Philosophical Perspectives in Clinical Psychology

limning disorder

2012-01-17T15:21:00.004Z

Neil Pickering has recently published a nice paper on the derivation of the concept of 'mental disorder' from that of 'physical disorder'. A family resemblance (perhaps his own?), and a secondary sense (mine), account of how this works are evaluated. (One rather nice if odd thing for me is that Pickering argues that my secondary sense account is more original than I thought it was - since I'd always assumed I was merely elaborating on T S Champlin's argument in To Mental Illness via a Rhyme for the Eye.) The question is asked: What makes for the validity of an extension of a concept from its primary domain to the new domain?

Pickering does a good job of undermining certain essentialist prejudices regarding what makes for the validity of a conceptual extension. The family resemblance account (that mental and physical disorders may share various features in common but none essentially) is shown to satisfy a certain somewhat relaxed understanding of what demands for determination (distinguishing members from non-members of a set) and coherence (inner unity of the set) impose on the acceptability of proposed extensions. The secondary sense account is shown to not meet these - but this is perhaps not surprising since the whole idea of secondary sense (and of Lakoff and Johnson's 'conceptual metaphors') is that our uses of such terms are governed by the unprincipled associative whims (as it were) of our culture-bound CNSs.

What all of this makes me think, though, is how rather strange it is that so many (well, a few) philosophers (like me) take themselves to be called to provide 'accounts' of what mental disorder consists in - and how odd it is really that it isn't just obvious whether the concept of 'mental illness' is a prototypical, family resemblance, secondary sense, subtype of physical illness, natural-(dys)function-explicable, etc. concept. Is it really the case that the language-games of mental disorder ascription are that opaque - that we must all be rather left merely gesturing from afar at what it is we are doing when we say of someone, as we all sometimes do, that they are or are not mentally disordered?

I have (groan) another (somewhat deflationary) theory of all this. Which is that there probably just isn't really any such thing as 'the' language game of 'mental disorder'. Rather there are a range of different aspirations, phantasies, habits, understandings, cultural histories, departmental quirks, etc., underlying talk of 'mental disorder', 'mental disease', 'emotional disturbance', etc. Different presentations of different kinds of patients pull us this way and that both within and between the deployment of these notions; the seas and shores of language shift a little between regions and nations, or over historical times, or between the clinic and the academy.

So perhaps there is not really any determinate language-game being played out by different people with terms like 'mental disease', but a set of overlapping and ill-defined moves in conceptual space are nevertheless constantly being made. It's all a bit of a mess, but we get by. The philosopher however strives for tidiness - and perhaps even more so wishes that the tidiness is already there waiting to be discovered. So they project a conceptual structure underneath all this mess, and generate accounts which propose what the language game is 'really' all about.

Reading Kuusela's lovely Struggle against Dogmatism gives me another idea of how to proceed. Which is that, rather than trying to determine 'the' logical structure of 'our' (whose?) concepts, we could instead steer our philosophy to two other ends: a) noticing when muddles arise due to the un-noticed using of terms in different senses, or due to prejudices about what 'must' be meant by the terms in use, and b) articulating clear stipulative paradigms for the use of such terms for the purposes of clarification. Whether that will ever be enough to dent the wish or need or phantasy of philosophers to take themselves to be uncovering deep facts about existence is however another matter.

normality and the language game of reason giving

2012-01-15T20:42:00.005Z

Here is a frequently encountered dialectical situation well known to the philosophically minded clinician. Someone is carrying on, in speech and behaviour - in a very odd way. You and I are wondering if we can make sense of what they are saying. 'Why did you not put your bins out?' 'Because the aliens are keeping me under surveillance.' That, I propose, just doesn't provide what counts as a good reason for acting. As Roger Teichmann has it, in his super little book Nature, Reason, & the Good Life, 'Roughly speaking, a reason for an action is meant to show why the action was, is, or would be a good idea; and the content of 'good' is provided by the context, by what is at stake, and, in an important class of cases, by what is normal and natural for human beings.' (p.12)

But you are in an anti-conservative mood and ask me 'Aren't you being rather restrictive in saying that often only what is normal and natural for human beings can count as fixing what the goodness of a reason for acting is?' 'Isn't that rather discriminatory of you?' 'What if doing something else had been normal?' 'Don't we need to be able to critique what is normal and natural as well - to hold it up to some standard?' 'Doesn't an unwillingness to do this show that our judgements as to what is and what is not humanly intelligible, sane, are grounded in nothing more than fiat?'

Now, I have come to think that there are different ways in which we can make sense of actions, and providing reasons for them is only one such (albeit the most important). There is also making sense as we might say psychologically, of why people do the strange things they do. That, it seems to me, amounts not to articulating the reasonable grounds but, on the whole, to looking at the inner motivational push for believing this or that - in terms of what is made thereby more manageable, more bearable, less galling, in one's experience and in one's self-conception. But when it comes to the rational sense-making of (which as Roger Teichmann notes, is not itself to be conflated with the giving, ad infinitum, of justifications for) actions, I suspect that less good sense can be made of madness than we sometimes hope. In what follows I'm going to borrow from my ancient PhD thesis to explicate what I see as the form of the conceptual temptation which underlies the anti-conservative move above.

The move was, I think, one to which Isaac Newton succumbed in the Preface to the Scholium of his Principles of Natural Philosophy. A man is walking along a ship from stern to bow. He crosses the top of the boat west to east at 4 mph. But, Newton wonders, what is his 'real' speed? For the boat itself is travelling east to west across the sea at 6 mph. So is the man 'really' going at 2mph? But then, Newton considers, perhaps the earth is itself in motion relative to the 'fixed stars'. And so on. What has happened here is that the notion of 'real motion' has floated free of the contexts which give the very idea of motion (one thing changing position relative to another) its sense. To ask 'yes, but free of such local restrictive contexts what is his motion?' is not as yet to ask an intelligible question - since the contexts provide the meaningful conditions for the very notion of motion.

So too, I suggest, with the idea that 'the content of 'good' is provided by the context, by what is at stake, and, in an important class of cases, by what is normal and natural for human beings.' To abstract away what is normal and natural for human beings is often not to emancipate reason from excessively restrictive, conservatively patrolled, parochial boundaries - to the greater purpose of bringing the psychotic subject within the fold of the humanly intelligible. It is, instead, to traduce the language game of reason giving by abstracting from the preconditions for the intelligibility of the practice.

This, ultimately, is I think what we find when we consider those phenomenological alternative universes which the psychotic person is supposed to inhabit. Whilst we can shed light on what it means to be insane by referring to a profoundly altered background of embodied dispositions, we do not thereby also get to shed light on the meaning, in an alternatively structured world outlook, of what they say and do. For to suppose that we still here have to do with a 'world outlook' is to imagine that we can talk about motion in abstraction from a stipulated frame of reference.

It is important to get the analogy right. The point is not that, just as we can talk about different motions relative to different frames of reference, different sets of reactive dispositions make for different frames of reference of intelligibility. That really is precisely not the point at all. The analogy is rather between a particular ('normal, natural') set of reactive dispositions (which provide a frame of reference for different utterances and actions) and a particular (namely a non-abstract, physical, fairly rigid and internally static) kind of object (providing a frame of reference for talking of an object's movement). (To go on '2+2=5' is not to add differently but not to do what is called 'adding'.)

therapy as ethics: from intervention to recognition

2011-11-24T20:04:00.001Z

I've recently come to the end of a three year post as a clinical psychologist working in an NHS primary care service. And have been looking back over my clinical notes and teaching session notes from this time. Much has changed me in the last couple of years, including my experiences with the 150 or so patients that have graced my consulting room.

What I notice, when I look back, is a significant change in my clinical understanding and clinical practice. It would be too easy to gloss this at the level of the 'model' I most typically deploy - having moved from a mainstay use of cognitive-behavioural, ACT, solution-focused, narrative, and schema-focused modes of formulation, towards something best characterised as psychodynamic. But characterising the move in that way, on the basis of the model used, misses - in fact it seems to me it covers over, obscures - what I now feel to be what is essential to the change. I shall call that, instead, a change from 'intervention' to 'recognition', and will now try to spell out what I mean by that.

When I started out I think I took myself to be in the business of formulating the patient's difficulties, and then - either from within my own expertise, or in closer proximity to the patient's own comprehension and wish - developing and deploying an intervention. The intervention might, for example, have involved exploring with and explaining to the patient the disorder-maintaining function of certain 'safety behaviours', and inviting them to relinquish these in the knowledge that anxiety is self-limiting. Or it might have involved asking them a series of 'solution-focused' questions designed to elicit an anti-depressive sense of self-efficacy and possibility. Or it may have involved formulating the patient's emotional difficulties as the product of certain habitually deployed 'defence mechanisms', and trying to push through these defences; to intervene in, or disrupt their hold on, the patient's emotional functioning.

I think it is still true that the above are what I do much of the time. And perhaps that is often-enough not such a bad thing, even if I suspect that intervening is too often something I do out of laziness or defensive omnipotent narcissism. And I think it is true, too, that no doubt certain skills get 'internalised' and so I have come to automatically, unreflectively, deploy therapeutic skills. But what I want to resist here is the idea that the growth of the therapist away from a conscious deployment of 'interventions' is best explicated in terms of an internalisation, automatisation, of such therapeutic knowledge, models, and skills. That is the tempting but banal thought; a thought which, I believe, it takes philosophical reflection to 'undo' (hence this post appearing in this blog).

One way of describing part of the difference in me over that time makes reference to becoming, rather than delivering, the therapy. What I mean by this is something like: rather than providing 'psychoeducation' to the patient at an explicit, conscious, level - about the nature of anxiety for example - this learning is instead something which gets embodied at an implicit, unconscious, level in the therapeutic interaction. The patient comes gradually to automatically, unreflectively, internalise my own tolerance of, and capacity to carry-on-thinking in the midst of, anxiety. And this happens in and through my own non-intervention-driven interactions with the patient in the room. What I am claiming, that is, is that this really isn't primarily a matter of my automating my interventions. What matters is not whether I have an automatic capacity to draw on a piece of knowledge, but whether I can automatically 'contain' their anxiety, keep on thinking, non-reflectively metabolise their projections, and the like. This is not a matter of intervening on my part, automatically or not, but a matter of being able to continue relating to the patient as to a person, despite their defensive (fear-motivated) evasions of their own personal being - their unconscious evasions and distortions of their autonomy, responsibility, agency, and inner integrity.

I don't mean to suggest by this that skill and knowledge are not needed on the part of the therapist who practices therapy as 'ethics' rather than as 'intervention'. They surely are, but it seems to me that the real skills are often not in knowing what interventions to perform how on whom, but rather in explicitly or tacitly recognising such forms of disturbance as may otherwise lay latent within, and prove disruptive for, the therapeutic process - recognising them so that the helpful recognition-providing conversations can continue, unabated, un-derailed.

http://www.carolcamfield.co.uk

psychological vs neurological

2011-07-05T12:41:00.164+01:00

So I'm wondering if it's possible to do better, when unpacking the distinction between psychological and neurological forms of mental health problems, than:

a. Psychological problems are psychologically caused; neurological problems are neurologically caused.

The problem with this is surely that

b. Since all psychological factors are realised in the brain, and since there just isn't any substantial paramechanical psychological domain which causally impacts on the brain, and since talking therapy can affect brain function and neuroleptic therapy can affect psychological function, the very distinction - neurological / psychological - looks to be otiose.

It seems so very tempting to suppose that b. must be true - to suppose, say, that the very idea of distinguishing between neurological and psychological disorders reflects adherence to an unthinkingly dualistic metaphysics.

One salvaging move at this point might be to recast the distinction along structural / functional lines: neurological disturbances being disruptions in the 'hardware' of the brain, psychological disturbances being disturbances in the software being run on the neurologically intact system. That distinction might itself break down if we take too fine-grained a look at the hardware - i.e. at the level of the software implementation, but on the whole seems to work well enough. But still, construing the psychological / neurological distinciton in such terms might easily be seen more as a case of changing, rather than elucidating, the subject.

Despite the above problems, I want to make a case that the psychological / neurological distinction is well worth preserving. Why it should be preserved is, I think, an object lesson in the philosophy of psychiatry. The basic idea is that we do better to consider how these terms ('psychological', 'neurological') are actually used in clinical practice, rather than impose decontextualised meanings onto them from within philosophy's own metaphysical preoccupations. What I want to claim is that psychological disturbances are those mental disturbances which are a function of an individual's self-understanding; neurological disturbances are not.

This approach is metaphysically neutral about minds and brains, and about the ultimate causal origins of psychological disturbance (perhaps one particular psychological disturbance was originally caused by a one-off quirky mishap in the prefrontal cortex). What makes for its psychological character, however, is its having been caught up in the self-creating ongoing dynamics of a subject's self-understanding. Psychological disorders are, in this way, disturbances of inwardness: disturbances in aspects of those processes by which we become characters and steer ourselves around the interpersonal world.

A neurological disturbance is not first and foremost a disturbance in self-understanding. It may give rise to such disturbances, but the idea of the fundamental disturbance ought not to make mention of them.

Another way to try to make the distinction between psychological and neurological is on the basis of intelligibility: neurological disorders are intelligible only in the sense that the pattern of breakdown in a causal mechanism is intelligible given what we know about its mode of functioning. Psychological disorders, however, can be thought of as humanly understandable, in that kind of a way that someone's reasons for acting may be intelligible. Intelligible by being placed in the human order of rationality, that is, rather than merely in the natural order of causality.

In itself that seems just fine to me. What is perhaps less desirable is a commonplace way of spelling out what the basic ingredients of an intelligible response might be. The cognitive behaviour therapist, for example, tends to find distorted beliefs or thoughts underlying the psychological disorder. But whether the distorted forms of understanding are really captured, in anything other than a rather loose metaphorical way, through such notions as 'false or unhelpful beliefs', 'automatic thoughts', etc., is I believe doubtful; this is simply too intellectualist a form for the understanding to take. (The analyst's 'unconscious phantasies' seem closer to the mark, although this notion also risks conjuring up the idea of hidden occurrent imaginings, rather than of disturbed living dispositions.)

On the other hand it would not do to take too general a notion of disturbed understanding - to look, for example, for the kinds of 'understanding' that are contained in every unreflective perceptual act. For then, once again, we struggle to maintain our distinction between the neurological and the psychological. What gets lost here is what I believe is the essential reference to a disturbed self-understanding - a disturbed self-understanding which gets inscribed and reworked in the heart of the psychological disturbance.

I notice, to finish, that the notion of 'psychological disturbance' that I have arrived at is not very dissimilar to the old fashioned notion of a 'neurosis'. It occurs to me that this might not be such a bad thing, and I wonder whether that concept has simply gone 'underground' for a while, still shaping and unifying our conceptions of disorders from beneath whilst being temporarily erased from our reflective clinical consciousness.

Review

2011-06-17T14:24:00.001+01:00

John Heaton: The Talking Cure: Wittgenstein’s Therapeutic Method for Psychotherapy - Draft of a review for the British Wittgenstein Society

Wittgenstein, Philosophy, and Psychotherapy

In considering Wittgenstein and psychotherapy in the same breath, our first thoughts naturally go to Wittgenstein’s use of the metaphors of (mental) ‘illness’ and its ‘therapy’ or ‘treatment’ to characterise the intent and manner of his engagement with philosophical questions. The central idea of the analogy is by now clear (thanks to Fann, Cavell, Fischer, Petermann et al.). Unbeknownst to himself the metaphysician is held captive by a ‘picture’ which unconsciously influences and thereby distorts his thinking. He then consciously attempts to articulate the resultant perplexities and doubts into clear questions; the hope is that such perplexities and doubts can be relieved by developing theories and explanations which answer the questions. In doing so, Wittgenstein contends, he is much less like a scientist providing us with global or foundational knowledge, and much more like a neurotic, than he realises.

The obsessional neurotic, for example, struggles to habituate to her underlying anxieties and accept her losses; instead they are deflected by being articulated into obsessional questions or forged into intentions. The underlying anxieties may then be quelled when the questions and intentions are compulsively answered or acted on. But because the questions and intentions do not truthfully articulate the underlying anxiety, the resolution of the anxiety is only temporary and it soon rears its head again. Thus the obsessional often presents to her doctor hoping for a better, more conclusive, answer to her doubts.

So too the epistemologist wants a better, more conclusive, explanation of ‘the mind’s’ relation to the ‘external world’; the ontologist wants a better account of the fundamental nature of ‘reality’; the metaphysician wants to develop a comprehensive theory explaining how mental events ‘cause’ bodily movements. In each case the Wittgensteinian treatment is the same: rather than trying to answer our philosophical questions and develop more secure knowledge, we are to unearth, clarify and undo the underlying deflections. Whether such philosophical deflections are best grasped i) cognitively – as resulting passively from the distorting influence on thought of tacit conceptual metaphors (Fischer), or ii) psychoanalytically or existentially - as actively if unconsciously motivated by a wish to avoid intolerable anxieties (Cavell) – is still a matter of debate. What is shared by all sides, however, is the idea that we do well to direct our interrogation not to philosophical answers but to the philosophical questions themselves.

Considered against the backdrop of this debate, John Heaton has written a surprising book. Rather than enter into the debate, or pursue distinctly philosophical scholarship of any sort, he instead takes back Wittgenstein’s distinctive clarificatory methods for psychotherapy. The form of therapy which results – which is clearly the method Heaton himself espouses – gets called the ‘talking cure’. Along the way he provides what I found to be a fascinating and really rather compelling account of emotional disturbance and the therapeutic resolution provided for it by the ‘talking cure’, and a somewhat uncharitable and less compelling critique of psychoanalysis, cognitive therapy, and psychiatry. I will now consider the therapy and the critique in turn.

The Talking Cure

Heaton’s vision of psychotherapy is modelled on Wittgenstein’s practice, but its value does not consist in its faithfulness to Wittgenstein’s philosophy (how could it?), nor in the evidence gathered for it (for how does one evidence a vision?). It consists rather in its capacity to make clear to the clinician what she already tacitly knows, to open up new insights, and to provide a sometimes radically alternative articulation of the character and goals of therapy, all in a form uncontaminated by pre-existing theories and their over-theorisations of the phenomenological facts of therapeutic interaction, misleading analogies and unhelpful ideologies. If I were to locate him on a pre-existing map I might describe Heaton as an unusually tough-minded, psychodynamically-inflected practitioner of Rogers’ Person Centred Counselling, or as a rather sophisticated exponent of Hobson and Meares’ Conversational Model. The transformative power of an honest and thoughtful encounter between two people is held up as important, rather than the doctor doing something (e.g. applying expert knowledge) to a patient.

But rather than continue to describe Heaton’s therapeutic method in relation to other therapies, or in terms of his fidelity to Wittgenstein’s philosophical method, it will be more instructive here to let it speak for itself; in this way the reader can arrive at her own judgement. Let us first consider Heaton’s characterisation of the nature and origins of psychopathology. In ‘neurosis and psychosis’, he writes, ‘there is an inability to speak of experiences that were traumatic or important but ‘unspoken’ … The victim [accordingly] is … not able to understand the reasons for her unhappiness …’. (ix) Misleading ‘pictures and analogies … hold our thinking in a cramp and stand in the way of our recognising the extraordinariness of the ordinary. The particular pictures that we fix on are rooted in our human way of life and culture, and therefore connected to our desires, fears and aspirations. They may be the expression of a wish to control the seemingly arbitrary world, especially if our childhood experiences were chaotic and unjust.’ (10)

It is part of Heaton’s understanding that the ways clinicians try to explain mental conflict often renders them ‘caught in a confusion whose character is not transparent to us. We are driven by a wish to find an explanation for the conflict, as if that will enable us to cure it. But this search for an answer is also the driving force in the conflict; we need to be liberated from the persistent inclination to seek answers to all questions. It is the conditions in which conflicts emerge, and the confusions which arise, that need attention.’ (10) The following provides an example of the kind of confusion Heaton has in mind. Someone ‘gave an account of his childhood, which was a variant of the ‘wicked stepmother’ theme. When he finished he turned to me and said, ‘ I suppose it was all inviteable’. (146). ‘[W]hen he said ‘inviteable’ truthfulness spoke, in that it showed he was trying to live as if the inevitable could be invited – a confused relationship between freedom and necessity, a compulsive attempt to live a life without suffering. He was saying something that cannot be meaningfully said as he was trying to live something that cannot be lived.’ (148)

This vision of what counts as worth attending to in the clinic entails certain goals for the talking cure. If someone is in ‘the grip of a problem’, what matters in therapy ‘depends on his free acknowledgement … If he does not agree with an elucidation, the appropriate expression has not been found. … This contrasts with much psychotherapy which is addressed to the problem as diagnosed by the therapist rather than the grip of the problem on the individual.’ (56). ‘By revealing themselves to some other person who they trust’, the patient ‘may come to see creative possibilities, differences and similarities they had not seen before. So they may realise that things need not be as they thought they must be, or that things may be as they imagined could not be.’ Elucidating the grip of unconscious pictures, rather than ‘being told what to do, or being interpreted in terms of a theory’ allows the patient to move on ‘spontaneously’ (94). Such elucidation is not to do with correcting mistakes, but with a more fundamental shifting of the way things are seen; it is to do with releasing us from captivity by a picture, rather than replacing one picture with another.

How does this elucidation and freedom to flourish spontaneously proceed? Not by ‘learning new facts, explanations and theories’ but rather through ‘reminders of what we have overlooked’ (ix) and by ‘attending to possibilities’ (209). Pyrrhonian scepticism provides an ideal: ataraxia (peace of mind) is ‘not achieved by cognitive accomplishment, attaining knowledge or insight – but rather by putting down dogmatic beliefs, by ceasing something’ (24). Therapy involves the patient finding their own voice. Free association is used to this end, not (as in psychoanalysis) to allow unconscious determinants come to the fore, but because it breaks up static language use, allows in chance and promotes different ways of seeing (140-1).

The patient’s movement from picture-engendered confusion to authenticity calls for a commensurate ‘response from the therapist… [whose words are] ‘simple, and … ideally spoken without a touch of ill-feeling, contempt, arrogance, bias, frivolity, jargon or word intoxication.’ (31) The therapist is required not just to help us relinquish the grip of pictures, but also to ‘support the [emerging] sense of our own experience. To listen to an expression of despair with a bored, all-knowing expression deprives the words of sense in a person who is unsure of herself. It is the involvement of others in our words that constitutes a condition of their meaningfulness, and which helps to bring order to our confusions.’ (97) The practice of elucidation and the provision of genuine rather than ersatz recognition involves spontaneous action by the therapist ‘and not the application of a theory or technique... Spontaneous action allows the subject to unfold out of itself the richness of meaning.’ (210) The psychotherapy adequate to this task is accordingly ‘a motley of techniques and practices… [using] pictures, analogies, metaphors or humour’ to develop the patient’s thinking (52). The psychotherapist is, unlike (say) the clinical psychologist who styles herself as a ‘scientist practitioner’ applying general scientific knowledge to the particular case, more like the ‘parrhesiastes’ of Ancient Greece: they must possess ‘virtuous knowledge’ – an individual, personal and practical ‘knack for acting’ (15).

