal was gone, the man would get well again. And so he did. (Jo Marchant, Cure - citing Clifton Meador, Symptoms of Unknown Origin.)
Other medical anthropologists give us good data on similar healing rituals. Moxibustion (cupping) draws 'bad blood' out of the body. Leaches do something similar, as do Hopi ear candles. The psychic surgeon from the Philippines performs 'psychical' incisions on the patient's abdomen, reaches his hand into their inside, and pulls out the source of the illness (some chicken guts he's earlier secreted up his sleeve), before magically healing over the 'wound'. The exorcist draws out the bad spirits from the body (Jesus conveniently displaced them into the interiors of the now-suicidal Gadarene swine). Th 'energy healer' passes 'healing energy' from his hands to the patient's interior. And so on.

proto-synthesis

To summarise: what we have above are:
  • the need for a theory of how unconscious expectancy effects and meaning responses work (to grasp the placebo effect in all its scope, and not just in relation to conscious belief) 
  • the Kleinian contention that our primitive experience of our own bodies - good and bad substances going in and out of us - is unconsciously organising, in a constitutive way, of our whole emotional life
  • the linguistic observation that many of our idioms for our psychological processes are offered in precisely such a corporeal register
  • a range of anthropological observations that reveal that whether we're talking of children's play, shamanic healing, new age complementary medicine, voodoo, schizophrenic self-experience, etc., we find once again an organisation of personal being through a corporeal set of lived metaphors having to do with bad spirits/energies/cooties/emotions/parasites being lodged in the body and needing the right kind of ritual to displace them.

The suggestion I'm now making is that effective healing ritual does well to itself deploy this same unconscious corporeal register of the body. (A nice example is given by Marguerite Sechehaye in her analysis of the young schizophrenic 'Renée' - who's brought to eat once again once Sechehaye/Maman holds pieces of apple to her own breast for her. But we can think more generally of how the Kleinians perceive maternal/therapeutic action: as the capacity to receive from the infant/patient intolerable projections of undigested feelings (Bion's 'beta elements'), so that they can be emotionally digested by the mother/analyst and fed back in assimilable form to the child/patient.) The healing ritual, to resonate with the patient in his autonomic life, must deploy the language of the body as spoken by unconscious phantasy. It is at this 'between' level - between properly conscious thought and any merely physiological description of autonomic nervous system responses - that anxiety is digested or festers. It is at this 'between' level of unthought comprehension that the Cuna mother-to-be can, through participating in the ritual to recover her purba from Muu, find the courage and relief and sense of coherent trajectory to finally give birth (as, presumably, her adrenaline and oxytocin may now stabilise, enabling parturition to progress). It is at this 'between' level of semi-thought anxiety and comfort that bad feelings/wind/indigestion/spirits assail the interior and are soothed by means of rituals which once again deploy the idiom of unconscious corporeal phantasy. To extend our theoretical hypothesis, perhaps we would do well to pay attention too to other resonant dimensions of phantasy - I'm thinking in particular of that which maps the body onto the room/house (think of those mathematicians who work better in rooms with tall ceilings; think of the aesthetic effects of hospital rooms on healing), and of body to body (think of voodoo; or Sechehaye's patient Renée who has a little doll with whom she is identified and who must first be cared for before she can be); think for that matter of sympathetic magic quite generally.  

And now we have a theory as to why open label placebo responses obtain. Why should it matter whether you know that you're taking a placebo - if much of the action is obtaining, at any rate, at the 'between' level of phantasy? If I'm right in the above, then it's medically negligent for any doctor to not also be a shaman - to not also be someone trained in the ritual arts of harnessing the immune and ANS system responses through speaking and dancing the inherent language of the body. Of course, and to some degree, doctors precisely do this - with their array of good potions to put into the body, or operations to take bad things out; with their shaman uniforms of white coats. We tend to think, because of the extraordinary cross-over between what turn out to be the medical facts (germ theory, worm infestation, etc., do precisely have to do with bad being trapped inside the body; pills and operations precisely are about putting in combative agents or opening up the interior to take out the bad), that expectancy effects relate to what we take ourselves to know about medical facts. Perhaps it is this extraordinary sympathy between the two that enable, say, medicines such as anti-depressants which basically function no better than placebos to function so very much better than wait list controls. But perhaps it's also this synergy of the 'shamanic', as it were, and the medical facts, that prevents us from grasping just how expectancy effects might be mediated by unconscious corporeal phantasy.

reading

Wilfred Bion 1963 Elements of psychoanalysis.
Jim Hopkins 2000 Psychoanalysis, metaphor, and the concept of mind.
Lawrence Kirmayer 2003 Reflections on embodiment.
Lawrence Kirmayer 1993 Healing and the invention of metaphor: the effectiveness of symbols revisited.
George Lakoff & Paul Johnson 1980 Metaphors we live by.
Claude Lévi-Strauss 1963 The Sorcerer and his magic. In his Structural Anthropology vol 1.
Jo Marchant 2016 Cure: A journey into the science of mind over body.
Marguerite Sechehaye 1951 Symbolic realisation: a new method in psychotherapy.
Hanna Segal 1991 Dream, phantasy, and art.