Wednesday, 23 December 2020

sanity, madness, the family... and the kettle

In Where's the Problem? Rachel Cooper offers us, amongst other things, a reading of a central aspect of Laing & Esterson's classic Sanity, Madness and the Family. Much of her paper is concerned with evaluating the idea that mental disorders are or are not 'in' the individuals diagnosed with them. I want to leave off discussion of philosophical psychiatry's curious use of that preposition for another time; for now the focus shall be on her reading of Laing & Esterson (hereafter: Laing). In that reading - which I believe to be both wrong and wrongheaded in almost every detail - Cooper mentions a patient called Maya Abbott - the first reported in Laing's book; we shall return to consider her case in more detail after first presenting Cooper's argument. Suffice it for now to say that she's a 28 year old only child who has mainly stayed in a psychiatric hospital during the last 10 years, and who was evacuated to live away from her parents during WWII. Her diagnosis is 'paranoid schizophrenia'; she believes others can read her thoughts and are constantly discussing her.

Cooper's Argument

As I detail Cooper's reading I'll number her key claims:

  1. Laing offers us an 'account of schizophrenia' and claims that 'schizophrenia is not 'in' the diagnosed patients.' 
'When the interviewers go to Maya's home ... they notice that her mother and father seem to be winking and nudging each other, as if they were seeking to pass messages to each other. In discussion, it emerges that Maya's parents have developed the idea that she can read their thoughts. They seek to test this, and wink and nudge each other as cues. However ... when Maya asks them what they are doing, they deny that anything strange is going on.'
  1. 'Maya's ideas appear delusional when she is considered outside of her family environment. However, when she is seen with her family, it makes sense that Maya would have the odd ideas that she does.'

As a conceptual tool to evaluate claims that mental disorders are located 'in' individuals, Cooper offers us the kettle analogy:

  1. 'How in general do we locate a problem when a complex system fails to function? ... Take... a kettle that has been plugged in but fails to boil water. The problem might lie in the kettle, or it might be a problem with the socket. How does one locate the problem? ... We try plugging the kettle into another socket. If we then get hot water, we conclude that the kettle is okay. Conversely, if we can get a different kettle to work in the original socket then we conclude that the socket is working.'

Sanity, Madness and the Family By R. D. Laing
Her reconstruction of Laing's alleged argument that Maya's schizophrenia is not 'within' her goes as follows:

  1. i. 'Laing and Esterson first speak to the woman in isolation from her family. She appears deluded... They then speak to the woman in her family context. ... In the family context, the woman no longer appears irrational; rather, the problem appears to be with her wider family. The tacit reasoning going on here, I suggest, is that Laing and Esterson think that they themselves would do no better if forced to live with the woman's family. ...[I]f the patient were replaced by a test 'normal' subject there would still be a problem. Thus, they conclude the problem is not within the woman.'

Cooper finds this reconstructed argument invalid:

  1. ii. 'The possibility they fail to rule out is that there is a problem both with the patient's family and also within the patient. Before concluding that there is no problem with the patient, we also need to consider whether she would do okay in some other environment (as we should only conclude that the kettle is functioning if we can find some socket in which it works). ... The information [Laing] provide suggests that the diagnosed women do not actually do very well when placed in a different setting. Maya ... had [after all] been hospitalised for nine of the preceding ten years.'
Just to clarify what she takes Laing to argue and not argue, Cooper notes:

  1. 'If one thought that schizophrenia could be caused by dysfunctional family situations (in the sense that problematic family dynamics could cause internal cognitive dysfunction in an otherwise potentially normally developing child), then schizophrenia would also count as an environmentally caused disorder. Note that Laing and Esterson's ... claim is not that schizophrenia is caused by families but located in individual patients (they explicitly state that their claim is not 'that the family is a pathogenic variable in the genesis of schizophrenia'), but that schizophrenia is not a condition to be located within patients at all.'

Critique

Let's go through these key points one by one:

  1. Whilst Cooper says that in Sanity, Madness... Laing offers us an account of schizophrenia, one arguing that 'it is not 'in' the diagnosed patient', in fact he explicitly denies this. First off, he tells us that he's not offering an account of schizophrenia, doesn't 'accept it as a fact' or 'adopt it as a hypothesis', does not 'assume its existence' and 'propose[s] no model for it'. (I quote here from the Preface to the 2nd edition.) When he talks of her 'illness', the inverted commas around the term signify that the perspective from pathology has here been 'bracketed'. Laing's social-phenomenological study looks at the family relationships enjoyed and suffered by individuals who are diagnosed as suffering schizophrenia; whether the diagnosis is apt or valid is not his concern. Second, he explicitly denies that it makes sense to attribute psychopathology such as schizophrenia to a family system: 'The concept of family pathology is... a confused one'.