In the above I have let Heaton speak for himself regarding his talking cure. As a vision of therapy I found it, as I said, compelling. What is not so clear to me is that it adequately captures the entire ground or field of either extant psychological distress or of apt psychotherapeutic practice. As I understand it, Heaton conceives of his own practice as a better way of doing therapy than that encouraged by cognitive or psychoanalytical approaches. I shall now therefore turn to his critique of these alternative theories and methods, and spell out some of my misgivings.

The Critique of Psychoanalysis and Cognitive Therapy

Throughout his book Heaton contrasts his talking cure with the theories and practices of psychoanalysis and CBT. He takes these therapies to task for their imposing on us: a vision of our mindedness as the possession of an inner realm of mental entities; a conception of neurosis as a quasi-mechanical disturbance in this realm; a version of the discipline of psychopathology as the causal explanation of such inner disturbances; and an account of therapy as theory-driven intervention in the internal world to undo the disturbances generated there. The question that continually recurred for me was whether it is primarily the therapies Heaton criticises which are to be taken to account for their mechanistic and objectified account of our mental life, or whether instead it is Heaton’s reading of the idioms such therapists deploy in their theoretical work which should be taken to account for its literalism.

As I read it, there are two related aspects of Heaton’s work which contribute to its unpersuasiveness as critique. One is its eschewal of the academic methods of philosophical, psychological or literary scholarship ; another is its running together – despite its oft sensitivity to precisely the same distinction – of matters ‘grammatical’ and empirical.

There are several ways in which the non-scholarly nature of Heaton’s text is a bonus rather than a detraction. In particular it makes for a refreshing directness of communication and a greater expressive force. Nevertheless it also means that there is no significant engagement with other attempts to read psychoanalysis and Wittgenstein together – which engagement, had it occurred, may have provided a better balance to his work. Take, for example, Charles Elder’s book The Grammar of the Unconscious, which makes its way into Heaton’s bibliography, but not into his discussion. The merit of Elder’s curiously disjointed book is its determination to read the intension of psychoanalytic discourse out of its extension – its meaning out of its use, as one might say – rather than out of its explicit (and readily criticisable, naturalistic and scientistic) metapsychological self-understandings. At times one may suspect Elder of an overly liberal application of the principle of interpretative charity. Heaton’s reading of psychoanalytic texts, by contrast, reminds one of the tendency of (say) physicalists to read religious or human science texts as if they were to be judged and understood according to the epistemic and semantic standards of the natural or physical sciences – from which such texts may nevertheless metaphorically extrapolate some of their terms.

I will consider this further in the following section, but first wish to document the other difficulty caused by Heaton’s otherwise pleasing scholastic restraint. This is his offering of unsubstantiated opinion, rather than hermeneutically or empirically evidenced argument, regarding the clinical practice (and not simply the theoretical apparatus) of psychoanalysis and of particular psychoanalysts. I will now – hopefully, thereby, avoiding the charge of hypocrisy – illustrate this with a wide range of examples:

Freud ‘did not distinguish the use of language, on a particular occasion, to describe how things are, from the more therapeutic use of clarifying how expressions are being used.’ (p. 1) [We are not given illustrations.] ‘He treated the patient as an evidence-exhibiting body – rather than a speaking human being.’ [No biographical data are provided.] ‘Psychoanalytic interpretations and CBT … are not based on a fixed truth about reality. [The meaning of the philosophical expression ‘fixed truth about reality’ is not explicated.] The analyst is not in a position to observe reality and put it into words without representing it. Although he should strive to be just, he is not neutral. [No detailing of psychoanalytic discussion about what clinical neutrality might and might not amount to is provided.] ’ (p. 10). In psychoanalysis, the ‘patient is instructed to speak freely but the analyst interprets dogmatically according to a rule. [No evidence of this dogmatic practice is provided.] He assumes that any deviation in free associations is caused by unconscious processes in the mind. [Whether analysts actually practice like this – or whether this is just a working assumption regarding material important for the business of psychoanalysis – is not explored.] He ignores the influence of external and physical factors.’ [No evidence is given.] (19).

‘In analytic circles no other self-analysis is authentic if it differs in any significant way from Freud’s ‘discoveries’. It is therefore discouraged. Experts know best.’ [Again, the alleged attitude of un-named psychoanalysts is stated but not evidenced – nor is contrary evidence investigated.] (26). ‘The psychoanalyst has an external relation to her patient. She aims to extract from the individual his inner subjectivity through a particular technique and the subject is supposed to interiorise the norms imposed upon him. … Instead of throwing light on the person’s confusions, it creates theoretical chatter behind their back.’ [We are not told what psychoanalysts would make of this accusation.] The ‘traditional description of speech by analysis breaks it into units that are static, discrete, and context-free. The theory of meaning that underpins psychoanalysis is that these units are combined by a finite set of rules which give structure to our speech.’ [No evidence is given for their being any such underpinning theory of meaning, or for the idea that psychoanalysis even needs a theory of meaning to underpin it.] (45) ‘Much theory in psychotherapy answers questions posed by the theorist rather than the patient. Instead of thinking through the problem together with the patient, the therapist takes the easy way, bypassing the problem by appealing to theories.’ [No evidence is given.] (53).

‘The technical language of psychoanalysis encourages us to believe that we know what we are resistant to, that is, our unconscious sexuality and ‘primitive instincts’. Human vanity and self-deception are not mentioned.’ [Heaton does not investigate what psychoanalysts have to say about narcissism.] (54). Saying ‘to people that they ‘have’ a phobia or depression can cause them to think they have something in them they need to get rid of. It distracts us from the fact that it is they that have become lost, not their mind or brain.’ [The clinical literature on the benefits and the pitfalls of the use of externalisation is not considered.] (139). ‘The not yet expressed is ultimately an expression; however; it is not an object co-existing with the expressed, such as a complex in the unconscious, as Freud’s subjectivist conception of expression would have it. The appeal to the unconscious takes away our responsibility to make sense. It is nihilistic in that it separates freedom from necessity, suffering from living.’ (149) [How this connects with the analytic goal of increasing freedom and responsibility by ‘making the unconscious conscious’ is not considered.] ‘The confusions generated by the picture of the inner world can be illustrated by the Freudian and Kleinian belief that there is a death instinct that is opposed to the life instinct in the inner world … But death is not an entity.’ (170) [Heaton does not give examples of any such curious psychoanalytic texts which presuppose that death is ‘an entity’. The clinical uses of the concept of ‘death drive’ are not discussed, nor is the considerable intra-psychoanalytic controversy regarding the cogency and value of the very idea.]

For this reviewer these hermeneutic deficiencies made for an uncomfortable reading experience. Let me be clear: I sometimes found myself sympathetic to the points of view expressed. Yet the text itself did not show me why I should believe what it claimed, and I found myself thinking that if I had started off with a different point of view I may have become more rather than less reactively entrenched within it by the end of the book.

The Conceptual and the Empirical

Whilst Heaton frequently joins Wittgenstein in urging us to distinguish between the conceptual (or ‘grammatical’) and the empirical orders, a similar conflation seemed to me to crop up when he criticises therapists for not having reflective, conceptual clarity regarding the nature of their and our terms – as if this was a criticism of their theories or practice. That is, he seems to suggest that tacit philosophical beliefs may underpin or underlie (and hence, when the beliefs are confused, undermine) therapeutic practice. Thus the following: ‘differentiating between logical propositions and ordinary empirical ones is vital in psychotherapy but they are often confused. Thus most psychoanalysts and CBT practitioners assume the uniformity of propositions. Their scientism and psychologism lead them to this. Reality as described by science is the only true reality; there is an a priori structure of the world which science describes. The specific features of a person’s language must be reduced to the ‘neutral’ descriptive language of science. Thus expressions of love may be reduced to ‘attachment’, or the sexual instinct, for these lend themselves more easily to empirical explanations.’ (121) And this: ‘The confusion between concepts and objects is endemic to psychoanalysis, CBT and neurosis. Perhaps this is most clearly seen in such notions as that there is an internal world containing internal objects and that thinking occurs in our heads or brain.’ (123).

The alternative suggestion – that psychoanalysts may deploy concepts to perfectly good effect as tools in their clinical work (to organise their intuitions, guide their interventions, and inform their discussions with colleagues), whilst yet often unsurprisingly failing in a separate philosophical task of achieving a second-order clarity in such beliefs as they do have regarding the character of their own concepts – is not pursued.

On this alternative – and what we might reasonably think of as a more faithfully Wittgensteinian – reading, conceptual confusion shows up in clinical theory and practice not when psychoanalysts unwittingly engage in bad philosophy, or use terms which invite the unwary or uninitiated into asking and attempting to answer misguided questions, but rather when in-itself innocent talk about ‘internal objects’ or ‘mental representations’ or ‘transference’ or ‘projection’ gets recruited to pursue explanatory agendas which only find a clear application regarding the objects of the roots of the metaphors (i.e. only regarding actual physical objects, images of such objects, and the movements of the objects or the images). Whether this muddle based on a conflation of the logic of categories takes place in any given instance cannot, I submit, be assessed at a general level but only at the level of a detailed investigation of particular cases. Heaton, however, talks as if the very ideas of a ‘transitional object’ or of ‘transference’ or of ‘projective identification’ or of a ‘mental apparatus’ are impossibly contaminated by conceptual confusion, and his disagreements with psychoanalysis are accordingly pitched at this (arguably far too abstract) level.

For example, Freud is taken to be radically confused as to the nature of mind and of his own (alleged) discoveries because ‘he thought that we only know of the existence of others by inference … But does the mind consist of things and processes that are present to be discovered by inference?’ (28) This leads the way into a series of claims regarding how psychoanalysis ‘conceals human dignity … removing the personal from itself … removes the dignity of self-understanding’ etc. But these (self-understanding, the recovery of dignity, the acknowledgement and growth of the personal sphere), as any examination of a modern textbook of psychoanalytical psychotherapy will reveal, are precisely the goals of psychoanalysis. Just because psychoanalysis deploys a vocabulary, derived by metaphorical extension, of inner objects in causal interactions, need not mean that we have to read the ‘logic’ or ‘grammar’ of this in terms appropriate to the roots of the metaphors. The misreading, to my mind, appears to be Heaton’s, and not (on the whole) that of psychoanalysts.

To exemplify this consider the following: ‘People having only one perspective that are unable to cope with changes in it have difficulty in placing their feelings and emotions in a context. They have difficulty with propositional attitudes and tend to think in a primitive causal fashion about their feelings and thoughts – ‘that’s to blame’ – instead of being able to reflect on the context and their relations to others that enables propositional attitudes to develop. It is this primitive seeking for an immediate cause that psychoanalysts conceptualise as using mental mechanisms such as projection and introjection. These theorists, however, are as mechanical as the people they seek to understand. They assume that there is an entity, the mind, so there is an inner world and an outer world, and as such beliefs must be either ‘inner’ or ‘outer’, introjected or projected’ (90-91). As can be seen, the actual grammar – the logic of the living use of terms such as ‘projection’ and ‘introjection’ in clinical thought – does not get a look in. It is what we might call this ‘sociological’ aspect of Wittgenstein’s project – investigating the uses to which terms are actually put in diverse clinical language games – that receives the barest attention by Heaton.

As a final example, consider this: ‘[The] theoretical concept of transference is confused due to false analogies and a language myth… It assumes that there is a speech circuit that involves the transfer of the speaker’s thoughts and feelings across to the hearer. … Meaning is thought of as some kind of entity which we can take into ourselves, by introjection, and then discharge it, by projection, into other people. … This is a muddle. In transference the person is not introjecting a thought or projecting one; thoughts and meanings are not entities in the mind or head that can be transferred.’ (176) Once again the living meaning of ‘transference’ – in particular, its use to describe the rich undertow of affect in the therapeutic encounter, or its more nuanced use to describe the ways in which a patient may unconsciously re-enact past relationships in the present – is neglected, the unsubstantiated argument instead being prosecuted at the level of a putative and general entification of meaning by psychoanalysis. Psychoanalytical language games (of transference, projection and introjection) are described as if they involved subscription to false theory about reality; the nature of the language games remains obscure.

Dogmatism and Dialectics

Throughout his book Heaton tends to deploy various self-coined or Wittgensteinian mantras as if they were transparent condensations of prêt-a-porter arguments to be wielded against the alleged tacit conceptual confusions of psychoanalysts and cognitive therapists. I found the results of this strategy to be mixed. At times it provided a helpful shortcut, but at times I was left either confused or with the impression that an at best optional interpretation of Wittgenstein was simply being foisted onto me.

A recurrent claim which just confused me was the idea that people cannot be explanatorily subsumed within their own theories. Example: Psychoanalysts or cognitive therapists tend to assume that phantasies or cognitive schemas drive pathology. But both ‘forget that in any empirical theory the one who makes the theory is necessarily outside it. We … make theories for various purposes but we cannot be subsumed under them. Whenever there is a representation of the world in propositions, there is a subject who is in a position to say ‘I think…’ This applies as much to the patient as to the therapist. Everyone measures the world. To subsume a particular group of people under a theory is to impose a measure on them, to fail to recognise their humanity and to fail to have an unconstrained relation to them.’ (96). The idea sounds intriguing, but further developments of it fail to shed further light on its possible content. Thus the next page has it that the idea of an inner world standing in a representational, mirroring, relation to an external, independent a-priori-ordered-and-structured reality ‘is a functionalism that has thinking as irrelevant to what is thought.’ This is said to be ‘based on the confused notion that there are facts, ‘external and internal reality’, which serve as a standard against which we judge whether our propositions make sense. … We make theories for various purposes; to identify with a theory results in our being used by it, acting as if it were true.’ (97).

Those familiar with Wittgenstein will recall his frequent insistence on not conflating empirical and grammatical statements or, to put it in other words, on not conflating representations with rules for the deployment of representations. We may also recall his diagnosis of the confusion of conceptual ‘sublimation’: when we take a term like ‘real’ which has respectable deployment within various linguistic practices (e.g. real versus fake money or paintings, real versus imaginary scenarios or numbers, real versus pretend smiles or love) and then hold it over and above such discourses, with an ambition – diagnosed by Wittgenstein as disreputable – of asking if they themselves correspond to anything ‘beyond’ them ‘in reality’. It may be something like this which Heaton is aiming at in the above, but his use of phrases such as ‘thinking as relevant to what is thought’ or ‘identifying with a theory’ was to me more confusing than clarificatory.

Furthermore, Heaton himself often lapses into dressing such grammatical insights in a troublingly epistemic garb – that is, in a manner which has recently received much critical attention from Wittgenstein scholars. What in particular I have in mind is the critical attention which the very idea of limits or bounds of sense of thought has received from recent Wittgenstein scholars (e.g. Kuusela). On one understanding, our rules of grammar which as a set constitute the domain of the thinkable, act as some kind of constraint on our thought, or mark out certain ideas as unthinkable, at least for us. Against this idea the New Wittgensteinians in particular have urged the function of grammatical rules as ruling in, rather than ruling out, certain uses of sentential forms. The problem for particular usages of English, including those which pepper the pages of many philosophy books, is not that they contravene what can be thought, but that they are tacitly undetermined or unstably vacillating in their applications. Nonsense characterises words without a use, not words with, as it were, an inadmissible sense (cf Diamond).

Heaton, however, appears to me both to sublimate and to lapse back into the idea of limits of thought, when he offers us such sentences as: ‘The [pyrrhonian] sceptic relies on what seems to him to be the case, while he suspends judgement on how things are ‘in reality’, that is, the fantasy that we can know the essence of things beyond what can be expressed in human language.’ (24) ‘Much of Wittgenstein’s writing was concerned with studying our limits and showing the incoherence of attempts to describe anything beyond them.’ (28) ‘For Wittgenstein, therapy should help us to see that the world does not present itself as a collection of objects to be known, possessed or rejected. We have no direct access to the world. For us humans, thinking involves language.’ (60) ‘Both the Tractatus and Philosophical Investigations were crafted by him at length and painfully to convey the limits of knowledge and the limitations of language for expressing the world.’ (49) On the contrary, as the ‘New Wittgensteinians’ frequently urge, both the Tractatus and the Philosophical Investigations were designed precisely to deconstruct the very idea of limits or limitations of knowledge and language.

The final point I wish to make concerns dogmatism. Heaton tells us that ‘The most important and difficult task of elucidation is that it must avoid all dogmatism for this rarely has any therapeutic action other than that of suggestion.’ (99). Several times he describes the work of therapy as the patient working through of individual, idiosyncratic confusions and troubles. This in part is what riles him about the general theories of psychoanalysis and CBT which he sees, not as providing us with some helpful bearings and moorings whilst we tackle the distress of the individual, but as all too often functioning dogmatically to obscure the individuality of the patient. I feel sure that every honest clinician could recall of examples of this happening in both his own and his rivals’ practice.

What is troubling about Heaton’s book, however, is that his presentation of this very theme is itself dogmatically and non-reflexively pursued. Thus we are frequently simply told what is wrong with psychoanalysis or wrong with CBT in general. The failings of the uses of concepts as wielded by individual theorists on particular occasions recedes into the background. Wittgenstein urged that, in our philosophy, we pursue the process of working through our difficulties with careful attention to the details of how language is being used in particular instances. Here, however, both Wittgenstein’s ideas regarding philosophical therapy, and Heaton’s regarding psychological therapy, are presented in a purely dogmatic form. Wittgensteinian mantras are intoned in lists without explication and without a hint of dialectical handling: ‘The structure of reality cannot be understood as necessarily mirrored in language. We cannot ground propositions with sense in any intrinsic structure of an independent reality. The meaning of a word is not something in the world that is correlated with it.’ (106). Chapter 3 contains an extended discussion of the differences between writing and talking, and constitutes a eulogy to the immediacy and particularity of speech away from the abstractions of the written word. But curiously the chapter presents no self-conscious reflection on the fact that it itself is a piece of writing. Freud’s generalisations are criticised, but Heaton’s own general claims (some of which appear rather extraordinary, such as ‘every oral utterance is unique in respect to its context, pronunciation, and meaning’ (43-4)) remain unsubjected to self-reflective criticism.

Conclusion

Heaton, along with Steve de Shazer, is one of a small handful of psychotherapists who have developed their understanding of therapy through an engagement with Wittgenstein’s philosophy. His enthusiasm for and inspiration by Wittgenstein shine through throughout his text. His own pleasingly a-theoretical explication of the ‘talking cure’ provides a significant addition to the therapy literature. His use of Wittgenstein and his critique of psychoanalysis and CBT is however marred by its non-dialectical dogmatism. Rather than look and see how psychoanalysts use terms in the midst of clinical practice, metaphysical views about the nature of mind and meaning are foisted onto them on the basis of their explicit formulations. In this respect Heaton falls significantly behind Elder’s work on Freud, and the field of modern psychoanalytic psychotherapy still lacks a perspicuous grammatical synopsis.

Wittgenstein is of course not the only 20th century philosopher to have provided inspiration to psychotherapists. Perhaps the greatest influence came from Heidegger, and was felt by the ‘Daseinsanalytic’ and existential therapists who aimed to deploy Heidegger’s insights in the treatment of disturbed forms of ‘being-in-the-world’. Ludwig Binswanger, one of the earliest such proponents, has long been understood, including by his later self, as offering us a ‘creative misunderstanding’ of Heidegger’s philosophy. In short, Binswanger’s patients are presented as embodying pathologically different forms of meaningful world-construction, rather than having partly and in different ways fallen out of that being-in-the-world constitutive of meaningful life itself.

In attempting to bring Heidegger’s philosophy to bear on the psychopathology, matters ontological are tacitly and mistakenly reduced by Binswanger to ‘anthropological’ (empirical) concerns. Heaton, like Binswanger, also aims to set aside what are frequently the dehumanising scientific preoccupations in therapy, replacing them with a welcome focus on people as, or as potentially, free individuals. Like Binswanger, however, and despite his own sometime sensitivity to the key Wittgensteinian distinction between matters ‘grammatical’ and empirical, Heaton too often ends up conflating the two. Mere usages of psychoanalytic terms are described as implying adherence to metaphysical theories; grammatical rules are described as providing limits to the knowable or as mediating our experience; and dogmatism rather than dialectics too frequently ends up ruling the day. Medard Boss and later existential therapists were able to provide some kind of corrective to Binswanger’s creative misunderstandings of Heidegger. Despite Heaton’s considerable creative efforts we still await an interpreter of Wittgenstein comparable to Boss for the psychotherapy community.

psychotherapy and the relation of theory to practice in clinical psychology

2011-06-16T15:03:00.008+01:00

I want to have another go at articulating a fundamental difference between the use of theory in clinical psychology on the one hand, and in psychoanalysis and psychodynamic (and other) psychotherapy on the other. It is, I believe, one which easily gets lost in the way that clinical psychologists - such as myself, too much of the time - articulate the relevance of different models of disorder, or of different formulations, for the treatment.

The psychologist's articulation typically has it that the job of the reflective scientist-practitioner is to formulate an explanation of the patient's difficulties within the terms of the model, and then to guide the therapy by this explanation. You treat the disturbance-as-formulated-by-the-model, and this treatment consists accordingly in the model-guided interventions that you make. The formulation may be in whatever terms seem most appropriate (cognitive, behavioural, phenomenology, psychoanalytical, systemic, narrative, etc.), and the treatment follows from the formulation.

There is perhaps nothing wrong with this way of putting things in and of itself. I think it is a very natural way to describe the relation of CBT theory to CBT practice for example. However it can come to seem just so obvious that it can force out other ways of understanding the relation of theory to practice. The way it does so is, I believe, a clear example of the way in which what we could call the 'ideology' of CBT comes to affect the way that all the therapies are understood and practiced with clinical psychology.

Recently I've been noticing how the very idea of the scientist practitioner, implementing theory-laden understanding in the clinic, can get in the way of my own clinical practice. Let me start by explaining what I am not going on about. Here is one way of reacting against the above-described practice - the practice of the scientist practitioner: 'It is far too non-collaborative; we have an expert clinician thrusting their interventions on the patient. Whereas what would be better would be a collaborative enterprise in which clinician and patient come together to understand the patient's difficulties and figure out what to do about them'.

Now that might sound just lovely, but it really isn't what I'm on about. And the pitfalls of it as a general approach are obvious: it may i) encourage the therapist to eschew the very real expertise they do have, relative to the client, and the way they can be helpful in and through that expertise, and it may ii) encourage us to ignore the way in which the client is unable to grasp what they need (in fact that is why they have come in to start with) because their defences and transferences get in the way of their access to the understanding in question, and it may iii) lead us to ignore the way in which the therapist must beware of getting caught within the re-enacted narrowings of experience, understanding, and relating which the patient brings with him. Further, for me I think it all-too-readily leads to a kind of 'virtual therapy', in which I and the patient discuss together what they would, as it were, need from their therapy (were they to have it!), what new understandings they would need to reach; the 'they' who this is to happen to now comes to seem like someone other than the 'they' who is in the room (explanation-driven approaches to therapy such as CAT (cognitive analytic therapy) seem in particular to run the risk of this) .

But in any case, I now understand, despite the above sometime cul-de-sac in my own thinking and practice, that I'm on about something quite different from this, when I question the rightful hegemony of the reflective scientist practitioner model in the psychotherapies. And here is an alternative - and, I believe, sometimes more fruitful, although my aim here is just to clear some space for it and resist the hegemony of the scientist-practitioner approach - construal of the relation of theory to practice, a construal which draws more on a psychoanalytical, than on a clinical psychological, self-understanding:

That what is curative or restorative for people is the extraordinary ordinariness of everyday empathic conversation, acceptance, love, sharing, connection, being understood and knowing one is understood. That new development, disintegrations and reintegrations, occurs in the context of such relating. That what happens in neurosis is that development, inner movement, becomes blocked. And that the therapist must therefore work to break through defences, work to find room to stand outside of transference and make himself available nonetheless, work to negotiate projections and ally himself with the patient's better self against these forces of inner stasis. This is the 'negative' work of therapy: i.e. it is here that psychological understanding must sometimes be deployed by the therapist to inform their practice of negotiating defences. But the 'positive' work of therapy is just the therapist making themselves available as a new 'object' (a new person who can make possible a new constellation and growth of personal being) through their personal qualities as a human being. That of course is also the work that is done, when it is, by the parent or priest, friend or boss. Their human qualities may outshine some of the best therapists. But the best therapists ought at least to have a good understanding of what gets in the way of psychological transformation - gets in the way of a process which, when unblocked, will happen by itself.

Along the way, then, the therapist will use theory. But this will not typically be to guide an intervention, but to un-derail the therapeutic process. The therapist finds himself thrown out of the healthy use as an 'object' by the patient, in a cul de sac, bored, caught up in a reenactment, stuck. Theory and supervision help him at this juncture. There may or may not be an intervention; what we have instead might be, say, an interpretation. Or some other such utterance which has the function of creating space for the making of meaning once again.

---------------

In an interview in 1998, Jerome Frank put it this way: “Psychotherapy

is not applied behavior science. I think that is the wrong model. Because

all science is based on facts, but psychotherapy is the world of meanings,

which is far from the world of facts. Psychotherapy relies on the fact that

human beings react not to the facts or events themselves but to the meanings

of the facts as they interpret them. Psychotherapy is the transformation of

the meanings that patients attribute to events from negative to positive. I

think it should be taught as an art” (Holland and Guerra 1998).

against mineness

2011-05-14T23:11:00.006+01:00

There are some questions in philosophy that I really just can't get on with. My hunch is that they dress themselves up as honing in on genuine theoretical projects whilst really being able to claim no more than the mere appearance of explanatory respectability.

One which bugs me considerably is: 'What makes (me aware of) a particular experience (as) my experience?' The question gets asked, and then somewhat-phenomenalistically-inclined phenomenologists provide a theory of 'mineness', 'ipseity', 'self-intimating presencing', or what have you, by way of an answer.

But is it really a good question? Well, I do know what it is to ask 'What makes the car outside my car?' We know what kind of answer is called for - and in that knowing, know what the sense of the question is. The answer makes reference to certain paperwork, a certain financial transaction or gift, etc. But an essential part of the possibility of this kind of answer is that cars don't necessarily belong to me. I stand in a relation to the car, the relation being one of ownership, and I can say (by appeal to last night's poker game) what makes it the case that it is I rather than you who stands in this relation.

So too, I know what is being asked when you put it to me: 'What makes a chicken a bird?' To answer the question I just explain what a bird is. Here the matter of the question does not (a la 'my car' case) have to do with the possibility that a chicken might not have been a bird. Rather we just want to know what the essential features of bird-dom are that chickens enjoy. We have a grip on what such questions are asking because we know what to make of these two different deployments of 'makes'.

What I am submitting is that we don't really know what to make of 'What makes' in 'What makes a certain experience mine?' Substituting 'In virtue of what are' for 'What makes' doesn't get us any further. It just isn't obvious to me, to put a grammatical proposition in a rather too de re dress for my liking, that certain experiences are mine 'in virtue of' anything at all. Since there is nothing to be said about what makes a certain experience mine, there is accordingly also nothing to be said about what makes for my putative awareness (or what would make for my putative lack of awareness if I am suffering from a particular pathology) that a certain experience is my experience.

Similar difficulties arise for me in several other instances which the metaphysically minded are far more likely than I to find intriguing. If someone asked me 'What makes now the present moment?' I think I'd probably just have to let my jaw go slack. The only answer I can come up with is: 'Er, a grammatical rule', and I have a sense that this will probably be experienced as more facetious than helpful.

You ask me 'What makes that woman your aunt?' I say 'Well, that's a slightly funny way of construing a question, but I can probably give you what you need if I let you know she is my father's sister.' And you say, 'No sorry, I know what an aunt is, and I appreciate how you are related, but what I want to know is what makes this woman, who is your father's sister, your aunt? Wherein the 'yourness'?' What I don't do now is develop a theory of a quality of 'myness' or 'yourness' which attaches itself to this particular relation.

Here is what I think is going on for those who talk of the 'mineness' of my experiences. They have gotten held captive by a picture of experiences as inner objects. They may in all sorts of ways explicitly deny this but, as Eugen Fischer has described in his lovely book on Philosophical Delusion and its Therapy, this conscious denial need not prevent unconsciously entertained pictures from exerting their tacit influences on the kinds of questions we find ourselves wanting to ask.

If instead we remind ourselves that experiences are not objects but (intentional) relations to perceptibilia et al., the idea that grammatical possessives always imply ownership will rightly seem obscure. In truth we know all too well that we don't have much use for sentences which seem to invite us to suppose that we must enjoy some kind of relationship (such as ownership) with our relationships themselves.

pigs, positions, preferences: the zeugmatics of causal theories

2011-04-01T11:54:00.010+01:00

It has - in my experience - become common for philosophers to try to persuade me of the fallacious character of what I previously took to be an a priori piece of understanding regarding my knowledge of my own mind (that reasons for action, if not actively (ie psychodynamically) repressed, are avowable) by making reference to the empirical findings of Nisbett and Wilson.

A classic example is the case of why I make the choices I do. You present me with a line of differently coloured or patterned pairs of jaunty socks, and ask me to pick one. I take the pair on the right. You ask me why I took this one, and I tell you something about the charming 'little piglet' motif embroidered on them.

But then it turns out that I am no exception from a general empirical finding: that people in such situations are more likely to pick the socks (or whatever) on the right. "Aha", you say, "You thought you were picking those socks because you liked the pig motif, but really it was because of their position". The disturbing conclusion is supposed to be that we don't know our own minds - we don't know (as the gloss, which already builds in some optional philosophical 'commitments', will have it) which causal processes lie behind our very own actions.

The problem with the typical gloss is, to my mind, that it encourages a conflation which for shorthand could be described as an undiscriminating amalgamation of reasons and causes. It conflates the causal processes which lead me to perform certain actions (a bias for the right guides my choices) with the teleological ends of these actions (the reason I chose the socks because they had a pig on them) - bringing both of these under a global concept of 'reason for action' which is obfuscatory as regards the different logics of the different forms of explanantia. (The tendency I've commonly met with is to bring these two forms of explanation together by placing the teleological ends as the contents of desires and to see these desires as entering competitively into the matrix of causes which guide our actions.)

This, it seems to me, just won't do. Let us accept that desires have a dispositional form. If I like little piggy socks then, everything else being equal, I will avail myself of some. Desires, that is, are not individuated simply through our avowals ('I like piggy socks') but also through our actions (getting myself some piggy socks). Let us accept too that I am sometimes or often unaware of the efficient causes of my actions (thus I just didn't know that I am more likely to pick things on the right of a line). Finally let us accept that we may be prone to offering post-hoc rationalisations or justifications of our choices by references to appealing features of the objects chosen. It still doesn't follow, I want to claim, that it is perspicuous to present the findings of the experiments with a sentence like "You thought you chose them because of the pig symbol, but really you chose them because of their position".

One way to bring out what is wrong with this is to note that we wouldn't think it correct to describe a tendency to take objects on the right as a desire for objects on the right. Even to describe it as a preference seems more obfuscatory than clarificatory. To talk here of 'unconscious desires/preferences' seems further to conflate an epistemological with a logical concern.

How then should we describe what has happened? Well, we must acknowledge that our choice was (partly) determined by position. We must acknowledge too that, had another pair of socks with a little sheep motif been on the right, then we may have misleadingly talked of our appreciation of the sheep motif as the reason for our choice. And accept the implication from this that we tend to post-hoc rationalise our choices - to invoke desires where such an invocation is otiose.

But at no point need we fall into supposing that there is some general sense of 'explain' or 'reason' which pits positional effects against piggy appreciations. Instead there are two separate matters at play in such experimental results: (1) The limited character of our knowledge of the efficient determinants of our own actions (this is what is interesting in the findings of Nisbett and Wilson), and (2) the tendency of two key criteria (avowal and behavioural disposition), which jointly give meaning to the language game of desire, to come apart in practice (with avowal unwarrantedly outstripping behaviour through egregious self-confidence).

My confidence regarding my desires (2) may be overinflated. My lack of knowledge regarding the determinants of my actions (1) may be deflating. Nevertheless my overconfidence in my desires (2) is not to be understood as a pretence to the same kind of self-knowledge as would be held by someone who knows better than I the determinants of their actions (1). To say "You thought you chose them because of the pig symbol, but really you chose them because of their position" is not itself logically wrong-headed, but then neither is Dickens' zeugma: "Miss Bolo went home in a flood of tears and a sedan chair". Unlike the scientific naturalist, however, Dickens remained content to play; we are not asked by him to take seriously the idea that on another occasion, whilst we thought Miss Bolo went home in a sedan chair, actually she went home in a flood of tears.

The Narcissism of the Private Linguist; the Private Language of the Narcissist

2011-02-13T10:18:00.015Z

I've been busy writing papers recently, so have been neglecting my blog. Here however is a draft-in-progress of a talk to be given at Eugen Fischer's Philosophy as Therapy: Wittgenstein and Beyond workshop in March 2011:

1. Introduction

In this paper I present not so much a competitor, as a supplement, to the prevalent understanding of Wittgenstein’s view of metaphysical philosophy as illness and philosophy as its therapy.

On this prevalent understanding, illness in philosophy is caused by an entrapment by ‘pictures’, which pictures are due to the cognitive distortion which occurs when we unwittingly read the grammar of some concept too little along its own lines, and too much along the lines offered by the model of some other concept.

Philosophical illness then consists in the dis-ease felt when we are left having to try to reconcile our picture-driven beliefs with what we take ourselves to have reflectively grasped about our experience, understanding, and environments. Metaphysical and epistemological theories result when we try to explain (in that well worn yet curious philosophical phrase) ‘how it is (so much as) possible that’ some perfectly ordinary phenomenon – albeit one which might well start to look a good deal less than possible when seen by a vision corrupted by a philosophical picture – even obtains. (Example, when the meaning of the other's behaviour is rendered unavailable to us by a reflective conception of human mindedness which renders our internal worlds external to our comportment, we may start to feel in need of a theory as to how it is so much as possible that we can have knowledge of other minds.)

Eugen Fischer (2010) has offered us the clearest articulation of this cogent understanding of metaphysical illness. Wittgenstein’s philosophical therapy is, as Fischer sees it, a form of cognitive therapy which works by unearthing the distortions – the tacit assimilations – which drive such disease-engendering pictures. Released from the pictures which hold us captive, the dis-ease disappears and, along with it, the perceived need for explanations of (as I at least would put it,) the possibility of the actual.

By comparison with this I shall today be articulating an alternative (yet still, I believe) Wittgensteinian understanding of pathology and cure; my aim as I said is not at all to displace this cognitive conception of philosophical pictures, but to provide a supplementary perspective – in particular, a supplementary perspective which considers emotional and motivational – as well as cognitive illusory – sources of the grip which such pictures have on us. Whereas Fischer’s model of pathology and therapy is derived from cognitive therapy, mine is drawn from psychoanalysis.[1]

The psychoanalytic concept which will take centre stage here is ‘narcissism’. If I was brave enough I should attempt to trace the narcissistic strain running through the metaphysical impulse in its many manifestations. (I - perhaps foolishly – sketch some developments of this thought in the final section.) What instead will be the focus is what I am calling the ‘narcissism’ of Wittgenstein’s inner interlocutor known as the ‘private linguist’. The focus is on this because I believe that, as well as drawing on the psychoanalytic concept to make clear the character of its own arguments, philosophy is able here to return the favour by explicating a core feature of narcissism’s meaning.

This is the structure of what follows: First I document the importance to Wittgenstein of overcoming intellectual temptations to pride or vanity. Next I spell out a little of the psychoanalytical theory of narcissism. Third I provide an alternative reading of those sections of Wittgenstein’s Philosophical Investigations which are more often taken to contain something called ‘the private language argument’. This alternative reading of mine views Wittgenstein’s better self as engaged in a moral battle for honesty with that of his inner interlocutors known as the ‘private linguist’. Fourth I stress what psychoanalysis can learn from this moral battle. I conclude with some more general remarks on the narcissistic character of the metaphysical impulse in philosophy.

2. Wittgenstein and Pride

Wittgenstein’s later writings are confessional in character: ‘I want to say’, … ‘I feel like saying’… ‘Here the urge is strong’… frequently preface his remarks. Augustine’s Confessions were part of his inspiration and model (and object of critique). As Stanley Cavell writes, ‘The voice of temptation and the voice of correctness are the antagonists in Wittgenstein’s dialogues’ (Cavell, Availability, 71). This confessional character is not just a rhetorical feature of Wittgenstein’s writing. His biographer Ray Monk comments that ‘his life might be said to have been dominated by a moral struggle – the struggle to be anstandig (decent), which for him meant, above all, overcoming the temptations presented by his pride and vanity to be dishonest.’ (Monk, 278). He was preoccupied by honesty, bad and good faith, integrity, truthfulness – both in his friendships and in his work.

In his personal life Wittgenstein took great pains to make confession of his faults to his friends (Monk). In his writings we find him saying: ‘What makes a subject difficult to understand - if it is significant, important - is not that some special instruction about abstruse things is necessary to understand it. Rather it is the contrast between the understanding of the subject and what most people want to see. ... What has to be overcome is not a difficulty of the intellect, but of the will. ... Work on philosophy is ... actually more of a kind of work on oneself.’ (BT86) ‘The edifice of your pride has to be dismantled. And that means frightful work’ (CV 30); ‘One cannot speak the truth, if one has not yet conquered oneself. One cannot speak it – but not because one is still not clever enough’. (CV 35) One cannot speak it, one might rather say, because one cannot yet speak from it. Or: ‘When I say I would like to discard vanity, it is questionable whether my wanting this isn't yet again only a sort of vanity. … As long as one is on stage, one is an actor after all, regardless of what one does.’ (PPO 139)

How, we might ask, can one dismount from this theatrical stage of merely representing purported truths about one’s life – and instead be at peace, and of a piece, with life itself? How can one 'conquer oneself' and live out of the truth, rather than resigning oneself to providing descriptions, evocations, representations or approximations of it?

3. Narcissism and Psychoanalysis

Psychoanalysis aims to chart and treat the unconscious forms of evasion which prevent us from meaningfully connecting with significant others (our ‘primary objects’) in and through our feelings. As psychoanalysts see it, love is to the mind what food is to the body (Jonathan Lear). Loving attachments are the mind’s cradle (Peter Hobson): they are what make both for its growth and for its capacity to weather the storms of self-dissolution at times of stress.

The social and physical helplessness of the human child makes for the necessity of a form of (‘primary’) narcissism which will not be of interest to us today: namely that healthy yet excessive self-regard of ‘his majesty the baby’ (Freud) tolerated and encouraged by the loving parent. Too little loving attachment – too great a disturbance or absence of the child’s recognition of himself in the mirror of his objects’ gaze – and there arises the need to defend against this recognition, or against the feelings of anger which might, if expressed, damage the attachment relationship. We therefore see arising the needs to internalise prohibitions against self-expression, or to manage intolerable ambivalence through splitting the world into good and bad objects, or to destroy our capacity to know of our own emotional vulnerability.

It is at this juncture that ‘secondary narcissism’ is understood to come on the scene. To defend against the perceived unavailability of others’ loving acceptance, the narcissistic individual attempts to become her own ‘good breast’, i.e. to use the self as a surrogate for a secure base (Jeremy Holmes). Correlatively she may enviously or destructively denigrate the importance to her of others (Heinz Kohut). Self-soothing behaviours (drug use, self harm, promiscuous sex) take the place of loving relationships; others are treated un-empathically as means to ends rather than as ends in themselves.

As we might expect, narcissism takes several different forms. The thin-skinned or hyper-vigilant narcissist is shy and sensitive to rejection or criticism; rather than enter into real relationships they are condemned to fearfully patrolling the boundaries of their self-as-perceived-by-others. The thick-skinned or oblivious narcissist, by contrast, has little feeling for others and shows arrogant self-serving ruthlessness; they talk at, rather than to, others (Rosenfeld; Gabbard). The destructive narcissist does not so much as try to control his objects, but more dramatically takes ruthless pleasure in destroying inner signs of attachment and dependency (Rosenfeld).

The psychoanalytic theory of narcissism is complex. There are many different sub-plots; 'narcissism' may best be described as a 'family resemblance concept' (Rustin); and there exists a tendency (which may not be a bad thing) for the theory of narcissism to become more a theoretical lens through which all psychopathology (depression, personality disorders, schizophrenia) is understood than a set of testable claims of empirical psychology.

In what follows I shall take just one aspect of narcissism as central: this is the way in which the narcissist’s mind is bent out of shape through their attempting to take themselves as their own object. What I shall claim (in section 5) is that we can use Wittgenstein’s therapeutic attempts to emancipate his inner interlocutor the private linguist to give a clearer characterisation of the logic of narcissism. My hope is that in this way we will come to an understanding of how the illusions and the aspirations of the narcissist are sustained, and also come to a clearer understanding of just why the narcissistic ideal of self-sufficiency must be understood as an illusion.

4. The Private Linguist as Narcissist

Paragraphs 243ff – and especially 258 – of the Philosophical Investigations (PI) are often taken to contain an argument – the ‘private language argument’ – which is supposed to show us how we cannot develop psychological concepts (with terms (‘S’) for sensations, feelings etc.) using purely intrapsychic resources – say by ‘inwardly pointing’ to (quasi-ostensively referencing) our sensations and naming them.

As the secondary literature has it, either there is in the internal world a lack of the requisite ‘stage-setting’ for the quasi-ostensive act in which ‘S’ is to be paired with its referent (eg M McGinn), and/or it can be proved, from the absence of a consequent operational ‘criterion of correctness’ for deploying ‘S’, that the antecedent ostensive act which aimed to make for ‘S’’s normative deployment must have failed (eg Hacker, Glock). This latter interpretation, which takes the absence of a criterion of correctness as a demonstrable conclusion of a (private language) argument has, to my mind, itself conclusively been shown to fail as an argument in recent years (especially Law’s Five Private Language Arguments; also Schroeder).

The outline of this traditional (Hacker, Glock) interpretation goes something like this:

a) We can see that no operable criterion of correctness obtains for the use of 'S' despite the putative inner ostensive act.

b) Such a criterion is however required for the meaningful deployment of 'S'.

c) Therefore no actual ostensive definition can have occurred.

Depending on how it is elaborated, the difficulties said to obtain for the argument usually turn on an implausible implicit verificationism present in the demand that genuine ostensive definitions must result in operational criteria (e.g. samples, charts or measures) for the use of 'S' - or instead in (rather pointlessly) taking for granted what the private linguist is simply unlikely to accept, that criteria of correctness be of necessity publicly available (rather than available only to the private linguist). My purpose in outlining these matters here is not however to enter into a complex interpretative and logical discussion, but rather to provide a foil for the rather different interpretation of PI258ff in what follows.

Here are its broad outlines:

a) The inner world is marked as a non-normative domain, in so far as, of its very nature, there is here no scope for talk of: erroneous or correct inner judgements, a seems right / is right distinction, etc. (The 'Cartesian' idea that error in the inner world is impossible because of the clarity and distinctiveness of the deliverances of inner sense doesn't even get a look in. 'Grammar' (the logic of our concepts) has already taken care of the work of this putative inner faculty.)

b) practices such as ostensive definition, however, aim precisely to introduce or refine the meaning, and make for the normativity, of particular ostensively defined terms ('S').

c) There is therefore no possible place for ostensive definition in the inner.

In what follows the claim will be that the private linguist's resistance to such reminders is of a piece with his narcissism. The fantasy of being able to help oneself to both (i) the grammatically sanctioned certainties of subjective expression and (ii) the epistemic certainties of objective knowledge is, I shall suggest, of the very essence of narcissism itself. Wittgenstein’s struggle against his narcissistic inner voice is a perfect instance both of what is described in PI255: ‘The philosopher’s treatment of a question is like the treatment of an illness’, and of his ‘struggle to be anstandig (decent) … above all, overcoming the temptations presented by his pride and vanity to be dishonest.’ (Monk). The paragraphs following PI243 accordingly – I believe – constitute what in psychoanalysis would be called Wittgenstein’s working through of the narcissistic phantasy structure which pretends that one can reap the benefits of normativity (i.e. objective correctness, genuine empirical knowledge) without sacrificing the benefits of subjectivity (i.e. the inalienable authority of the genuine subject).

258 contains the first voicing of the key argument. The private linguist wants introspectively to define the term ‘S’ by inwardly concentrating on and pointing to a sensation arising within. Wittgenstein replies:

But “I impress it on myself” can only mean: this process brings it about that I remember the connexion right in the future. But in the present case I have no criterion of correctness. One would like to say: whatever is going to seem right to me is right. And that only means that here we can’t talk about ‘right’.

Many readings of this have, I believe, been led astray by the idea that ‘the present [our] case’ (unserm Falle) refers to a predicament peculiar to the private linguist, rather than to a feature of the quite general (subjective) context. If that (first option) were so, the most striking about the above passage would be its complete emptiness of any argument showing why and how the private linguist has failed in providing the requisite criterion. Yet substitute an acknowledgement that the inapt character of talk of correct judgement here is a function of the subjective context in general, and the argument becomes clear: Why (Wittgenstein is asking) is the private linguist aspiring to something (the founding of normativity) in a domain which, of its essential nature, repels the normative?