  1. Cooper tells us that Laing found Maya to appear delusional only when interviewed alone, but that when set in the context of her family's strange behaviour, her odd ideas make sense (i.e. are presumably, by implicatur (see her 'However'), not to be taken as delusional). But Laing doesn't deny that Maya 'has queer experiences' and 'act[s] in a queer way'. He doesn't deny (or assert) that she suffers delusions. He says that he has seen many of the patients, perhaps Maya too, both when they were 'acutely psychotic, and apparently well'. But in this study he simply 'brackets off' such psychopathological considerations. And most importantly, Maya's ideas are not presented by Laing as rationally intelligible responses to her parents' strange behaviour. Instead they are presented as emotionally intelligible responses to her parents' intrusions. 

r d laing
I want to hammer this home a bit since, it being Laing's central contribution to psychiatry (for which we've to thank his own desperately intrusive mother), we should get it right. The narrative regarding the parents' interactions with Maya is one of an utter existential stifling that prevents her from developing a well-functioning mind. Her father always sits too close; she isn't given room to express and enjoy her own preferences; she struggles to individuate and achieve autonomy; the Abbotts regard Maya's 'use of her own mind', her attempts at 'autonomy' and 'self-possession', as synonymous with her 'illness'; it's her 'illness', her 'selfishness' and her 'greed' that makes her 'difficult', they say. She shouldn't 'want to do things for [her]self'. Maya complains, and Laing affirms in his observations, that her parents do not 'see her as the person I am'. Her father just 'laughs off' what she tells him of her own experiences (her preferences, opinions, night-time dreams), disturbing experiences that she desperately needs to be taken seriously and psychologically contained. In short she's consistently invalidated rather than offered recognition. Laing's claim isn't that Maya's behaviour can be seen as sane / not delusional in the family context. It is that, in this context, her psychodevelopmental difficulties in becoming her own person, knowing and having her own clear thoughts, make perfect psychosocial sense. Her father's mind is experienced by her as so intrusive that she can't develop a clear sense of her own. Her 'delusions' thematise this existential struggle. She lacks the ego strength to trust her own mistrust of her parents' sincerity; because she cannot trust her own mistrust, she cannot develop a stable mind. At puberty she's troubled by her sexual thoughts, and tries to express this to her parents; they simply deny to her that she has thoughts of this kind. And 'when she told her parents in the presence of the interviewer that she still masturbated, her parents simply told her that she did not!' There are many, many, more examples like this in the book.

To reiterate the main point: Laing's claim isn't that Maya can be seen as not delusional and hence as rationally intelligible in the context of her parents' intrusions. It's rather that Maya's preoccupations and disturbances, whether or not we call them delusional, are emotionally, psychologically, and developmentally intelligible in that context.

  1. And now for the kettle! Striking about this rather peculiar analogy for a person's existence is the non-diachronic nature of the relationship between the kettle and the socket. The kettle just carries its fault around inside it, quite independently of its past and ongoing relationship with the socket. But here it's surely the contrasts between people and kettles that are (perhaps unsurprisingly!) more illuminating than the similarities. For as Laing writes, 'The relationships of persons in a nexus are characterised by enduring and intensive face-to-face reciprocal influence on each other's experience and behaviour.' Laing doesn't go into it in this book (but see his second book Self and Others - that came after The Divided Self and before Sanity, Madness...), but he fully accepts the idea that internalised object relations enduringly structure the psyche. In short, Maya's parents' intrusiveness doesn't just affect her when she's with them; it's internalised into her psychic structure; they continually dwell in and distort her internal world. It's not only when she's with her father that she cannot find her own voice. She has so struggled with individuation that her mind is still engulfed by his even when they're apart. To make the peculiarly inhuman analogy work, we'd need first to envisage rechargeable battery-powered kettles. These kettles work autonomously (at least for a while) so long as they've had a healthy enough link up to a power supply in the past. Absent that, and they just don't have sufficient power in their cells to boil the water. And here's the painful predicament, as Laing understands it, that's faced by Maya and all the other patients about whom he writes: in order to individuate they first need to receive recognition and containment from a parental figure. If this relationship is damaging to their selfhood, they withdraw from it in self-protection. But this withdrawal also cuts them off from the possibility of ever internalising what they need. By shutting their mouths they take in no poison, yet also starve to death.

  1. not a refrigerator mother
    I think enough has now been said to make clear why Cooper's reconstruction of Laing's tacit reasoning is inapt. His thought isn't 'If I were now in this family I too would say and do such things'. It's rather 'If I'd grown up in this family, I too might never have been able to develop a self-possessed mind. I too might be inwardly riven; I too may have shut down my motivation; I too could have been fated to become but a 'ghost in the weed garden'.'
  2. And finally, recall Cooper's suggestion that Laing's refusal to 'locate' schizophrenia in Maya amounts to his instead locating it in the family. It should by now be clear that this is wrong in two or three respects. First, Laing brackets considerations of 'schizophrenia' in this study. Second, he straight out declares that the 'concept of family pathology is... a confused one'. He takes it that, whatever 'schizophrenia' is, if indeed it is anything at all, it's an individual pathology. But, third, what he's instead interested in, in this often misunderstood book, is the maddening character of certain families. Or, well... perhaps all families are, to some degree, maddening in this way, he suggests. (It's notable that Sanity, Madness... was the first of two projected volumes. The second was to be on families which didn't have a child labelled 'schizophrenic' ... but Laing found these families too deadly dull to continue his research.) Perhaps, one might think, some children are more sensitive than others to intrusion, and so need a more sensitive parent to help them develop a solid sense of self. Perhaps many children would have been able to hold their own and develop enough ego structure even in the midst of such an intrusive and non-recognition-providing family as Maya had. And perhaps Maya would also have struggled even in a family with just average levels of parental failures in recognition provision. Such quantitative concerns are, however, simply not Laing's. What he wanted to do was instead to make the thought and behaviour of those diagnosed 'schizophrenic' intelligible to us by setting them in the context of their family dynamics. 
And, in my view, in this he succeeded.