Let us get a fix for a moment on what it means to describe the subjective domain as (as I put it) ‘repelling the normative’. On an uncontentious understanding of Wittgenstein’s explication of selfhood, part of what is meant by talk of ‘being a subject’ and ‘subjectivity’ is that we do not normally leave it open to doubt that such a subject may think they are feeling happy, sad, pain – yet not be (hence PI258: ‘…whatever is going to seem right to me is right’… or far better: ‘here we can’t talk about ‘right’.’). (There are of course exceptional cases in which someone may be said to be self-deceiving even about occurrent feelings, cases of central importance for psychoanalysis; yet these are precisely cases in which his or her subject-hood is itself compromised. (Cf Cavell, MWM 264 (my italics): ‘to say that behaviour is expressive is … to say that in order not to express it he must suppress the behaviour, or twist it. And if he twists it far or often enough, he may lose possession of that region of the mind which that behaviour is expressing.’))

As a (grammatical) rule, to be a subject is to be treated as an authority on what one thinks or feels – an authority of a special sort, since one’s avowals of what one thinks or feels are authoritative in virtue of their being ‘transparent’ to – directly voicing, rather than correctly or incorrectly reporting on – the thoughts and feelings themselves (Finkelstein). After all, we do not typically report judgements on – express beliefs about – what we think and feel (since we normally just avow these thoughts and feelings directly). But even when we do treat ourselves in this somewhat self-alienated manner, the second-order beliefs which we thereby express are themselves presumably directly avowed, and therefore at least their articulation is not coherently describable as correct or incorrect (which is not to say that it is not coherently describable as true or false: truth and falsity one could say are functions of propositions; correctness and incorrectness functions of judgements).

There is of course nothing mysterious about this authority. It is due neither to a mysteriously incorrigible faculty of ‘inner sense’ (Kant), nor to a constructivist entitlement we are given to ex post facto ‘make up our own minds’ (Wright). It is rather a simple point of logic (‘a whole cloud of philosophy condensed into a drop of grammar’. (PI p. 222)): since an avowal of a feeling transparently voices that feeling, rather than (say) voicing a judgement about the feeling, it straightforwardly follows that talk of ‘correctness’ or ‘error’ is out of place when the avowal itself is what we are considering. What is avowed or expressed – if it is (say) a belief or judgement rather than an emotional feeling or sensation – may be correct or incorrect; the avowing itself will not be.

We achieve first-person authority to the extent that we achieve subjectivity: i.e. to the extent that we speak from (rather than about) our thoughts and feelings. What this means is that we cannot coherently be said to be ‘right’ or ‘wrong’ in our avowals, and what this in turn means is that the very idea of inscribing normative practices (i.e. practices the following of which can be described in terms of ‘right’ and ‘wrong’) through quasi-ostensive definitions in the intrapsychic context is a mere fantasy. The fantasy is however compelling precisely because, if it could be realised, it would amount to an idealised self-dependence: we could reap the harvests of inner authority whilst also not having to look outside the authoritative domain of the mind for the normative resources that are prerequisite for true knowledge. It is for this motivating reason, I believe, that Wittgenstein’s inner interlocutor does not easily relinquish his ambitions.

In 259 the interlocutor asks if there might not at least be a subjective version of normativity: perhaps ‘the rules of the private language [could take the form of] impressions of rules’. Wittgenstein’s natty reply is that ‘the balance on which impressions are weighed is not the impression of a balance.’ Working through the hold of the fantasy of (the very idea of) subjective normativity constitutes the work of several further passages. For example in 267 we have: ‘Suppose I want to justify the choice of dimensions for a bridge which I imagine to be building, by making loading tests on the material of the bridge in my imagination. This would, of course, be to imagine what is called justifying the choice of dimensions for a bridge.’ But, Wittgenstein ironically asks, ‘should we also call it justifying an imagined choice of dimensions?’ 265 contains a similar answer to the private linguist: to perform a normatively characterisable act in the imagination is to do nothing other than to imagine performing such an act. ‘Looking up a table in the imagination is no more looking up a table than the image of the result of an imagined experiment is the result of an experiment.’

What the psychoanalyst would call the ‘omnipotent’ allure of being both judge and judged, measurer and measured, nevertheless maintains a strong hold over the private linguist, a hold which reduces them to desperate measures. In 260 for example he asserts ‘Well, I believe that this is sensation S again’. Doesn’t the alleged fact of this belief at least guarantee that he must mean something by ‘S’? The answer of course is that the normative dimension of the use of ‘S’ is what gives any such assertion of belief its content – and not the other way around.

As the working through proceeds, Wittgenstein’s tone grows more confidently ironic. Hence in 268 he notes:

My right hand can write a deed of gift and my left hand a receipt. – But the further practical consequences would not be those of a gift. When the left hand has taken the money from the right, etc., we shall ask: “Well, and what of it?” And the same could be asked if a person had given himself a private definition of a word; I mean, if he has said the word to himself and at the same time has directed his attention to a sensation.

A two place relation that does work has collapsed into an otiose application. In 279 this is reduced to the even pithier: ‘Imagine someone saying “But I know how tall I am!” and laying his hand on top of his head to prove it.’ The fantasy (the 'picture') has finally lost its hold.

5. The Meaning of Narcissism

The private linguist hoped to be able to make for normativity by purely intrapsychic means. The fantasised rewards are clear: if he succeeded he would be able to help himself both to that authoritative incorrigibility which is the mark of subjectivity, yet also to the possibility of correctness, of genuine cognitive content, that is the mark of objective judgement. Such a subject would be self-satisfying in his knowledge, immune to error, closed to interrogation by others; his cognitive self-esteem would be second to none. In what follows I claim that this phantasy is the very heart of narcissism itself; the private linguist expresses narcissism as it manifests in an intellectual register, but the same wish to inscribe normativity within subjectivity is what constitutes narcissism in its emotional manifestations too.

I once witnessed an unpleasant exchange on the bus from London to Oxford. At the end of each day a preening young man manifesting a thick-skinned variety of narcissism talked on the phone, at length and at volume, to his partner. This had begun to irritate his regular fellow commuters. One of them finally confronted him, pointing out the notice on the bus window which asked passengers to keep phone calls short and quiet. The young man speedily and angrily shouted: ‘Who do you think you are to tell me what is too loud or too long?’, and carried right on with his obnoxious conversation.

This young man wanted to maintain a sense of his own entitlement, whilst at the same time refusing to submit to the authority of anyone other than himself to determine whether or not he was entitled. His angry response was so thought-stopping that no-one could reply with the obvious non-rhetorical answer ‘Well, I am a member of the general public’. In asserting here the propriety of that response I do not mean at all to sanction the viability of a reduction of normative content to the matter of how the general public tend to carry on (Kripke). The point is rather that what counts as too loud or long in a public context is precisely not something which any of us can determine within himself – as if (279) we were to place our hand on top of our head to affirm our knowledge of our own height.

A more honest response for the young man would have been to have turned his face against the idea of validation altogether: to say that he didn’t care a damn for the values in play regarding the making of phone calls. This however is where the narcissistic ‘solution’ comes in: with the idea that I can still be right in what I do whilst denying the say of anyone else regarding what is to count as right. When we are young – in the phase of ‘primary narcissism’ – this is precisely what is indulged in us. We decline (sensing its cruelty) to always hold the young child’s thoughts and actions accountable to those very same standards which at other times are nevertheless tacitly invoked to inform the meaningfulness of these thoughts and actions.

Secondary narcissism is the defensive pursuing of this strategy in later life, the strategy of having one’s own emotional cake and eating it. The narcissist cannot take the risk of authentically speaking from his own feelings, because then he would risk being found accountable in whom he himself is. Instead he tacitly authors a story for himself and others about his own life; and then lives, not out of his life, but out of his story which he endlessly rehearses. The imagined sphere of his authority is extended through the authorship of the story, but there is little real life – with its attendant doubts and wonders – here. The face that peers back from the narcissist’s mirror is cold and lifeless. The more that the narcissist attempts to ‘become his own object’ – the more that he holds himself accountable to and recognisable by what are really only ‘subjective standards’ (i.e. not actual standards) – the more lost and perverted[2] he becomes.

The everyday concept of narcissism is of someone who is self-loving and apparently indifferent to others. The psychoanalytic concept aims to trace the various manifestations of narcissism – pathological self-preoccupation, inability to relate, treating others as means rather than as ends, self-defeating self-reliance, addictive self-soothing behaviours, etc. – to a deformation more in the form than in the contents of the narcissist’s mind. Narcissism places a kink in the subject’s capacity to give and receive acknowledgement and love. We may say with Freud that the narcissist substitutes his own ego as the object for his libidinal cathexes. What I am here suggesting this amounts to is an attitude which shows itself in a skew in the distribution of subjectivity and normativity in the narcissist’s self-understanding. The narcissist wishes to enhance his subjective authority whilst diminishing his need for objective recognition, thereby failing in the ethical challenge of acknowledging the two as correlative sides of the single coin of the personality. He eschews dependence on others, and all the creative, enriching, meaningful possibilities of this dependence. Humiliation is avoided by also avoiding that humility which is a necessary precondition for a genuine responsiveness to the other. In the place of object dependency is substituted a domain of quasi-pornographic, solipsistically deployed images which now only carry an echo of the meaning of that domain from which they have been tacitly lifted (cf Sass, Paradoxes of Delusion). The narcissist's defences are, like the insistent urgings of the private linguist, geared up to preserving the illusion of the independent determinacy of this land of shadows.

6. Narcissism and the Metaphysical Impulse

To end let’s return again from psychoanalysis to philosophy. The example of philosophical narcissism pursued above was that of the private linguist who hoped to make room for normativity in the intrapsychic context. The narcissistic character of this is clear not only in the way he argues, but in what is argued for; it is this, I claimed, which allows us to take the distortions of the private linguist as shedding light on the meaning of narcissism itself. Accordingly we have to do with here more than cognitively-driven misunderstandings of the grammar of psychological discourse; instead we have emotionally motivated forms of self-misunderstanding which have their heart in our perennially failing attempts at tolerating having to purchase inner authority at the cost of outer responsibility.

But what of other forms of metaphysical puzzlement? Are these best understood simply and only along the cognitive-linguistic model – as e.g. grammatical propositions wearing empirical clothes? Or can we see Wittgenstein’s (or our own) other battles with the metaphysical impulse as further instances, in the intellectual register, of his (and our) ‘moral struggle … to be anstandig (decent)’ (Monk, 278)?

I see no reason to accept a universal answer to this, any more than to trace all actual psychopathology to either cognitive or motivational sources. Instead I will consider two aspects of metaphysical illnesses which seem to me to be narcissistic in character. Both concern what D Z Phillips (following Wittgenstein) called our disposition to (not merely misread, but to) 'sublime the logic of our language'. Where what 'sublimation' amounts to here is something like a tacit wrenching of a concept out of its conceptual home, followed by setting it up as an external measure of the ingredients of that home.

This becomes clearer with an example. We use the words 'real' or 'reality' to make a range of discriminations (real versus fake watches, real versus put-on emotional expressions, 'he behaved like a seargent major but in reality he was a dustman', etc.). There are what we might call the different kinds of reality or existence enjoyed by various phenomena: emotions, occupations, numbers, colours, shapes, physical objects (watches, artworks), money, etc. But if a philosopher comes along and sublimes the concept of 'reality', they may now start asking whether (even what within the local language games we take as paradigms of) smiles or primes or artworks or God or thoughts or colours or values or particules or stories or minds are 'actually real'. What it is to be 'real tout court', as it were, is not explained - and characteristically we are just supposed to intuit how to deploy the term in its decontextualised form.

Here is another example: In the preface to his Principia, Newton reported that his physics aimed at the goal of determining the 'absolute' movements in space and time of celestial objects. By 'absolute' he means: not relative to a temporal or spatial frame of reference. For example, of a man on a ship, we may ask about the direction and velocity of his movement, but in reporting this we may fail to note that not only is he walking over the deck, but the ship itself is moving over the earth, and the earth is itself moving through space. From this we might (rightly) conclude that questions about motion are necessarily relative to frames of reference. Newton however, having 'sublimed' the concept of movement, (wrongly) takes it that there is a 'true' or 'absolute' movement to be had which is what we get when we take account not only of the man's movement over the ship, but also of the ship and the earth. Similarly when we think about measuring time: it will not do, if we are to follow Newton, to (rightly) stipulate one or another natural oscillation as a temporal frame of reference against which the phenomena of interest to us can be contrasted. Rather we should (wrongly) be able to determine the regularity or absolute duration of such measures themselves. (In order to perform both these moves Newton tacitly and incoherently attributes parts, or rates of flow, to space and time respectively themselves.)

The question remains: What is narcissistic about such acts of sublimation? As I see it there are two related aspects of such metaphysical tendencies to sublimation which betray the theorist's narcissism.

The first concerns the ambition to extract oneself from the world and to understand the phenomena we encounter from without. (The desire for context-transcending abstraction in itself is of course no bad thing - it is an essential component of thinking and theorising per se. What is incoherent however is when, with metaphysical hubris, we attempt to deploy thought outside of any context whatsoever (the 'view from nowhere' as Nagel calls it).

The second concerns the theorist's tacit arrogation to herself of the capacity to hold onto and vouchsafe the meaning and meaningfulness of her theoretical terms despite their being wrenched from those social contexts which (if she would but admit it) constitutively embed their deployment.

The psychological narcissist attempts to nourish themselves with their own love - yet love must always come from without for it to be psychologically transformative or nourishing. The private linguist indulges in the fantasy that he can make do with a subjective form of normativity to ground the meaningful deployment of the terms he introduces for his own use. More generally, the procedures of the philosophical narcissist reveal - in the very asking of his questions - his arrogation to his own mind of functions that can only be performed by socially and materially embedded discursive practices. 'I know what 'real' means all right' he says; 'What I want to know though is whether these [points to some trees which might normally function rather nicely as paradigms of 'real trees'] are real.' The narcissism consists in the tacit belief that one could, purely from within oneself, hold onto a meaning for the word 'real' despite its decontextualisation.

We could view a large part of Wittgenstein’s later philosophy as devoted to the task of persuading us that we do not after all know what we mean when we ask, say, the sceptical questions which beset us. The confident belief that we do know what we mean by our questions, but are just stuck for answers, and so must busy ourselves by ‘working on’ the theory of this or that, is a precondition of much metaphysical philosophy. It might then not be misleading to describe our coming to this ashamed yet therapeutic acknowledgement – that not only our theoretical answers, but even the questions which prompted them, fail to carry the sense we assumed they carried – as a prime intellectual example of that ‘frightful work’ of dismantling ‘the edifice of [our] pride’ (CV 30).[3]

[1] Both CBT and psychoanalysis investigate the irrationalities that lie at the heart of emotional suffering. To simplify greatly: CBT tends to trace the irrationality to inferential mistakes, whereas psychoanalysis views it as motivated by the avoidance of emotional pain. CBT, that is, looks to disturbances of mental, and psychoanalysis to disturbances of personality, functioning to explain environmentally unintelligible emotional distress. Fischer views Wittgenstein as unhelpfully constrained in his understanding of illness and therapy by the then unavailability of today’s cognitive theories of psychopathology. Like many clinicians I tend in my clinical work to use both models where appropriate; in this paper however I start to explore the rich resources of psychoanalysis for developing Wittgenstein’s understanding of philosophical illness and its therapy.

[2] Perverted: per vertere: turning away from what is genuine.

[3] This paper has been greatly improved by helpful comments in particular from Louise Braddock, and also from Sarah Richmond, Jim Hopkins and Edward Harcourt.

identification, projection and interpersonal understanding

2010-10-19T15:01:00.004+01:00

Peter Hobson's chapter on Emotion, Self-/Other-Awareness, and Autism: A Developmental Perspective in Peter Goldie's (Ed) Oxford Handbook of the Philosophy of Emotion posits identification as a core driver of our developing understanding of one another. Against simulationists he holds that imagination, as it is normally understood, is not what it takes for us to grasp another. It is not that we understand one another because we imaginatively project ourselves into their shoes. Importantly, it is not as if we start with a viable understanding of ourself, and then go on to make use of this in understanding other people. Against simulationist's main rivals, the theory theorists, he holds that the relevant abilities are far more developmentally primitive and non-cognitive than the idea that they are a function of deploying a tacit theory would suggest.

And that all sounds very attractive. But what is identification, and how does it help us to make sense of one another? Well, I suspect the latter part of that question may be badly put - in so far as it suggests that we know what it is to understand one another but are just unsure about the route we take to come to this understanding. At any rate, here is my answer to the question.

First, understanding someone is here not something other than being able to unreflectively anticipate their next gesture or movement or utterance. This pre-reflective non-predictive expectation is what it is for us to be able to find our feet with one another, to be able to 'make sense of' how someone is behaving.

Next, emotions are object-relations, where these intentional relations are primitive forms of social understanding. When I feel hurt, this feeling is my grasp of your hurtfulness, your slight of me. The emotion discloses to me the social meaning of your action. Emotion is a window onto the social world, and emotion - in all its own dispositional glory - is an embodied action-guiding grasp of others: without it there is no such thing as true social understanding, since this more cognitively elaborate forms of this understanding are always embedded on the most primitive emotional form.

It is true that to understand your anger I need not myself be angry. More likely I will be afraid. It is in my fear that your anger is disclosed to me. So there can be no straightforward story about identification leading to similar emotional experience leading (somehow) to understanding. That way of thinking about it in any case is highly external - once again we have the identification leading to understanding, rather than being part of its very form.

So what is it for me to be able to 'feel' or 'come to know' your anger? It could be that you remain blankly on the outside of my understanding, as may be the case for the autistic child. For this coming to know to obtain, two processes must, I believe, take place.

First we have the identificatory entering into the space of shared experience. This is a kind of loss of self, a merging. Your arousal becomes my arousal at this point. Identification is in a sense a pre-psychological process - part of something which makes for a psychological experience of understanding, but not itself something which is a psychological experience. (It doesn't happen within a psyche, one might say, to borrow the Cartesian spatial metaphor: rather it structures the psyche itself in a part of itself.)

Second we have the differentiating 'cut' of self and other, in which the directionality of emotion is registered. For example, your arousal is directed outwards rather than inwards: you are angry rather than fearful. In the conjoint intentional field, the reinstating of self-other differentiation leads to me feeling afraid. My fear is my recognition of your anger.

I've talked about 'first' and 'second' here, but I suspect that we don't have to do with two temporal segments of experience, but rather two merely-formally-separable aspects of interpersonal understanding.

Of course identification need not be accompanied by differentiation. For example, the little boy does the things his father does, adopts his mannerisms, all quite unconsicously. What it is to pattern yourself on someone in this pre-reflective manner is to allow your neurological system to reverberate with theirs. Well, actually the difficult thing is preventing this from happening, rather than allowing it: identification usually happens automatically. This is a powerful learning mechanism, but it does not come with understanding unless we also have the cut of differentiation.

Yet of course the cut can be drawn in the wrong place. Where it is drawn - how the arousal in the interpersonal sphere comes to be divided into the complementary doublets of anger and fear, for example (or sadness and pity) - will depend not only on the identifier but also on the identified-with. Forms of emotional micro-interaction can affect, skew, the placing of the 'cut' (or the 'chiasm' as Merleau-Ponty calls it). Hence we get projective and introjective forms of identification, where I take in some of you or lose some of myself in you. The placement of the chiasm is also, as we know all too well in therapy, under largely unconscious motivational control.

And we have the work of therapy itself where I manage, metabolise, and then reflectively or otherwise feed back your projections into me.

OC and OCD

2010-08-24T12:22:00.002+01:00

Wittgenstein's On Certainty contains a wealth of references to the 'madness' or 'insanity' or 'dementia' one would have to suffer from in order to not insincerely come out with the kinds of things that otherwise only the philosophical sceptic wants to say. Within the text the appeal is made from an intuitive understanding of what it would be to be 'mad' to an explication of the logic of the non-epistemic foundations of our negotiations (epistemic and otherwise) with others and with our environments. Perhaps that serves well the philosopher's purposes but, from a psychopathologist's point of view, what is more interesting and more illuminating is the tracking of the phenomenological implications in the reverse direction. What, that is, does the account of the character of our 'lived certainties' - which it makes no sense to talk of doubting or believing or justifying (or perhaps even 'knowing') - tell us about the foundations of our sanity? And what, by implication, does it tell us about the primitive location of the deficit in psychosis: a disturbance not in inference making (and in this sense not in rationality), nor in 'mistaken' perception, but rather in our embodied, embedded, (logically, not developmentally, speaking) pre-rational and pre-reflective coping and comportment. (See Rhodes & Gipps (2008) and Gipps & Rhodes (2008 & 2011) for development of this idea.)

In this post, however, I want to start to explore another way in which On Certainty provides rich phenomenological pickings for the psychopathologist. This time my focus is not on psychosis but on obsessive compulsive disorder. Whereas in delusion and psychosis the focus is on what is believed, here the focus will be on what is doubted.

Cognitive models of OCD (see e.g. chapter 9 of Wells' Cognitive Therapy of Anxiety Disorders) would have us believe that the psychopathological action is to be located in the character of the patient's meta-cognitive relationship with their intrusive thoughts. To take a typical example: Mary finds thoughts of her son being run over coming unbidden into her head. She also worries that the having of such thoughts betrays a wish she has, or in some other way may magically bring about the feared outcome. Delighting as they do in reinventing the psychoanalytical wheel, cognitive theorists since Rachman have relabelled 'magical thinking' as 'thought-action fusion'. The relevant confusion in the mind of the OCD patient that 'thought-action fusion' betokens is thought to be a meta-cognitive one: thoughts are meta-cognitively taken to cause actions or events and/or to signify the likelihood of having actually performed the terrible action which the thought is taken to betoken.

This location of the mental disturbance at a 'meta' level fits well with the 'You're alright Jack' normalising ambitions of the practice of cognitive therapy. "There's nothing wrong with your thoughts themselves - everyone has lots of strange or unpleasant thoughts all the time don't you know. The problem lies only with how you are appraising these thoughts. That's why you think you're going mad, etc. You are taking yourself to be responsible for the having of your thoughts, whereas in fact the mind just likes to churn them out; the only difference between you and someone without OCD is that they don't take much notice of their similar thoughts since they don't assume that they betoken intentions or veridical memories." The cognitive theory is, one might say, almost a direct inversion of the psychoanalytical one - the latter viewing the obsessions as expressions of intolerable and ambivalent wishes which, because of their intolerable nature to the patient, are expeirenced as foreign and intrusive - and because they cannot be assimilated and the ambivalence tolerated, retain such constant anxiogenic power. Whereas the cognitive practitioner tells the young mother 'Of course you don't really want to stab your baby; you are probably only having this intrusive thought because it is the worst thing you can think of and because you are trying not to think of it' ( - like trying not to think about a pink elephant, you're just onto a loser with such attempts at mind-control, especially if you think that there's something intrinsically evil or dangerous about thinking about pink elephants), the psychoanalytic practitioner wants to explore the possibility that it might be quite natural for the young mother to sometimes want to stab her baby, and to pursue the thought that perhaps such anger is better assimilated rather than split off (none of which is to say that she is any more likely than normal to actually stab her baby).

Now I have no wish to bluntly undo the 'you're not mad' message of the cognitive therapist for the OCD patient. (In fact we don't need the normalising theory to achieve this, since it is usually already contained in that which differentiates OCD from psychosis: namely the patient's own insight-ful and at-least-occasional appraisal of their own thoughts - and of their own compulsive rituals which are designed to reassure them and alleviate the anxiety caused by the obsessions - as irrational. 'I am performing this compulsion mainly to reduce my anxiety, regardless of whether the obsession is actually true'.) Therapeutically, however, normalising can come at quite a cost - when it tacitly indicates an unwillingness in the clinician to tolerate and contain the 'mad' parts of the patient. But, therapy aside, it is the viability of the psychopathological theory which concerns me here.

Here are the questions I wish to ask: 1) Is it the case that the patient with obsessive rumination is best understood as having normal first-order thoughts which are being meta-appraised in an irrational way through the lens of a hyper-responsible attitude? Or is it the case that what we have are rather first-order thoughts which, as part of their very own form, encourage an elision of the distinction between the real and the imagined? What could help us decide between these two formulations? 2) Further, if we opt for the latter, what are the key characteristics of the obsessional mind?

Shortly I will draw on Wittgenstein's On Certainty to describe what I take to be (2) some of the key features of obsessionality. But to consider questions (1) first: It is certainly true that the patient is able, in the clinic, at calmer times, to occupy a meta-perspective on their own thoughts - to see that they are being irrational when they are caught up in their anxious rumination and compulsion. Yet, at the time, what seems rather to characterise the obsessional struggle is not so much a being-pulled-between two opposed meta-attitudes (one saying: thoughts are causally inert; the other saying: I am now responsible if what I think happens) to first-order thoughts, but rather amounts to a being-pulled-between a) ordinary propositional attitudes and b) structurally degraded propositional attitudes.

Children sometimes show a form of thought which, especially if it became prevalent in adulthood, would be deemed obsessive-compulsive in character. The idea of the possibility of magic (action at a distance, mind reading, etc.) has not yet been fully overcome; the distinction between what is 'inside' and what is 'outside' the mind has not fully taken form. And this failure occurs in particular when the child is anxious - anxiety destabilising the intentional field (the field within which thought separates off from the world into a domain which can then be said to represent facts which are other than it itself). It can take the reassuring presence of the mind of another to allow the child to gain that composure required for going-on-being in the face of anxiety which otherwise overwhelms and undermines the very possibility of (the essential intentionality of) true thought. (By 'intentionality' I mean: thought's directedness at a world independent of it.)

And, to recap, my thought is here that what the anxiety makes for is not the presence of false meta-cognitive appraisals of first-order thoughts, but rather of structurally degraded first-order thoughts themselves. The child is going into a kind of altered state in which their thought itself is falling apart, failing to cling on to that separation from its objects which gives it the right to its title of 'thought'. In this magical thinking state, which is (more) aptly (than the cognitive theorist realises) called 'thought-action fusion' (since the thought is no longer comprehending itself as such), the child gains (in phantasy!) the ability to magically mend mind-splitting terrors, but also, and terrifyingly, a felt vulnerability to the terrors which their imagination, now failing to maintain its separation from reality-oriented thought, presents as if real. In describing this phantasy-ridden magical thinking state we naturally slip into the vocabulary of thought, imagination, understanding, etc., and find ourselves forced, if we are stick with this vocabulary of the 'propositional attitudes', to describe the patient's obsessional thoughts as such - as thoughts - and then to locate the pathology at what could now only be a metacognitive level. Rather, that is, than acknowledging the glimmering quasi-psychotic character of this aspect of the patient's mental function (which is not to say that, unlike the actually psychotic patient, they are unable to take insightful perspectives onto the contents of this mode of functioning, in particular when disengaged from the fearful phantasy state. I will say a bit more below about what makes OCD non-psychotic).

I want to turn now to the other question (2), namely the core characteristics of the obsessional mind and, here, to begin to make use of OC to theorise OCD. The feature I shall focus on is obsessional doubt. An important strand of On Certainty is Wittgenstein's diagnosis of the way the sceptic, in formulating their doubts, 'sublimes the logic of our language'. Doubts, Wittgenstein notes, are necessarily localised matters, arising as they do within the context of this or that enquiry. As such they presuppose a background framework of certainties. To attempt to raise a doubt outside of such a framework, or regarding the very framework, is precisely to obviate the essential preconditions for, well, for intelligible thought (including doubting thought) itself. By comparison we might imagine someone trying to make the car go faster by pushing on the dashboard, or someone trying to use a lever without a fulcrum (or with only a simulacrum of a fulcrum which nevertheless remains of a piece with the lever or with that which is to be levered), or someone trying to pull themselves up by their own bootstraps. The doubting operation takes place in a particular context and requires the doubter to stand firm on general issues before they can raise an intelligible question regarding some specific detail. (Just as the 'private linguist' in the Investigations (mis)takes themselves to be able to generate genuinely normative distinctions (the 'private' intra-subjective definitions) whilst nevertheless remaining within a domain of subjectivity (which, qua subjective domain, is defined precisely through the absence of normativity); they fail therefore to gain the necessary traction for talk of wrong or right uses of a term to mean anything.)

A second feature of doubt and its relation to certainty that receives treatment in OC is the sceptic's tacit misrepresentation of the character of the certainties we everyday enjoy. For the sceptic these are to be treated as propositional in character: beliefs to which we can rightly feel ourselves entitled, which we can readily justify or which are otherwise self-revealing in their ownmost indubitability. Earlier in OC Wittgenstein introduces the idea of a 'framework' or a 'hinge' proposition: propositional beliefs which are the lynchpins of our whole 'enquiry', propositional foundations for our practices of believing and doubting. Later, however, Wittgenstein stresses the more primarily praxical character of such foundations: the certainties I enjoy are certainties in acting. Well-grounded belief gives out in belief that is not grounded (OC253), which requires no grounds, but which also is not obviously propositional in character. I am certain of what will happen next, of the solidity of the ground under my foot, of the progression of the day into night, that the waves will continue to lap against the shore, that my mind will continue to function, that I will not forget how to speak, that I will be able to understand what people say to me enough of the time. And these certainties consist neither in beliefs which have an actual propositional articulation, nor are derived from their potential propositional articulability, but consists rather in the lived animal dispositional praxical retentive protentive habitual visceral character of my going-on-being.

And how to theorise OCD in such terms? Well, first we note that the person with OCD has some degree of weakness within particular aspects of their praxical bedrock of lived certainty. This I believe, admittedly without compelling research grounds for doing so, often stems from an insecure attachment relationship in childhood, sometimes along with over-protective forms of parenting. (The point being that the child does not internalise enough certainty that the world and their mind will continue to function as anticipated, and that they will be able to cope with such variation as there is.) This weakness is not as radical as in psychosis, and certainly does not prompt the reorganisation of the substructure of the intentional field that we find in the neurological systems of persons, systems which solve for foundational anxieties by radically restructuring the structure of the world. Furthermore, the diathesis often remains largely unactivated due to absence of significant stressors.

Second, when the diathesis is activated, the obsessional person is disposed to use reason to attempt to solve for their uncertainty. They try to find reasons for believing in the health of their body and mind. They attempt to justify to themselves their actions. They attempt to check, verify, double-check, prove, logically ascertain their veracity in their belief that their doubts are unfounded. Yet, whilst temporary relief may be obtained by such methods, the underlying pre-reflective doubt - in particular, the diathesis - remains intact. Once it has been unhelpfully raised to the level of a reflective question, the way it invites its own repose is by means of attempts at reflective answering. And these may indeed settle the question for a time. But because the foundations of our certainty are pre-epistemic, not themselves well-founded (or ill-founded, for that matter - but rather, non-founded and in principle not intelligibly founded at all), the questions which arise regarding their validity can only really be silenced rather than answered. Sometimes the entire charade of question and answer will bubble up and settle down, anxious certainty replacing anxious doubt for a while, until the next tranche of worries rises to the surface. Wittgenstein's text helps us understand why obsessional strategies of resolving obsessional doubt are doomed to failure. Once doubt has arisen at bedrock and cracked it, it will not help us to attempt to dig below bedrock in order to found it: the digging exercise will, in the end, only unseat us further.

What does this imply about the therapy of OCD? Well, first that CBT therapy is on the right lines, despite the inadequacy of its theory. For what it encourages in its behavioural component is an exposure and extinction (through response-prevention) attitude to obsessional anxieties - and it explicitly proscribes reassurance provision. And second - if my aetiological speculations are right - that the therapeutic action will take place at the pre-reflective level, whereby the therapist provides, in and through the manner of their own comportment in relation to the patient's worry, a reassuring pre-reflective sense that going-on-being is possible, that the world and the mind are enduring and stable enough to be born, that they will survive.

---------------------------
On Certainty
246. "Here I have arrived at a foundation of all my beliefs." "This position I will hold!" But isn't that, precisely, only because I am completely convinced of it? - What is 'being completely convinced' like?

247. What would it be like to doubt now whether I have two hands? Why can't I imagine it at all? What would I believe if I didn't believe that? So far I have no system at all within which this doubt might exist.

248. I have arrived at the rock bottom of my convictions. And one might almost say that these foundation-walls are carried by the whole house.

249. One gives oneself a false picture of doubt.

250. My having two hands is, in normal circumstances, as certain as anything that I could produce in evidence for it. That is why I am not in a position to take the sight of my hand as evidence for it.

251. Doesn't this mean: I shall proceed according to this belief unconditionally, and not let anything confuse me?

252. But it isn't just that I believe in this way that I have two hands, but that every reasonable person does.

253. At the foundation of well-founded belief lies belief that is not founded.

-------------------------

Postscript.

I notice another nice parallel reverse use of Wittgenstein's intuitive reaching towards psychopathological forms of life to explicate philosophical points in 433 of the Philosophical Investigations:

When we give an order, it can look as if the ultimate thing sought by the order has to remain unexpressed, as there is always a gulf between an order and its execution. Say I want someone to make a particular movement, say to raise his arm. To make it quite clear, I do the movement. This picture seems quite unambiguous until we ask: how does he know that he is to make that movement? How does he know at all what use he is to make of the signs I give him, whatever they are? Perhaps I shall now try to supplement the order by means of further signs, by pointing from myself to him, making encouraging gestures, etc. Here it looks as if the order were beginning to stammer.
OCD is to thought partly what stammering is to utterance. Embarked on a regress, thought or language splinter and fall apart. The stammerer struggles to speak - instead they are left caught up in trying to speak. They are separated from their own life-with-spoken-language, standing outside of it, trying to instantiate it. How can they once again become linguistic beings?

but is it rational?

2010-08-15T15:42:00.015+01:00

In a recent literature review (forthcoming in Current Opinion in Psychiatry) I criticised the view - which might perhaps be ascribable to Tim Thornton - which equates understanding something with appreciating its rationality. Whilst one of the aims of understanding might be rational comprehension, I argued, what about other such forms - such as making something empathically intelligible, or symbolically (in the psychoanalytic - displaced association - sense) or emblematically (in the phenomenological - ontical emblem of an ontological disturbance - sense) intelligible? Might these not still be available to us - when we are trying to make sense of psychotic delusion - even when the project of rendering a delusion rationally intelligible has given out? Might not the equation of rationality with understanding amount to a prejudice of analytical philosophy, rather exclusively concerned as it is with rational argument; might we not have here a kind of illicit projection of philosophy's own methods back onto its subject matter, and an exclusive if unwitting focus on its own parochial concerns?

Whether or not my critique was apt will turn, I suppose, on a) just what we (are prepared to) mean by 'rational', and on b) whether I was correctly tracking such meaning/s as 'rational' enjoys. What I think I was imagining is that, to call something 'rational' we ought to be able to view it as supportable by reasons - as something which could be justified. But this, surely, is far too strict, for it immediately leaves out all of those claims we make which themselves exemplify, or paradigmatically instance, the rational, for which there is no (need or possibility of a) further justification. Inductive claims, I believe, work like this: Our long-standing experience of social or natural regularities does not stand to our belief that things will carry on as before as its reason or justification. Rather, to expect things to carry on as before just is what counts as 'rational' here: there is no room for a 'because' when we are already at the 'beginning of the language game'. (What I would need a reason for is if I were to maintain that something different was going to happen next time.)

So let's embrace the inductive not, to be sure, as a species of reasoning, but nevertheless as paradigmatically rational. The question remains: do we have grounds for completely equating the rational order with the intelligible order? Well, there are surely cases in which we may find ourselves wanting to use the term 'understanding' in which talk of what is 'rational' comes a little less naturally. Take, for instance, our non-intellectual understanding of a piece of music - how it can just 'make sense to us' that the tune should end like this, and not like that. More closely inviting of the 'rational' appelation are cases of skill learning (e.g. plastering a wall), where my 'getting', 'grasp', 'mastery' or 'understanding' of the requisite technique is not something other (even if not reducible to) my now being able to aim successfully at the goal which the skill itself aims to achieve (e.g. getting the wall plastered). I understand the reason why it is good to work the plaster like this or that, not merely when I intellectually grasp the benefits of doing so, but also when I incorporate the skill into my repertoire which itself has the telos of getting the wall nice and flat. And then too we have the kinds of cases with which, in the actual practice of philosophy, we are all too familiar: coming to understand, as I think we would often want to put it, why someone says what they are saying even though what they are saying isn't rationally defensible ('ah, an understandable mistake!' we say).

What about cases of secondary sense? This is a topic addressed here and here by Tim Thornton. Here are the relevant passages:

Neil Pickering ... criticise[d] a view he ascribed to Richard Gipps that mental illnesses are illnesses merely in secondary sense. His argument certainly helped to make that idea seem a desperate move. I’ll have to remind myself of what the argument for it might be. But one comment he made seems interesting. With the background thought that secondary sense is distinct from metaphor or simile because there are no shared features that justify it, he commented that a secondary extension of the use of a word is under no rational obligation.

That seems right, in the context of the contrast with simile, but less so without a codification of rationality. Isn’t it rational for those with minds like most of us to rebel against the substitution of synonyms in poetry, to treasure the picture of one’s beloved and so forth? I’m not sure. (I’m also not sure because a firm criterion here - ruling those out as instances of rationality - might come back to bite in the context of what following a rule isn’t: ie being gripped by a self-interpreting interpretation of a general rule.)

And:

Richard seems here to be probing the same issue I have become interested in. The appropriateness of the use of words in secondary sense seems to play a constitutive role in individuating experiences such as that the world feels unreal. The experience is the experience it is because of the appropriateness of using this set of words. This is how Wittgenstein describes it (RPPI:§125).

The feeling of the unreality of one’s surroundings. This feeling I have had once, and many have it before the onset of mental illness. Everything seems somehow not real; but not as if one saw things unclear or blurred; everything looks quite as usual. And how do I know that another has felt what I have? Because he uses the same words as I find appropriate.
But why do I choose precisely the word “unreality” to express it? Surely not because of its sound. (A word of very like sound but different meaning would not do.) I choose it because of its meaning.
But I surely did not learn to use the word to mean: a feeling. No; but I learned to use it with a particular meaning and now I use it spontaneously like this. One might say--though it may mislead--: When I have learnt the word in its ordinary meaning, then I choose that meaning as a simile for my feeling. But of course what is in question here is not a simile, not a comparison of the feeling with something else. §126. The fact is simply that I use a word, the bearer of another technique, as the expression of a feeling. I use it in a new way. And wherein consists this new kind of use? Well, one thing is that I say: I have a ‘feeling of unreality’--after I have, of course, learnt the use of the word “feeling” in the ordinary way. Also: the feeling is a state.

But despite the fact that just these words are the right words (I think that ‘right’ is the right word), they are not used in the standard, primary sense. And hence Richard’s twin utter propriety and yet strict meaninglessness.

Now, however, what seems interesting to me is that there seem to be cases where such a spontaneous use is shared. One might reply: I know exactly how you feel. But what of cases where the use is not shared? What happens if one simply cannot do anything with it? In a paper I wrote some years ago I pushed the line that the only criterion we have for secondary sense is such shared reactions. What I meant was that there was no content to the claim that there was any kind of sense to it once that broke down (by the way: I’m not naturally a communitarian Wittgensteinian). Now whilst I do not wish to say that that’s false it seems to be much less interesting. It is a kind of surd fact that we have no reason to call such a case ‘sense’ rather than a fact that might helpfully explain anything else.

But that still leaves the issue that Neil Pickering raised a year ago: does secondary sense ever impose a rational obligation? Is ‘right’ right?

First, the idea of mental illnesses being illnesses in a 'secondary sense' is owed originally to Champlin. It isn't prima facie obvious that a 'mind' can be ill in the same way that we can be ill in our bodily being. And so perhaps, he suggests, we could think of mental illness as standing to bodily illness like a rhyme for the eye (two lines of poetry looking the same at the end) stands to a rhyme for the ear (two lines of poetry ending with similar sounds). 'Rhyme' and 'ill' are used in a secondary sense in the latter cases to meet certain purposes - in the psychiatric case, for somewhat 'political' purposes to help ease the application of medical (and hence hopefully humane) rather than moral (and hence potentially punitive) approaches to people whose behaviour may be challenging of the social order. (The argument is worth making just to provide a contrast to standard anti-psychiatric polemic. Thomas Szasz now looks, not so much as if he had made a mistake of reasoning but, as if he mainly has a tin ear...)

Next: Tim makes clear one way in which an argument against equating rationality with understandability might start off on the wrong foot: if it started by wrongly assuming that rationality was codifiable, and then urged that certain codifications were lacking in the present instance. But still, I think we can reasonably ask whether anything is being said if our practice of kissing the photo of a departed beloved is described as rational or irrational. It isn't irrational, since it isn't that I kiss the photo because I have mistaken it for her. Yet it is also neither something for which further reasons could be given, nor - I think - exactly a paradigm of what it means to here act rationally. We might want to describe it as a constitutive behaviour of missing and honouring - 'to be so disposed just is what it is to miss and honour her' - and it is certainly a behaviour which can be described as intelligible - but, I submit, we don't have any clear use for talk of 'rational' here.

The quote from Remarks on the Philosophy of Psychology was delightful - I never knew, or had completely forgotten, that Wittgenstein himself applied the secondary sense idea to the unreality experience. Tim's remarks on shared and unshared secondary sense reactions are however puzzling. He tells us that he is interested in cases of shared dispositions to use words other than in their primary sense, and that (by contrast with this interest?) the idea - that what makes it the case that a particular non-standard deployment of a term is an instance of secondary sense rather than of mere senselessness is a function of whether a disposition to deploy it thus is shared within the relevant linguistic community - is much less interesting. (But why? I'm not trying to defend a communitarian view of secondary sense, since I suspect that it would be no less dubious than communitarian views of primary sense (and that both originate when we are alienated from our life-with-language, and as a result split it into inner and outer aspects that we then struggle to rejoin).) Then Tim says 'It is a kind of surd fact that we have no reason to call such a case ‘sense’ rather than a fact that might helpfully explain anything else.' I go along with the surdness of the fact (since the idea that it is non-surd seems, as just suggested above, to be born of an alienated stance towards our life-with-language that then seems to beg an explanation of us), but why shouldn't the fact, however surd, itself be deployed in explanations of this or that other matter? (Tim - What is going on here?!)

What I find interesting is what the pressures of thought are that might impel us to a communitarian view of secondary sense. But first, let's return to the question: what makes something a case of secondary sense, rather than just gibberish? What comes to my mind is that the term's deployment is most paradigmatically an instance of secondary sense when it is part of a somewhat structured language-game (shared by however many, as with primary sense discourses). Various inferences may - in the secondary language game - be licensed, inferences which map the structure of some of those in the primary discourse. (So with emotions, feeling 'up' is contrasted with feeling 'down', moods may rise and fall, we can feel 'high' and 'low' too, etc.) The more one-off a use of secondary sense is, the fewer other similar things one wants to say in the conceptual neighbourhood, and the more, er, semantically embarrassing the term's deployment seems to be.

Second, I'd want to suggest that, as with metaphor, users of secondary sense ought to have some awareness that they are doing so. Consider Wittgenstein's derealisation feeling: he finds himself wanting to use the term. We are unlikely to understand him unless we have had a similar experience, part of which experience is the disposition to use the same ('unreal') description. But when someone uses the term fully in the throws of delusionality - when they start to believe that nothing is real - their praxical grasp of the difference between secondary and primary senses breaks down. (That, I believe, is what really constitutes psychosis proper: a disturbance in what is unhelpfully called 'reality testing' which, put better, amounts to an inability to keep apart the orders of i) the metaphorical / symbolical / secondary / imaginary and ii) the real / primary. The failure is not so much one of self-knowledge (i.e. not so much one of knowing what order one is in), but rather of one's experiences or thoughts (however selectively) to themselves sustain relegation to one or the other domain. (Contra Sass, I suggest that such a 'regressive' disturbance is precisely of a piece with hyper-reflexive world-disengaged thought.))

The temptation to communitarianism with primary sense arises when in the grip of a certain picture of language. The theorist starts alienated from their life-with-language (i.e. with the inner and outer aspects of language having come quite apart, with a conception of language as consisting not of living exchanges but of discarnate signs awaiting animation from without), and then asks 'What makes it the case that rule 'xyz' has the extension it does?' Depending on one's metaphysical leanings, the temptation is (as Tim documents in his book) to rejoin the two halves of language by an appeal either to inner acts of interpretation, or to the linguistic behaviour of the community (both of which, as Tim shows, are hopeless strategies). And (as Tim also documents) the real trick is not to cleave our life-with-language in the first place - to view it as animated expressive behaviour through and through.

So: what is it that makes a certain putatively secondary use of a sign a genuine, meaningful, use? Well, what I find myself wanting to say is: why should we take it to be in the predicament of needing to be made meaningful? I suspect that it looks like this if it is being approached from the outside, as a non-participant might approach it; when we wonder whether this is a practice in which we can share, whether it might not just leave us cold, wondering if it is we who are unimaginative or our interlocutors who are self-deluding.

But isn't that precisely, so often in particular in matters aesthetic, precisely our predicament? Well, yes it is, so often. Stanley Cavell makes a similar, related, point about matters psychological - how that which intellectually gets 'deflected' and generalised into an epistemological discourse about scepticism actually (or: so he tells us) begins life as a perfectly unavoidable, natural, existential uncertainty about the inner lives of others. Others can, it just must be admitted, be enigmas to us at times, be frighteningly baffling, impenetrable, suddenly alien. Often enough they are not, and that they are not is the transcendental precondition for the language games of the inner. (Consider too D Z Phillips' claims about what the most profound form of scepticism amounts to (in, but not restricted to, the philosophy of religion): not a denial of the possibility of knowledge, but an expression of a struggle to find one's feet with, to make any sense of, the discourse (e.g. talk about God) in question.)

But note that there are two different concerns here. One is that we share enough by way of our linguistic dispositions to get the (primary or secondary) language game off the ground. This however is not to provide a communitarian answer to the second, and misguided, question 'What makes it the case that 'xyz' means xyz?'' What makes it possible that we can play a particular primary sense language game is - platitudinously (in the same sense in which 'meaning = use' can be taken as platitude rather than as dubious metaphysics) - that we are wired for it. For secondary sense the question is - are we game for letting that semantic organ - our brain - spin playfully out of gear for a time? Are we prepared to submit ourselves to the requisite aesthetic education (as is most strikingly necessary before one can learn to play the language games of psychoanalysis, musical appreciation, wine tasting, and literary criticism)? We move to the misguided question out of anxieties regarding our ability to answer the first question.

I once performed an ad hoc survey of people's dispositions to classify Tuesday or Wednesday as fat or thin. The one reaction I still remember (apart from the anticipated preponderance of fat Wednesdays) was from someone who became quite agitated. 'I don't like things like that' he said, revealing not a blank disengagement or puzzlement, but a powerful defensive hostility which was a function of no other aspect of the social encounter other than the asking of precisely that kind of question. It wasn't its silliness, either, he explained; something about what I was asking him to do made him deeply uneasy.

My tentative theory would be that a willingness to (as it were) play the secondary sense game is of a piece with the ability to play (in Winnicott's sense) simpliciter - to let the mind idle and function symbolically without fear of thereby losing the plot (i.e. the neurotic fear of psychosis). Hannah Segal's paper on the difference between symbolism and the symbolic equation seems to the point here: symbolism involves the ability to take things for other than they are. If we want meaningful lives we must harness forces which also have the possibility of making for psychosis. Symbolic equation, by contrast, means getting stuck with the symbolic relation: not being able to play.

Is play rational? Not: is it rational to play (it may or may not be, depending on the circumstances) but: are the forms of play forms of rationality? I suspect that there is simply no answer to this question. That, if we wanted an answer, we would need to invent one, and add nuance to the language-game of 'rationality' that is not currently there. As with play, so for secondary sense: I can, when I find my feet with someone using a word in a new (playful, secondary) way, find it within myself to say: 'Now I see how to go on like you' even when it would feel excessive to say 'Now I see why you went on thus'.

the value of quietism

2010-08-15T14:05:00.006+01:00

The approach to which I seem to be drawn, in philosophical psychopathology, is typically a Wittgensteinian one, and as such tends towards quietism. Which is to say, it tends towards a non-theory-providing, mere-undoing-of-mistakes, content-less, activity at the end of which, one might want to say, one is 'no further forward' than when one started. But what, then, is or could be the value of that? How are we then better off than the (pictured) cat, lying inert on Wittgenstein's grave?

Well: to render latent nonsense patent, however merely destructive, is at least a means to stop us wasting time pursuing (pseudo-) explanatory agendas which, previously unbeknownst to us, have started off on the wrong foot. On this understanding of quietism, philosophy prepares the ground for genuine empirical enquiry in psychology, once the houses of cards of only

misbegotten psychological theory have been cleared away. And that may surely be of value. Minimally, it is better to lie on one's back than to break it in pointless labour. If philosophy cannot itself engender theory then, well, at least we will be spared the embarrassment of kidding ourselves that we are up to something of cognitive import when we are not.

That however all sounds a bit depressingly paltry to me. In place of this vision which only has philosophical deconstruction and theory-building on its menu, I want to suggest a richer diet which would include something called 'phenomenology'. In particular, it would include a dialectic of phenomenological and quietistic understanding.

By 'phenomenology' I mean simply the rich description and expression of the diverse facts and experiences and their place in our world. Philosophy can help in this project of unconcealment by showing negatively how phenomena may be covered over both by being assimilated to other phenomena and through being recruited merely to bogus explanatory projects. (For one thing is sure - as I once noted in an introductory article on theory of mind research in autism: those theorists who eschew the unedifying edifice of the 'theory of mind' and inferentialist projects regarding others' minds are precisely those able to pay best attention to the diverse reaches and characters of our mindedness.) Phenomenology by contrast is the articulation (either expressive or descriptive) of these facts in all their unconcealed sui generis glory. By moving back and forth what we gain is the world in all its richness - where 'the world' includes, importantly, one another.

Does this richer description of the world - in particular of those corners of it which have become obscured to us because we have recruited the light of our understanding into a focal spotlight, shone elsewhere, to enact mere fantasies of penetration - constitute real advance or progress? The attraction of the enlightenment idea of a mass of scientific knowledge and understanding moving forward is that it enables us to think of our contribution as adding up to something solid which will outlast us and our generation. Once the knowledge and the explanations are generated, then they are 'there forever'. Quietism might seem to have a more modest goal, and will always be parasitic upon the presence, within contemporary understanding, of misguided metaphysics and its pseudo-explanatory epistemological products.

Yet this also sells quietism short. For over time we gain clearer understanding of the diverse (but often related) ways in which we contrive to misunderstand ourselves and our worlds. This is understanding that can, at least for a while, be 'banked'. And in any case, the belief that the explanation of the world is to be preferred to the capacity to encounter it fully is itself a parochial value of the enlightenment. Perhaps our emancipation from that set of goals as the only viable set of intellectual goals could start right here, with questioning such values (and defences - against the fear of death, for example) as lie hidden within it.

recap and recant

2010-08-12T21:11:00.003+01:00

N's latest couple of posts made me think both that I hadn't quite properly expressed myself and that some of the thoughts I properly expressed were improperly formulated, in my previous post. But also I (someone whose Zen meditation cushion still looks rather tellingly unworn) want first to risk a comment on the koan analogy proffered by N.

N suggests - rightly I think - that trying to get from a delusional to a sane experience can be like trying to solve a koan. Let me conflate Wittgenstein and Zen a little (as Canfield and Gudmunsen and Huntingdon have taught us to do (cf also, though, Magliola on Derrida and Nagarjuna)) and suggest that what is needed in relation to the koan is not a solution but a dissolution. Within the terms of reference that the koan sets there is no solution; the dissolution comes from rejecting its tacit premises.

So, to take one koan with which I'm a little familiar: A master says (something a bit like this) to his students: 'If you say this is a stick, I will hit you with it. If you say it is not a stick, I will hit you with it. What do you say?' Predictably, all the students get hit right and proper. There is no solution in the terms offered. But, the further thought goes, why should we buy into this bit of demandingness? What we - the novices - do in so buying is accept the presupposition that we must answer the master's puzzles. We accept the power dynamic, we maintain - by remaining caught within - the bubble of the transference relationship. Better by far to grab the stick and give the old goat a thwack, or just chuck it away. That would show an emancipation from the terms of the argument. (I once had a similar experience on a training week at the Tavistock Clinic: the group leader (twice per day, 90 minutes per session, for 5 days) acted like a complete bastard, sighing and hurrumphing and interrupting and generally being very 'rude', throughout all the sessions. It wasn't until the end of two days of getting furious with him, or profoundly doubting whether my experience could really be veridical, that I realised instead his real lesson, which was: Why on earth would I be giving him, a complete stranger, such power to affect how I am left feeling during and after the session?)

If such a dissolutive rather than solution-based deconstruction of the koan is (in the analogical context) a matter of using thought to reconnect with reality after being caught within the purview of a phantasy/delusion, then I will happily accept this use of 'thought'. (What I meant in the post by (the need to abandon) 'thinking one's way to reality' really only referred to attempts to solve, rather than dissolve, the delusional experience - or, by analogy again, to try to disprove the justifiability of scepticism whilst accepting its tacit premises about the world-independence of the mind. When it comes to a thoughtful dissolution or deconstruction, however, then: bring it on!)

So to put better what I was previously saying: it is not that I want to urge that we would be misguided to provide ourselves with "reasons for returning from the study to the billiards table". The main such reason is the fruitlessness of attempting to arrive at veridical perceptions by supplementing inner experience with (epistemology-provided) causal or justificatory connections to reality. But start where the sceptic starts and remain there (despite all the thinking in the world); question his tacit non-disjunctivist premises, and (only then) abjure his problematic. (N's playful embracing/negating of the epistemological enterprise (toward the end of the 'part ii' post) thus seems to me de trop.) Hume found himself untroubled by his sceptical doubts when engaged in the game. Augustine found himself untroubled about the nature of time when taking it or giving it to someone. What got them into their respective puzzles was not, I submit, anything about time or experience per se, but rather, time or experience already refracted through misbegotten prior assumptions about the way that the respective language games work.

Where does this leave the discussion of schizophrenic experience? Here I want to clarify something I wrote before and to register what I think is a disagreement with N: Whilst I think it is entirely wrong to blithely accept that we know what is meant when someone tells us, or we tell ourselves, that we have had the experience or thought that (e.g.) nothing is real, I really can't accept that what is actually happening is that the someone in question is having a particular experience that they merely happen to thematise (narrativize) in this manner. As N says, the question then remains as to why it is so entirely natural for the someone to thematise it thus. (And here we are back in the territory of my earlier 'talking teapots' post.) What I would rather urge is that the content of the experience is given precisely through that avowal of it which makes use of the notion of 'unreality'.

But yet, or so it seems to me, this need not cause us to become complacent in assuming that we (could) know (that there could be such a thing as knowing) what it would mean to talk of an experience (as) of everything being real or unreal. We know what it is for a dollar or a smile or a problem to be real; do we really - really - understand what it would mean for the world to be real or not? Isn't "the world" precisely that within which discriminations of the reality of this or that are made? Isn't the world a transcendental precondition for necessarily localised talk of 'reality' or 'unreality'? Isn't it to 'sublime the logic of our language' - to ignore the necessary background context within which the concept of 'real' operates and to try to use it about the context itself - to carry on in this way?

One aspect of the model I would, then, use for making sense of the twin utter propriety and yet strict meaninglessness (although is it really right to call it 'meaningless'? I have a feeling that doesn't quite make the point I'm aiming for) of talk of depersonalisation or derealisation is secondary sense. We are drawn to using the terms in the ways we do by the experiences we have. That we are so drawn is not something which could be justified by reference to the content of the experiences; rather, our being-thus-drawn is the 'beginning, and not the end, of this [particular] language-game'. It is the condition of our finding it intelligible. Wednesday is fat and Tuesday is thin; happiness is up and sadness is down; sopranos are high and basses are low; anger is red and envy is green; and so on. We know how to use the relevant terms in their everyday deployments, and then we redeploy them spontaneously and groundlessly to express or report such further experiences and phenomena. I know how to talk about unreal diamonds, and then I find myself using the same word to characterise the very being of others. The logic of my language is sublimed (I cannot - however hard I try, with however much sincerity - mean it in the way I normally mean 'real'). But, damn it, that really is the only way to describe the experience!

against non-disjunctivism in the philosophy of psychiatry

2010-08-11T23:13:00.008+01:00

Non-disjunctivist conceptions of mind are presented blithely throughout the corpus of philosophical psychopathology, as if we could and should just take it for granted that they are the only show in town. I don't want to - don't know how to - don't really know what it would mean to - argue against them here, only to point out the different direction that a disjunctivist conception takes us. (I say 'don't really know what it would mean to...' because, to be honest, I don't really think that disjunctivism and non-disjunctivism are best understood as two opposing philosophical positions about the formal character of experience. Rather, I would posit disjunctivism as a non-position, a grammatical reminder which somewhat exceeds itself, still slightly under the sway of the (very idea of the meaningfulness of the) metaphysics that at best it aims to 'cancel' rather than oppose.)

Recall what the non-disjunctivist says about perceptual experience (I take (rather from memory), as my source, John McDowell's paper Criteria, Defeasibility, and Knowledge - although it should be noted that McDowell doesn't actually talk about 'disjunctivism' per se): that the possibility of my not being able to distinguish, on occasion, whether I am hallucinating from whether I am having a (so-called (by philosophers)) 'veridical perception' entails that the two cases have some 'highest common factor' (e.g. an inner experience, a sense datum, a mental image) in common. Against this the disjunctivist insists that in 'veridical perception' (let's just call it 'perception' shall we!) - in perception - the content of my experience is no inner proxy, no half-way-house-to-the-object, but rather: the object itself. When I see my cat, that is what I do - I do not need to be presented more 'proximally' with a visual image, a sense datum, an inner experience, of a cat. I've got the damn thing itself right in front of me, thank you very much. (So there is a 'disjunct' between the two cases - no common item of an inner cat image in cat hallucinations and cat perceptions.)

Now the kind of non-disjunctivism I have in mind in the philosophy of psychopathology is not simply that contained in the typical empiricist's (non-disjunctivist) conception of hallucination (although that is widespread enough). It is rather an analogue of this in a wider range of psychotic phenomena. What makes it analogous is the similar philosophical inventing of a whole class or form of (parts of) experiences, a class which is posited so that it can do apparent explanatory work (but which putative work will only itself seem to be required on the basis of some rather non-disjunctivist-like conceptions of experience itself...).

Take Zahavi- or Frith- or Graham-esque conceptions of self-consciousness. Here it is typically assumed that - from the fact that the patient experiencing passivity experiences has an experience as of, or just: of, someone else thinking my thoughts, putting thoughts in my mind that are not my own, extracting them, moving my body instead of me moving it - the non-patient must normally be having contrary (albeit subliminal) experiences of being the agent of their own thoughts/actions. Failures of this agency can then be appealed to in an alleged explanation of the psychopathological phenomena. But I can see no more evidence for this everyday tacit 'ipseity'-sense, for this automatic experience of myself as the agent of my own actions, than I can for the presence of sense data in the case of genuine perception.

I want to leave those examples for now, and turn instead to depersonalisation and derealisation - experiences of the self or the world as being unreal. From the presence of these we have the common inference that we must normally have some belief or experience or sense of the world or the self as real, genuine, objective, independent. It is then suggested that it is to some kind of failure in this mechanism of providing a sense of the real that we owe the psychopathological phenomena. (I seem to recall Matthew Ratcliffe arguing in a similar way - that we have some normal feeling of this or that facet of being-in-the-world which feelings of being (or 'senses of reality') can be disrupted in psychopathological self-disturbances.) But I see no reason why such putative normal senses of reality should be posited. Just because I may sometimes have a feeling of unreality does not entail that I normally have a feeling of reality that has been supplanted. (I may sometimes feel hungry. This does not mean that, when I don't, I always have a feeling of fullness, or just a feeling of satiation (although perhaps I might, after a nice meal). Rather I just don't feel hungry when, well, when I don't feel hungry.)

The extra explanatory potency of the 'non-disjunctivist's' conception should be clear: by positing a 'feeling of reality' I can 'explain' feelings of unreality as due to the breakdown of some normal part of our affective relating to the world. But, honestly, this seems just far too 'neat'. First, I'm not aware of any such feelings of 'reality' in the normal case (what would be the point of them anyway?). Secondly, it just won't do to invent explanantia for the job when confronted with puzzling explananda. Thirdly, just why is it that I take myself to be in need of some such explanation? Fourth, aren't we being misled by the psychopathology, asked to buy into the very conditions of (im)possibility of psychotic experience that it is precisely part of its pathologicality to tacitly posit?

Er, I think I ought to explain what I mean. So, compare the unreality experience to the sceptic's predicament. With everyday being-in-the-world, I need no 'feelings of being' to sustain my living conscious engagement with my surroundings and with others. I just, you know, get on with it. But in psychosis existential terror throws me out of this; and with scepticism, in an intellectual rather than lived register, I also stop viewing my understanding as, necessarily, always-already, embedded in a world. The mind now understands itself as a self-contained inner domain. It will now seem that there ought to be thoughts or feelings which bridge the gap between mind and world. A feeling of reality would do the trick nicely, where a feeling of unreality has come on the scene and threatens to unseat one's whole grasp of what is true, meaningful, real. But from within this 'sceptical' construction the fly cannot escape from the flybottle: once the seed of sceptical doubt has found fertile ground, there is nothing that can stop it growing and growing in the mind - not all the epistemology in the world can have the desired effect of intellectually sanctioning what is so valuable about Hume's walk to the billiards table from the study.

We might compare the predicament here with that of someone living under, or in the sway of, an unconscious phantasy. An existential-phenomenological recasting of such phantasy has it that something (some emotional understanding) which would ideally be revealed within 'the clearing' (in the 'intentional field') has now become part of its very structure. I inhabit an atmosphere which, in its all-pervasiveness, is peculiarly transparent to me (if not to the perceptive other). Attending from this phantasy, rather than to what would normally be its worldly contents, throws up a set of concerns for me, into consciousness, which concerns are actually irresolveable (and I am left simply with an unconscious 'compulsion to repeat' (actually, as Lear points out, it's not a compulsion to repeat - just a non-satiated compulsion to do that-which-is-repeated)) within this framework. Within the phantasy all the fly can do is bounce around the bottle; it takes a particularly skilled Wittgensteinian entomologist to show him out, not by solving the presenting puzzle but by untying the underlying phantasy.

Let me wrap up a little. What I have analogically been calling the 'non-disjunctivist' conception of psychotic experiences such as depersonalisation has it that these are on a par with putative normal experiences of 'personalisation' or 'realisation' (as it were) - that they represent a subjective registering of the breakdown of those faculties which allegedly normally give rise to the alleged sane varieties of affectively toned everyday encounters. What this theoretically presupposes is, I believe, an analogue of that conception of the mind presupposed by the non-disjunctivist about perceptual experience: some kind of 'inner world' or domain of 'sense data / phenomenological items' present in both hallucinatory and non-hallucinatory episodes as a common inner currency. The epistemological task now becomes that of finding one's way out of this inner landscape. The problem is that this is an impossible task. Rather than look for ways out (causal links of the 'right kind' etc.) of the inner world, we would do better to question its very premises. So, too, I have been suggesting, (semi-)psychotic experiences of derealisation might invite us to understand them as just further contents of consciousness, contents perhaps standing on a par with alleged other such contents (such as alleged feelings of 'reality'). But, I want to suggest, the decisive trick has taken place further back in the mind - not in what contents present themselves to consciousness, but rather - in the structuration of the field of experience which gives rise to the abnormal sensings. Because this field is something which can only be inhabited, not itself experienced, the fact of its distorted involution cannot be registered. Trying to 'think' one's way out of it - give oneself reasons for returning from the study to the billiards table - will inevitably be a doomed enterprise.

Those who move swiftly to explanatory theories of psychotic experience have, it seems to me, often failed to take in, in a first phenomenological sweep, just how very odd such experience is. 'Oh yes, depersonalisation, that happens in x % of people, is characterised by xyz, etc etc.' Hang on a minute, just listen to what you're saying! De-person-alisation! De-real-isation! A sense of the self or world as being unreal! What could that possibly be! I'm not trying to question the disturbing fact of the experience, only to invite us to linger a little longer over the idea that it is in any way obvious what its content is. Such a failure to linger and a flight to explanation sits well with that kind of (non-disjunctive) conception of the mind - as a domain that might quite naturally be populated by feelings of either reality or unreality - tacitly on offer. But wait! Are we really confident that we have either any clear sense of what it would be for an experience to be of something - or myself - as real or as unreal? Sitting with the bare thought of it, it can start to look like a strange philosophical joke. Deja vu is not dissimilar in this respect: the feeling presents itself as an uncanny feeling of having seen something or been somewhere before which we believe we haven't seen or been. But it isn't as if we have a quite general normal experience of having seen something before (is it?), or as if we don't in fact very often take ourselves to recognise people or places who or which, in fact, we had not previously encountered. Such formulations far-too-quickly invite us to reduce the uncanniness of the experience to the contradiction between 'I have' and 'I haven't' seen her or it before. Far from taking us nearer to the bizarreness of the experience, we are left - by the too-quick acceptance of how the psychotic experience articulates itself - further and further away from it.

what might philosophy be?

2010-08-09T08:53:00.004+01:00

The enlightenment is so very seductive. Better and greater understandings of the universe without. And - in philosophy of mind, or in psychology - deeper and richer, more empirically informed, more theoretically developed, understandings of the universe within. Making slow progress on the big problems. Yada yada yada....

What if the philosophy of mind came to look more like psychotherapy? Where psychotherapy itself looked less like an enterprise of education or growth, but more like - say - merely the ego's growing acknowledgement, tolerance, of the id. (Desires to be a certain kind of desiring creature giving over, at some point, to acknowledgement of the desires one actually has.) Or like - say - the manifest content coming to approximate the latent content of a dream.

What if the philosopher came to see himself - not as the foundations man, or as the ideas man, but - as a therapist for a particular vein of society's repressed desire? As a therapist who aimed to simultaneously increase our 'ego strength' (our capacity to tolerate understandings of ourselves which might not fit so well with our current manifest image?) whilst increasing, through an analogue of interpretation, our knowledge of the availability of other such understandings? Understandings which were all along part of our implicit self-conception, understandings which - if we could only allow ourselves to help ourselves to them - would enable us to breathe more comfortably?

If such understandings were made therapeutically available, they could help forestall manic attempts to build our way out of conflict zones which will always remain such given their narcissistic, omnipotent, foundations. We might find we do have the resources to live on the rough ground after all - rather than, fearing we do not, attempting to maximise the use of a few intellectual resources within the confines of some shiny narrow urban centre.

Each age will have its own self understandings and self misunderstandings. And within the conversation of mankind we will always find other variants - the pulls of idealism and realism, conventionalism and platonism - in a range of sub-localities. Our work will be cut out for sure.

It seems less impressive though, doesn't it? The business of 'merely' making available to the social patient the self-understandings they already have (somewhere)? The therapist as a more lowly profession than the scientist. One swimming forward, the other happy to help the patient happy to tread water, to help them understand that they can be happy where they are, that there is plenty to see and do there, that the sea monsters there are really not quite so scary as to devour one, that there will be other monsters in other places too, that the frantic efforts to move forward are really just doomed efforts at escape.

Can that be enough? Can we philosophers value the therapist role model as much as the scientist role model? Well, perhaps that revaluation could itself be part of a recovery of values and self-conceptions lurking somewhere within. Perhaps that recovery is itself the first job - of making philosophy content with a now-manifest image of itself as a 'merely' humanistic discipline, as just perpetuating and enlivening the conversation of mankind. Of coming to value ourselves a little more - coming to value an interest in ourselves couched in terms which are uniquely and intimately our own.

back again

2010-07-25T14:27:00.006+01:00

I've just been roused from my non-blogging slumbers by a post from the author ('N') of the Ruminations on Madness blog which is helpfully critical of some of my own previous contributions. What follows is an attempt at a defense of what I wrote before.

In 'Talking Teapots' I considered some dis/analogies between psychosis and imaginative make-believe. N aptly summarises some of my views and then quotes me as follows, and continues:

“The pre-reflective cogs which bind the mind to reality are disengaged, and it idles, spins in fancy.” This is nothing like anything I have ever experienced—indeed it sounds a hell of a lot more amusing and enjoyable than anything I have ever experienced! Instead, precisely the difficulty of operating within a psychotic space is, for me, the fact that so many choices must be made, that I must constantly navigate between consensus reality and its epistemological strictures and—like it or not, Gipps—another “reality.” That I am at every moment forced to make choices about which path to follow—and, indeed, how to construct, spatialize, and thematize that path. Constructing a delusion is, in my mind anyway, an extremely–even acrobatically–creative (and also terrifying) endeavor.

I would agree that spinning in fancy is not a good description of the operations of the delusional mind - in point of fact I think I was using this phrase to describe the mind imaginatively engaged with a fairytale (and I continued 'In psychosis there is not this element of ... playfulness.'). But N's point is mainly about the relation of choice to delusion-formation, and I had suggested that there is no role for choice in the entering into of delusional modes of thought. (Depending on what we count as volitional, this claim of mine is surely wrong: we can readily recall patients who seem to 'choose' their delusions, with convenient contents, at convenient times, for particular emotional purposes, etc. But we can also recall many who seem simply lost in, and lost to, modes of experience which are not reality oriented.) What I want to suggest, as a compromise, is that the delusional subject cannot simply choose to engage in delusional thought any more than the sane subject (and the psychotic subject in non-delusional times) choose to engage with many mundane matters. Our sane existence is characterised by being-in-the-world - which is to say that we do not approach our environments from the point of view of a disengaged hypothesis-former, but rather are always-already engaged in and through our interactions with a pre-understanding of the meanings of our situations.

If however psychosis leads to (or, better, is itself understood as) the partial loss of being-in-the-world, then the subject is indeed now forced to confront his or her environment as a radical chooser. Thought - thought which is no longer utterly pre-inflected through that tacit world-engagement constitutive of sanity - must be called on to arbitrate between a thousand possibilities, choices must be made: the cognitive load must often be overwhelming. Constructing a delusional system to make sense of the chaos of noise which results when the situations around us no longer call to us with their familiar cries would, I imagine, seem to be pretty much a survival necessity.

N and I clearly disagree about the helpfulness of describing the delusional subject as occupying 'another reality'. This is a huge question which can hardly be settled here. What I would be concerned to combat is any of what Hamilton, following Squires, calls the 'lost tribe romantic' view of schizophrenia. This view has it that the interpretative task of the person who wishes to understand the experience of the psychotic subject (and that task may very well be one for that subject him or her self, as well as for their clinical interlocutors) is akin to that of the anthropologist encountering an exotic tribe. On such a view, the task is to suspend one's everyday understanding and enter into a different reality, with different rules, structures of meaning, forms of experience, etc.

A cheap way to spell out this view would be to deploy some kind of degraded Kantian scheme-content dualism - and imagine that the person with psychosis is thematising the content of their experience with a different scheme of conceptual categories, and that entering into that world requires us to learn such categories. (I say 'degraded' because Kant would presumably have thought that the very categories challenged by psychosis (time, space, etc.) were constitutive of any possible experience whatsoever.) This strikes me as unpromising - basically because such dualism is so philosophically unpromising, but also because I think that Kant was right about the necessary ingredients of bona fide, paradigm case, genuine articles of experience. Sure, let us acknowledge the profundity of the psychotic break by acknowledging the breakdown in such structures. Let us willingly abandon the normalising attempts of the CBT pundit for just this reason (see N's nice post on this issue here). Let us acknowledge too what might metaphorically be called the attempts at world-making of the subject suffering such a break. But none of this means attributing any ontological parity between psychotic and everyday experience, nor acknowledging that psychotic experience reveals another world.

N continues:

Next, “sanity is synonymous with meaning”…? Delusional realities are only metaphors…? I think I have an even harder time wrapping my head around this one. Metaphors are not meaningful? And “sanity” is, what, consensual reality? And consensual reality is…what precisely? Are mystical experiences part of consensual reality? Buddhist satori? Dreams? Where does consensual reality begin and end?

So, er, yes: metaphors are meaningful. We have a meaningful metaphor when we talk of 'delusional realities'. But this does not mean that the delusional person's delusional claims have either a metaphorical or a literal meaning. They are not metaphors (although the claims often 'behave' like metaphors. (Basically, I believe they are not metaphors because a) the appearance/reality distinction has collapsed, and because b) the subject does not treat them as metaphors.)) The meaning attatches to the classification, not to what is classified.

And to talk of 'consensual reality' is, I believe, misleading, since it seems to reduce the question of what is real to the question of what a certain group of people say is real. What seems wrong about that, to my mind, is not that it contradicts some fancy metaphysical doctrine of Realism that I set out to believe in. (Not my style, being a hopelessly Wittgensteinian kind of chap.) To be sure, we need to look to our diverse language games to be able to appreciate the different kinds of reality enjoyed by economic crashes, motor cars, algebraic solutions, mood swings, etc. (The kind of thing which would mark the distinction between a genuine versus a false motor car or solution or mood swing is quite different (and this is a semantic, and not an epistemological, point).) What seems wrong with it is that it risks a conflation of the idea that what we say/think/do determines what is real with the idea that what we say/think/do determines what is called 'real' here or there.

Contrast conventionalism with Wittgensteinianism about logical necessity. The conventionalist says that the statement "2+2=4" is true because of how we go on in our mathematical language-games. The Wittgensteinian says that the statement "2+2=4" is how we go on in our mathematical language-games. The former invites us towards constructionist formulations of the character of meaningful experience - invites us towards the idea that we are all engaged in world-making exercises. And following from that we can readily imagine that different groups of people are engaged in different world-making exercises. (And just around the corner from that is the relativistically-minded subject's outrage along 'how dare they tell me/us what is and is not real!' lines...) The latter platitude encourages little other than philosophical quietism...

So, to return my wandering mind to what N actually wrote(!), no I wouldn't want to start talking about 'consensual reality' since it implies a relativism or constructionism about reality that I don't relate to. I think there are different 'criteria' (as the Wittgensteinian unpromisingly puts it) as to what is to count as real, actual or true (as opposed to unreal, fake, illusory, wrong) in diverse language games, and there are of course such diverse language-games regarding medium-sized dry objects as well as dreams, numbers, mystical experiences, miracles, scents, fashion items, wishes, stamps, etc. (One of the philosophical sins I'm trying to wean myself of is that of talking about some putative super-object called 'Reality' which is the putative object of all these diverse language-games. I confess I still commit this sin all too often though...)

N next writes:

Finally, I have a hard time understanding why it matters whether a given delusional statement is “correct” or not (when is anything ever absolutely and definitively “correct”?)… I’m also very unsure as to what Gipps means by a “rule of representation,” though I take it to mean that there would need to be (but why?) some kind of external criteria (that could be applied to delusions, or rather to individual’s delusions qua explanations of an anomalous experience) if we were to want to make some kind of evaluative judgment of them. Now, since the delusional experience is, certainly, deeply idiosyncratic and personal, I don’t see how this could happen. But isn’t the same true for much of normal human experience? Do we have “rules of representation” for the veracity of any given emotional or affective response, for example? For dreams? Day-dreams? Hopes? Desires?

This I think involves a (perfectly understandable) misunderstanding of my intent, and I would agree with much of what N writes. My concern was with whether we can say that a delusional subject's expressions of their inner experiences are or are not correct. For example, when someone says that someone is having an experience of (or, prodromally perhaps, as of) thoughts being taken out of their head, or inserted, can we say that they have given a correct description of their experience? I do not believe that we can, but I certainly don't think this knocks any spots off the delusional subject, since - yes - this is equally true of any avowal of subjective experience.

What I wrote in 'talking teapots' was that it seemed to be that there was no such thing as the delusional subject being correct or incorrect in their descriptions of their own experience. Why this matters? Well, it was all part of my critique of the adequacy of 'romantic' and 'psychiatric' approaches in psychopathology which either think that the meaning of delusional utterances can be recovered through interpretation, or think they can be seen to be meaningless because they can be shown to fail to describe something properly. I think that both approaches try to say too much, and fail to 'sit with' the delusional experiences themselves.

I turn now to N's comments on the 2nd of my ridiculously-titled 'aporiae of apophany' pieces. N worries that I am considering thought disordered thought to be thought which qua thought starts to unravel - or that I am considering delusions to be beliefs which begin to be damaged as beliefs. I plead unrepentently guilty to both charges. Next N worries that I'm

not proposing some kind of equal-but-different status for delusions, but, whether he means to or not, seems to be devaluing (how, after all, can a meaningless experience have value?) them...

Well, I'd agree with the not equal-but-different status bit (I don't think for example that delusional beliefs are, say, just different ways of understanding 'the world', that the delusional subject is just occupying a different 'framework', etc...). But I'm not so sure about the devaluing bit. I guess it depends on the context of the valuation. What I'm reminded by is what Wittgenstein said about the nonsense that metaphysicians unwittingly proclaimed, that the production of (what is in fact) nonsense can be very important, and that we should pay attention to it. Just because delusions are, I believe, not meaningful in the final analysis, does not mean that they are not revelatory and important, nor that it is fruitless (for patient and clinician alike) to engage with them. (A delusion may be meaningless but may reveal something of my state of mind, for example. Or it may have fragments of meaning that can be worked with and, through the gradual re-establishing of the relational terrain of meaning, be developed in meaningful directions.)

Perhaps, however, on this last point, what I ought to own here, as something I would maintain about the values and meanings of lives not exclusively my own, is my belief that such meaning and value arises in the midst of our relationships with: others, work, craft, our humbling private or relational attempts at supercession of our own narcissism, etc. Not all relationships are meaningful, by any means, but I do consider all meaning to be 'relational' - and I do consider solipsism and narcissism ('narcissism' in the psychoanalytical sense) to be the death of meaning - to harbour merely the ghost of living meaning.

N goes on to find a (putative) self-contradiction in what I say about there both being no such experience of having thoughts removed from one's mind, and yet urge that precisely this is the content of the delusional subject's thought (er, when it is...). I don't think this is quite such a mad thing to say, though: they are having an impossible experience which is individuated through what they are inclined to say about it. By an 'impossible experience' I do not mean to say that they do not have an experience which is best described as of having thoughts removed from one's mind, only to note that there is no such thing as having thoughts removed from one's mind, and nothing that that is like. Secondary sense is, I believe, the way to make sense of such contents of thought or experience. (Also, it is not, as N suggests, that I am sceptical of verifying the accuracy of the delusional subject's claims about their inner experience; rather I am sceptical that it even makes sense to talk of doing this. Verification doesn't seem to have a meaningful place in the inner - and this I believe is an 'ontological' rather than an 'epistemological' truth.) Further, I'm certainly not claiming this is true of all delusions, only making a point about delusions of 'inner sense' (inner passivity experiences etc.).

Should we (N's final point) resist attempts at explanation or understanding of delusions? I believe that we should not resist attempts to explain them (for example, to understand their origination). As for attempts to comprehend them (i.e. understand their meaning, rather than discover their causes), I would want to say the following: We would do well to try and understand what it is that delusions may betray about the subject's mind. For example, their themes may symbolically (in the psychoanalytical, somewhat associationist, sense of 'symbolise') represent a significant emotional theme. Or they may 'emblematise' (as the phenomenologists have it) an ontological sense of self-dissolution which, e.g., either gets projected onto the world or which get reduced to a merely empirical posit about something within the world being destroyed. But just as importantly, I want to urge that we pay attention to the way in which we may 'over-understand' delusions, in our haste to make psychotic thought more comfortable, in our desire to avoid sitting with terrifying affects of self-and-meaning-dissolution. How we - doctors, patients - may accordingly 'romanticise' what are either actually forms of world-disintegration or 'psychic retreat'-like modes of world-evasion.

a simple model of psychotherapy for psychosis

2009-12-05T14:03:00.004Z

Here is a very simple model for the pragmatic therapy of schizophrenic psychosis. (I say 'simple', and it is, but the theories in terms of which it is cast are not at all simple. I shan't be spelling out these theories here, and will instead assume a ridiculously happy congruence between i) the reader's prior reading and philosophical prejudices and ii) my own.) It is built on a) an understanding of the nature of the core psychotic disturbance drawn from phenomenology and psychoanalysis, b) an understanding on the nature of the self drawn from existential phenomenology, and c) an understanding of the nature of effective therapeutic treatment drawn from the behavioural therapy known as ACT or acceptance and commitment therapy. I'm posting it because it seems fairly obvious, but I've not seen it articulated in just this way in the literature - probably because a) or b) and c) are not often drawn into close proximity, but also because there is much in the RFT background to ACT which is inimical to the philosophical spirit of existential phenomenological theorising about 'the self'.

a) A person 'with schizophrenia' suffers from a schizotaxic deficit. This constitutes a fragility in their capacity to hold themselves together - or, more accurately, a fragility in the capacity of their lived body to remain held together - in the context of (in particular) emotionally significant interpersonal encounters. The fundamental disturbance is accordingly a 'self disturbance'. The boundary between self and world or self and other - a boundary generated by the body schema in action - is always somewhat fragile, and then when stressed too greatly, becomes altered. The boundary between self and world, or self and other, starts to fall apart. From this basic self disturbance arises all the secondary symptoms such as delusions, hallucinations, passivity phenomena, etc.

b) Additional strain is placed on the smooth functioning of the body schema by powerful affects such as anger/anxiety. Psychotic terror at the dissolution of the self itself promotes further self-dissolution. There is however nothing that any of us can do, directly with the resources of the conscious mind, to reduce self-disturbance. Any thinking will occur 'on top of', grounded in, the self-disturbance. The kinds of hyper-reflexive retreats documented by Laing and Sass do not promote genuinely different ways of grounding the self. (Instead they are simply that: retreats from being, however much they are narcissistically dressed up as alternative realities.) The grounds of the self always remain inarticulate, background, non-reflective, aspects of bodily going-on-being which we can only promote obliquely.

c) Part of that oblique treatment will involve any exercises of whichever sort which can aid in the recalibration and stabilisation of the body schema. The kinds of bodywork promoted by Rohricht and Schoop may help here. However ACT surely has something else - and something important - to offer. Which is the idea of dropping control agendas with regards the occurrence of distressing mental events, and also the idea of promoting an acceptance of whatever comes into the mind (acceptance tempered by a distancing acknowledgement of that whatever's mental as opposed to real state). That much has already been said in the ACT on psychosis literature. But I'd like to propose a third piece of groundless trust which it would behove the therapist to promote - namely, a trust that the body schema will look after itself if one allow it to. If one can allow oneself to 'go with' (without 'buying') the psychotic experience. Take courage, re-engage with the lived environment, and do not hyper-reflexively try to create a psychic retreat or a rigidified way of being to 'manage' the psychotic experience.

The self in psychosis has weak foundations, but these foundations are, as for everyone, constantly enacted (the path that is layed down in walking) in the course of a meaningful life lived. Can the schizotaxic patient allow that path to lay itself down, to not try to lay it down and thereby inadvertently build castles in the air which constantly threaten to crash down to earth, to instead take themselves on walks through familiar and comfortable terrains and tolerate the rough ground?

why psychology is a bit rubbish really

2009-11-21T18:24:00.013Z

Er... a shamelessly hyperbolic and attention-seeking title I know. Anyway, I thought I (a psychologist) would spend a few moments clearly specifying why it seems to me that psychology is a rather limited discipline when it comes to understanding psychopathology. Of course I'm playing rather fast and loose with what is to count as the extension of 'psychology' but I hope my caricature will at least be recognisable.

Psychology today tells us about - to use a shorthand - what happens 'in minds'. That's just what psychology is. It tells us about what people think and feel and intend and will and 'represent'. And as well as telling us about what representations are in the mind, it tells us about how people think and feel and... We have 'mental states' and then we have the 'mental processes' that link these states together.

The natural deployment of this framework in psychopathological contexts suggests that in psychopathology people's representations of others or themselves or their worlds are faulty in content (a faulty 'what'), or there are faulty links between these representations (a faulty 'how'). Perhaps someone's feelings are out of proportion to a situation; perhaps their beliefs are inaccurate; perhaps they are jumping to conclusions, etc. It is either mental states that are disturbed, or mental processes that are breaking down. And that is the sum of it, of what it means to 'do the psychology' of psychopathological conditions or states, on the story I'm telling.

The problem is, however, that most of what we recognise as proper psychopathology is not at all aptly characterised as due to a faulty contents or broken processes. What most frank psychopathology involves is not a failure in the mind's mirroring capacities, a failure of what is in the mind (states or processes), but rather in the structuration of the mind itself.

By structuration I do not mean 'stage of development' or 'degree of complexity'. That, it seems to me, is (in this context alone) another psychologist's red herring. I have in mind rather the way in which the faculties dialectically unfold into their mutually constituting yet opposing domains. To understand this we need the conceptual resources not of psychology, which can only tell us about what's happening within minds, but rather of existential phenomenology, which tells us about the essential character of mindedness itself.

Here's a rather daft pictorial way of demonstrating what I'm getting at. First we have a picture of a normal mind doing its normal job. (It's not supposed to instantiate a valid faculty psychology, just to help me make a theoretical point!)

Here we've got someone looking at a dog, recognising what to call it, laying down a memory, shutting their eyes and drawing on their memory to call up an imaginary dog, etc. We have a mental process of perception leading to a mental representation etc. etc.

Now we imagine someone suffering from some deficits in their mental states and mental processes. Here's one possible result:

What we have here are a whole host of different difficulties: a faulty perceptual processes leading to the internal representation of the dog being somewhat truncated; dodgy memory processes such that we have a lack of laying down of new memories, and a knackered verbal recognition ability such that the term 'hog' comes to mind instead of 'dog'.

Such a way of depicting matters comes fairly naturally when we are thinking of specific brain injuries or fairly localised dementing processes. What I want to claim is that, despite the ambitions of cognitive clinical psychology or cognitive neuropsychiatry, it just won't do at all when we try to grasp the essential character of psychopathological conditions such as OCD or psychosis.

The essential character of such conditions, I want to suggest, lies in the fact that, under certain pressures and in certain contexts, we have a failure in the structuration of the faculties and of the very mind itself. This is difficult to represent pictorially because another claim on the table has is that to the extent that we have deviation from that structuration which separates what is inside the mind from what is outside, or which separates the imagination from memory or from perception, we have a loss of mindedness itself. I've tried to represent this in the following picture by showing how, when we have a movement of the boundary of the faculty, we simultaneously and necessarily also get a loss of that very boundary:

Our ability to really talk about distinct faculties, to place a representation within one rather than the other, starts to blur. It may become hard to say where the self ends and the world begins (witness the intruding dog). Yet this is simultaneously to say that it starts to become hard to talk about distinct selfhood at all, since self and world-as-experienced-and-understood just are mutually yet opositionally defined. Whether we have to deal with a memory or an imagination or a perception becomes unclear. Verbal recognition starts to intrude into perception. Again, it's not just that, say, something within the mind gets mislocated, or mental processes mediating representations between faculties become impaired. (That's the standard cognitive psychological model of mental disturbance.) Rather, the very possibilities of making coherent distinctions between imagining and seeing starts, especially in particular affectively significant contexts, to fall apart.

Cognitive models of obsessive compulsive disorder tell us that 'everyone gets intrusive thoughts. It's just that the person with OCD wrongly perceives the significance of these, taking themselves to be responsible etc.' To my mind this radically misunderstands the nature of both intrusive thoughts and of obsessional responsibility-taking. The obsessive person 'takes responsibility for' things that it doesn't even make sense to take responsibility for. I mean that quite literally: pushed to an extreme we start to lose track of what it even means to say that they are 'taking responsibility' in these situations. We can have some kind of a psychodynamic understanding of this: faced by an intolerable self-shattering anxiety they enact self-constructions which distort the relation between self and world so that a damaged self can take itself to have more agency and therefore control over the unpredictable beyond than it makes sense to have.

Now normalising is often very laudable, and clinically this seems to be a useful strategy, but phenomenologically speaking it's mighty suspect, and I can't help entertain the thought that, like several cognitive interventions, what is helpful in aiding the patient to return to some kind of relative stability may get in the way of deeper restructurations of the self. One could even say that normalising is the precondition of (im/possibility of) the whole psychological project, since psychology, restricted to talking about what is happening within minds and faculties, simply lacks the resources of existential phenomenology for theorising the character of deep disturbances of mindedness and faculty divisions themselves.

when the puzzle falls apart and can't be recovered

2009-11-20T23:05:00.005Z

There's a curious state, phenomenologically speaking, to be had when philosophising. I believe it to be best characterised by Wittgenstein's idea of being 'held captive by a picture' and then being set free from this captivity. And the curious thing is that one can then hardly understand what it was one didn't understand before. Hard to understand what the problem was, how one was confused; even to remember the whole problem. It has just dissolved.

I don't believe this state is unique to the resolution of philosophical puzzlement. It also seems to be shared by the resolution of psychotic delusion, the bursting of the bubble of transference, being relinquished from the grips of an unconscious phantasy, and moving from dream to waking consciousness. We know we've just been dreaming, but often struggle to say what about; perhaps sometimes, through the day, we have a vague sense of still living in its penumbra.

Right now I'm caught in a puzzle about the nature of historical explanation. I've not been reading up on it, so this isn't a scholarly post. I thought I'd rather try to note my puzzlement now, since I have an inkling that it may be on the verge of dissolution and I want to use this as an exercise in trying to 'hold onto the madness'.

I'm thinking about the nature of historical explanation (I know nothing about history itself). I want to know, or so it seems to me, what the causes of an event are - e.g. the causes of the first world war.

And then I wonder to what extent I will be satisfied instead by a purely hermeneutic answer. One which specifies the intentions of the agents. One which sheds light on the meaning of the actions. Which recharacterises the actions so as to make them humanly intelligible. Which deploys 'interpretation' as its methodology.

And so I'm tempted to contrast interpretative or meaningful explication with 'efficient' causal explanation. But I wonder now what about the actual causes of the war. The thought goes: ok, so we have what inspired the military leaders, what understandings were reached by whom and when. But is this all? Can't we ask about the causes as well as the meanings? What it was that 'brought it all about'?

Well, it occurs to me now that here I may be in the heart of the kind of puzzlement that wants for dissolution rather than solution. (But can I avoid losing a sense of my puzzlement? That is my goal.) And when I first wrote this post I went on quickly, at this point, to just urge a distinction between reasons and causes, and to suggest that the felt need to articulate a causal as well as a rational story was otiose, since what was really requested by the question as to the causes of the first world war would be best and completely aptly met by a justificatory explication. (I've also had another strange experience: I thought I should go and read up on the issue, and pulled von Wright's book on Explanation and Understanding off the shelf - and found he uses the same example of the beginning of the first world war. Perhaps it is a common philosophical example that I'd forgotten I'd previously encountered?) And I think I then just lost a sense of my own puzzlement.

Donald Davidson and Bill Child both insist, regarding psychological explanation, for example, that it's fine to be told what sense we can make of someone's actions, but we also want to know specifically what made the actions happen when they did. And let me admit (now following von Wright) that we can of course talk of the circumstances, geological and political and economic circumstances which obtained at a particular time and only given which would certain motivations for action gain traction. But to go and tidy it all up in this way now seems to me to risk losing a sense of my original puzzlement. (Like providing a sensible answer (which would in fact be an answer to a sensible but banal question) to a silly (but nevertheless deep) question - I risk just being shut up, rather than being understood, by myself.)

Somewhere around here is where we must 'condense a cloud of philosophy into a drop of grammar'. And here's the thought: It sounds strange if we say 'nothing brought about an action' but this is because it looks too much like a spooky empirical, rather than a grammatical or conceptual, proposition. It looks spooky because it looks now like we're admitting uncaused events into our ontology. But conceiving of actions as events is part of what is at stake here too. We (well, we secularists) don't find it weird to talk about unintended events happening. Let's try not to get similarly freaked out by talk of uncaused actions.

Understanding just what it means to say that ''actions are uncaused' is a grammatical rather than an empirical statement' helps resolve some of the tension here. If I'm right, it's like saying 'colours are weightless', 'emotions are without length or breadth', 'integers are priceless', etc. It doesn't mean that there are these mysterious goings on (they aren't 'goings on'!); it means that no meaning has been given within the English language to talk of 'causing actions'. Perhaps we could provide such a use, and extend our language game in new and interesting and useful (but not 'truer'!) ways. That's another issue though. For now the trick is to know when we've just been un/reflectively assuming that it works in ways which are as yet simply foreign to it.

Last gasp. I find my internal interlocutor now proclaiming: Yes, but Richard, we do need some way of understanding how the world of intentions and actions relates to the world of events and causes. I acknowledge the temptation to ask this, but I suspect that the question once again comes from a mind in thrall to the very conflations which generated the sense of puzzlement which has now left me when I was finding myself wanting to ask about not just the motives but also the causes of actions. Unpicking this is however the task for another day.

making a difference

2009-11-16T22:42:00.015Z

It is sometimes suggested that there is a perfectly innocuous sense in which an agent's reasons for action can be understood as the causes of her action. A sense which it ought to embarass the anti-causalist about action to not acknowledge and which - if this is all that may be meant by 'cause' in causal accounts - might also give them pause for thought about just what they had been so busy making a fuss about all this time...

That sense is the sense in which a cause is something which 'makes a difference' to what happens or what is done. To whether the action is or is not done.

In what follows I want to risk embarassment by trying to turn the tables on the causalist. What I'll suggest is that, apart from in senses of 'makes a difference to whether something is done' which are not at all intuitively understood as cases of causation, the explanatory function of the proferring of reasons for Jane's actions is not discharged through their citation aiding us in grasping that, were it not for the reason being proffered, Jane would not have done what she did.

Let me acknowledge from the start that people do not tend to act for no reasons. That however is surely part of the conceptual analysis of 'person' and 'agent' and 'action'. So in this most general sense having reasons 'makes a difference to' what we do since, if we are a being who has reasons, then we are also in the runnings for being a being who acts.

Now I don't think that this kind of quite general 'making a difference' is what the causalist who appeals to difference-making can have in mind. In fact it would be better to phrase the actual difference made here in terms of a difference to that we do (that we are agents) rather than to what we do. Here the general having of reasons plays a purely constitutive rather than causal role in the being of actions. It doesn't touch on the issue of the likelihood of any action being undertaken, but rather on the question of whether anything that was undertaken would deserve the epithet of 'action'.

The question remains though: should we understand the role of specific reasons as making a difference to the performing of specific actions? I want to deny that this is the case.

Let's start by pitching the causal account against a hermeneutic account of action explanation. The hermeneut says that reason-explanations work by situating an action in a broader context. The explanatory work is done simply by this situating, which situating allows us to re-describe what was previously not immediately intelligible for what it is in itself as something which is intelligible for what it is in itself.

The situating, as the hermeneut has it, is not a matter of the rendering intelligible of the occurrence of an event in terms of its typical causes. It is not a matter of its origination or servo guidance but of its identity. (Er, and yes of course you can describe something - it's identity - in terms of its causes or effects, but that's not the point here!) The kind of elucidation that a reason-explanation provides is a kind which is to come simply from this identification of the action as what it is.

One of the main ways in which this identity elucidation seems to occur is through the provision of teloi for the actions. John is going across the room to the fridge. "He's getting a can of coke". Ah - that let's me know what this going across the room is: it's a case of going-to-get-a-coke. I can now place John's actions within the 'space of reasons', in Sellars' helpful phrase. The hermeneut's claim is that this placing is all there is to reason-explanation.

(Of course, you have to place it correctly in the space of reasons! One of Davidson's arguments was that you supposedly couldn't distinguish between correct and incorrect such placements in the absence of appeals to causation. Ironic, then, that Davidson himself was unable to provide a straightforward criterion to help us distinguish between cases of supposed wayward causal chains in which reasons which allegedly cause actions do and do not also explain the said actions.)

The causalist however wants to say that there is something more in action explanation by reasons, and that this is a matter of actions not being performed were it not for the reasons in play. John would not have gone to the fridge were it not for the fact that he wanted to get a can of coke. This, it is suggested, is implicit in the very idea of his action being explained by the reason in question.

But is this true? What if, were there not any coke in the fridge, he would instead have gone and got a lemonade from the fridge? It is hard to see why the burden of ruling out this possibility should be placed on the elucidation which cited the coke-getting. (As I write I seem to remember that Bede Rundle has a similar argument in his book Mind in Action.) And this surely generalises to many situations.

Again, it is surely inconceivable that John would have acted thus in the absence of some such reason. But this, I want to say, is not a function of a fact of reasons being causes, but of the fact that John is an agent: a being who acts for reasons. Without reasons we would not here have a case of action or of agency or of a person called John.

Sometimes, of course, people do also act for no reason. These are surely the exceptions rather than the rules of action undertaking. Their existence is not a prima facie challenge for either the causalist or the hermeneut, since their accounts are of how we are to understand the ways in which actions are explained by reasons when they are so explained. However it is part of the causalist's account of action that a particular action would not have occurred were it not for the actual reason for it's being performed being unavailable. What they must therefore explain is how it is possible for people to act, on occasion, for no reason.

The hermeneut claims that when people do act for reasons, as they normally do, and as is constitutive of the basic idea of action itself, their action is not guided or caused by their reasons. These reasons rather provide us with extra information about the intrinsic character of the action. It is an action aimed at a certain end, or expressive of a certain desire, for example. James is playing the piano. Why? He's practicing for his forthcoming concert. Neither the practicing nor the forthcoming concert cause the playing. Nor, according to the hermeneut, do we need to think of James' intentions or desires as causing the playing. They, too, simply further characterise it.

James may very well not have been playing the piano if he had not had to practice for the forthcoming conference. (Let's imagine he just is a lazy fellow. Then on the other hand, perhaps he is not, and would have been playing it anyway.) Again, this is because James is an intentional agent. It is part of his nature to be an agent, which is to say, act for reasons. To gloss this in terms of 'something which makes a difference to what he does is' to mistake a constituting for a propitiating contribution.

I hope these considerations will make clear why it is not ok for the causalist to simply say 'But are you seriously saying that having such and such a reason made no difference to whether or not such and such an action was undertaken?' Once again, the argument is that people are beings the essential nature of which is to 'act for reasons'; that action itself is generally, as a rule, undertaken for reasons. So of course it is unlikely that, in the absence of the reason, we would have the action in question. It is possible, of course, as an exception to the rule, but unlikely. But the point is here that we do have to do with a rule, and not to do with a cause.

I hope they also show that it wouldn't be ok for the causalist at this stage to appeal to analogies of redescriptions which reference causes. Of course such redescriptions occur (think of explanations of the character of car parts in terms of their functional roles).
But that is part of an appeal to explicate what it might be for a reason to be a cause, rather than part of an argument which shows why we should think of them as causes. The hermeneut is not claiming that we have no causal analogies which, if the causal claim was required in the first place, could not then be appealed to. They were arguing instead that the context-placing, intelligibility-enhancing-through-character-revelation, nature of reasons is all there is to their explanatory power, and that this does not need to be augmented by considerations of causation.

To return to James, at the general level his having reasons makes a difference to that, and not what, he does (ie that he is a do-er). At the specific level of an individual action it makes a difference to what and not that he does (acts).

Consider what I want to suggest is a comparable non-reason-providing explanation which also works by context situation (Julia Tanney has comparable examples in her nice piece Reasons as non-causal context-placing explanations.) I see a fragment of text on a piece of paper on the pavement; 'toes' and 'cumber' it says. How can I understand it? Well, it's a fragment of a shopping list. The shopper was reminding himself to buy tomatoes and a cucumber.

The full words do not cause in the sense of makes a difference to the occurrence of the part words, or in any other sense of cause. To be sure, it is unlikely that someone would have written the part words if they had not been writing these full words, but not impossible. (Perhaps they were writing a holiday memo about being encumbered by mosquitoes.) But this is not because the full words 'bring about' the part words. Neither does mention of teloi, reasons, desires, intentions, or beliefs discharge its explanatory duty through the identification of something which brings about something else. In recharacterising the action, the talk of intentions etc. does not serve to reference anything at all other than the action itself in all its glory.

.........................

postscript on the logical connection argument

The Wittgensteinian claims that one way to distinguish reasons from causes is through the fact that the relata in a reason explanation of an action are not 'distinct existences' whereas the relata of a causal explanation of a happening are necessarily 'distinct existences'.

It is sometimes objected to this that a) we can explain what something is in terms of its causes or effects, and b) we can say that 'the cause of A caused A', that this is a causal explanation, and therefore non-distinct existences can be invoked in causal explanations.

Against these: a) yes we can. But we cannot then merely invoke this concept in a causal explanation. If a carburettor is (I have no idea what it is but let's say:) just that which mixes the air and fuel in a car, and you say to me: what causes the air and fuel to mix? and I say 'the carburettor', I think it pretty clear that I have not just provided a causal explanation. This is even clearer in b): to say that the cause of A caused A is not to explain how A came about. It is just to reiterate that it did come about without magic!

Further, we may (perhaps) be able to think of descriptions under which non-distinct existences can be considered distinct, or in which distinct existences can be considered non-distinct (as above with A). But the relevant concern is the 'descriptions' which must feature in the explanations of the action or event. If explanation of action is causal explanation, then it must be that the action and the explanans are distinct existences. This is what the hermeneut denies. An intention is related to doing X through its being an intention to do X; the connection is constititutive and ergo not causal.

why reasons aren't causes

2009-10-31T16:12:00.019Z

Donald Davidson gave us a reason for thinking that reasons had to be causes. Julia Tanney killed off his argument - but reports of its death have been greatly played down. I want to start to put this right, and also to challenge a successor argument by Bill Child.

Davidson starts by acknowledging that the rationalising force of reason-giving - coming to understand something by developing a grasp of how it makes sense - is not to be simply conflated with causal explanation. However what he tells us is that by reflecting on certain examples we can see how the rationalising force of reasons is not enough to explain their explanatory potency. This leads him to the prima facie implausible idea that a reason explanation (I turned on the tap so I could water the geraniums) is, despite its univocary appearance, actually an amalgam of both rationalising and causal powers.

What are these examples? They are cases in which someone might have two (or more) reasons for doing an action, but nevertheless act for only one of them. What is it that makes it the case that the one reason eventuates in an action but the other does not? Causation, Davidson says, is the glue that binds the reason (or the reason's representation in the actor's mind - or the 'primary [set of beliefs and desires] reason' of the agent) to the action.

Davidson, however, has made a mistake that we need more than rationalisation here. Let us start by acknowledging (as Davidson himself would) that we may act for more than one reason. Given this, if someone does indeed have two reasons for performing an action, the best question to ask (Tanney suggests - if I remember rightly a paper I read about 8 years ago!) is not 'What binds the 'operative' reason to the action?' but 'What renders the other reason inoperative?' When we ask this latter question, what we find is that the latter (inoperative) reason must have been rationally trumped by another goal of the agent. Far from needing an extra ingredient - causality - to hitch operative reasons to actions, what we really need is just a deeper understanding of the justificatory play of reasons.

George wants to go for a walk. Two reasons can be offered, both of which index genuine desires of his. First, he hopes to bump into Georgina who he fancies. Second, he could do with getting a bit fitter. George goes for a walk, and we discern that the only reason for which he acts is his hope that he may have an encounter with Georgina. How do we understand this? By positing causal glue between the fancying and the walking? Not at all. What we need to understand is why George's action is not in fact justified by all his reasons. Then we find out: George also has an essay to write. This trumps getting fit for him - but it doesn't trump meeting Georgina. And the 'trumping' here occurs in the space of reasons rather than the space of causes. It is the rationality of his action given his actual preferences, now revealed to us, that the reason explanation makes manifest.

Bill Child tried another tack for making the case that reasons be considered causes:

For any putatively non-causal explanation of an event, we can always make the Davidsonian point: knowing this story allows us to fit the event into a pattern which potentially makes sense of it; but we are still left wanting to know why the event actually occurred, what made it happen when it did.

Later on he suggests:

it is wrong to think that the Davidsonian argument depends on the idea that there are cases in which an agent acts for just one of two equally strong reasons. The point of the argument is that we need to understand the 'because' in 'She phi-d because she believed that p'. Suppose there is never a case in which S has two equally good reasons for an action she performs for only one of them. It is still true that the mere fact that S's attitudes made it rational to phi does not by itself explain her actually phi-ing. ... we must appeal to causation in order to understand the metaphysics of the relation between reason and action.

...the understanding we get from seeing that reason explanation is a form of causal explanation is a reflective understanding of the metaphysics of this form of explanation; we understand what sort of explanation it is, and how reasons explain actions.

...perhaps we can add strength to the intuition by showing how naturally we exploit the idea of causality in thinking of the relation between an agent's attitudes and her actions. For example, one way of producing a result is to produce in someone else a motive for bringing it about; by inducing attitudes in you, I can affect your actions and, through them, the world beyond you. It is hard not to think causally of the whole transaction, and equally hard not to think causally of each of its stages. The first stage is clearly causal; when I induce some motive in you, I am evidently affecting you causally. And it is equally natural to think causally of the relation between your attitudes and your actions. And that, perhaps, may go some way to vindicate the causalist's conception of the explanandum in action explanation.

Well, perhaps. But the old-fashioned Wittgensteinian anti-causalist is hardly going to be moved by an approach which simply assimilates actions to events (rather than holds out for an analysis both of them, and of their relevant accountings-for, as sui generis in character), which supposes from the start that explanations of actions are interested in accounting for just why they occurred when they did (perhaps reason explanations are not that specific!), which also denies from the start what the Wittgensteinian suggests: that putting an action (which might not best be thought of as an 'event' or happening) in the context of a sense-making pattern precisely provides us with knowledge of why it was undertaken (if not of why it 'occurred'; similarly we wouldn't expect to explain why events are undertaken since it's only actions which are undertaken), and which in the process construes the art of rational persuasion as a matter of the 'production' or 'induction' of attitudes in someone else. (Although the point of the Wittgensteinian's analysis, it ought to be said, was not to issue a fatwa on the use of causal rhetoric in action-intentional context (although for the causalist to use it to vindicate an argument is a bit rich!). It was rather to suggest that a.) assimilating reasons and causes obscures more than it illuminates, and b.) that some of the reasons why we may feel compelled to bother offering causal analyses in the first place have (historically at least had) more to do with the unwarranted assumption of an estranged conception of the relation of (a disembodied) mind and (a deanimated) body in the first place, a relation which then will seem to be in need of causal glue to link together what the analyst has unwittingly sundered.) Further, no-one (so far as I know) has suggested that the mere fact that it would be rational to act for a certain reason makes it the case that someone acts for the reason in question (the reason needs to be theirs).

What then makes it the case that what could be a reason for someone to act is in fact one of the reasons - one of their reasons - for their action? In answer to this question the anti-causalist is typically happy to cite the kinds of factors which the causalist themselves would, if they were not beguiled by estranged and decontextualised conceptions of mindedness and embodiment, presumably also want to cite - such as the agent's ownership of the reason (do they cite it when asked? for example), or the meaningful contextual character of the situation of their action (the arm raising occurred in the context of a bicycle turning manouvre - John raised his arm in order to signal his exit from the main road). All they hold on to is the (alleged) fact that adding causation to the analytic mix is de trop.

This, the anti-causalist will claim, is just what it is to 'understand the 'because' in 'she phi-d because she believed that p''. We receive the kind of illumination we get when we see what the action in question really is: what the smaller fragment which eluded our prior comprehension is a fragment of. (If someone asks: "Well, and why is that illuminating?", then I think I'd just have to say the same about causal explanations: "Why are they illuminating?" The truth is: these just are what amount to two modes of understanding here: we need to understand what it is to 'understand something' in terms of such particular explanatory endeavours, rather than take it that we possess some prior notion of what 'understanding' consists in which can then be wheeled out in questions such as "And why [what do you mean "why"?] does this count as 'understanding'? ) Causal explanations and reason-giving explanations simply are - on the Wittgensteinian position I am recommending - to be considered two separate sui generis forms of explanation, and there's little sense in analysing either in terms of the other. If however what it is to understand a 'because' in either context is to apprehend something more than the differences between these conceptual contexts - for example, to be able to provide a reductive analysis of the concepts bound up in one form of explanation in terms of quite different concepts - then the anti-causalist of a Wittgensteinian bent will simply reject the project ab initio. Why should we even think such an analysis was necessary or desirable?

campbell's causal control criteria

2009-10-28T13:36:00.009Z

John Campbell gave a talk last night at the Oxford Philosophy Faculty. He talked about the nature of causal relationships, with particular focus on psychological causation. Against those who view causation purely 'extensionally' as one might say - as a fact about the relationships between (say) microphysical aspects of the world, relationships which may be very complex and leave quite unsatisfied our demands for straightforward and simple causal understanding - Campbell seemed to tie the nature of causality itself to that which is explained by satisfying causal explanations.

In particular Campbell explored the nature of 'control variables'. The idea here is that we can rightly claim to have identified the cause of something (e.g. what causes the volume of a radio to increase is the volume knob being turned) when the explanans stands in the relationship of a 'control variable' to the explanandum. I don't recall all of the characteristics of these 'variables', but they include the notion that there should be no gratutitous redundancy, a total mapping of causes onto effects, a dose response, and a ready computability of the cause, etc., in bona fide causal explanations.

Upshots of Campbell's view include the idea that there can, even in a 'deterministic physical universe' be non-physical (i.e. psychological) causation (since the best explanation of most human behaviour is psychological rather than physical: psychological factors behave more like control variables for behaviour than do microphysical brain states). This, to say the least, challenges in a very interesting way some of the presuppositions of mainstream physicalist philosophy.

An obvious worry - that was reflected in at least two of the questions (I had to leave after a few of these) - with Campbell's position is its apparent 'anthropocentrism'. One way to put this worry is to say: Campbell seems to be trying to derive a metaphysical conclusion about the nature of causation itself from explanatory considerations - about what we (humans) find explanatorily satisfying. This is a move which many hard-nosed metaphysically-minded sorts will want to resist.

Despite the worry, I find myself attracted to Campbell's position - mainly because of the easygoing, unpretentious way it pricks the side of the 'oh-we're-so-hard-nosed-and-scientific' contemporary physicalist philosopher of mind. And so I naturally wonder what a good defense of what may appear to be its anthropocentric bias might be.

I found myself thinking of the ways in which Wittgensteinian conceptions of the relation of meaning to use, or of the nature of the will, or of the relation of perception to its objects, have been defended against the objections to them lodged by Grice et al. The Wittgensteinian attempts to draw conclusions about what is intelligible - conclusions about meaning, what it makes sense to say - from premises about what people would say in various situations. For example, they would say that there are many situations in which we would not describe someone as trying to perform some action (because it's so easy and they just succeed straight off 'without having to try'). This then is used to count against theories of action which suggest that intentional action just is, at a minimum, action which we are trying to do.

The Gricean says: 'Well, just because we wouldn't it doesn't mean it's not true. Perhaps we don't say it because it's just too obvious - it goes without saying - it's already implied in the conversation.' Against this the Wittgensteinian (e.g. Glock in his Wittgenstein Dictionary, p. 389) may claim that it's hardly less obvious to say that John is trying to tie his laces when he struggles and fails than when he effortlessly succeeds. The fact of his trying is in truth far more patent in the former case.

Just as the Gricean seems to want to extend talk of (say) 'trying' to a whole gamut of cases - regardless of whether we would normally find it helpful to locate trying there - to the end of providing us with an objective account of what makes for intentional action, so too the metaphysician seems to want to extend talk of 'causation' to a whole gamut of cases regardless of whether we would normally find it helpful to cite the cited events in explanations, all to the end of providing an account of what makes for the happening of happenings. In both cases they find themselves tempted to say "In restricting your talk of 'trying' or 'cause' to those cases in which talk of causes or of trying is genuinely informative, you are merely demonstrating your anthropocentric bias."

By contrast the Wittgensteinian could reply: "The burden of proof lies not with I but with you. You are assuming that I am being anthropocentric (letting my sense of what counts as a good explanation get in the way of my ontology), but I am claiming that the concept just is like that. You are trying to remove it from the context which gives it its life in the first place. It's not that I'm giving a biased account of what a cause can be. It's that you are giving a misleadingly broad account of causation. A cause isn't to be defined as that which features in a satisfying causal explanation (that would just be circular), but we can look at which explanations are and are not successful in specifying causes to give us a good sense of what a cause is. (After all, as I seem to remember Campbell saying, causes just are that which are cited in causal explanations.) In your desire to secure the objectivity of genuine causality you try to distance it from human concerns, but unwittingly thereby also uproot it from its sense-conferring context of application."

Campbell's homely account of causation, to the extent that I understood it, brought that concept nicely back down to earth for me. That process was also helped by Wittgensteinians such as Anscombe - who talk of the ways in which pushing and pulling and cutting and startling are causal notions which jointly determine what is meant by causality (rather than instantiating some further hidden connecting phenomenon called 'causation'). As a result I find myself less inclined to turn to some special discipline called 'metaphysics' to help me work out what that mysterious causal relationship 'really' consists in. Causation is now even more than ever just one of hundreds or thousands of (albeit abstracted) concepts jostling around our richly elaborated form of life.

psychotherapy and prostitution

2009-09-12T17:29:00.009+01:00

Sometimes it's proposed that psychotherapy is really a form of prostitution. (R D Laing suggested it, for example - as more recently has Rupert Read.) The suggestion, I believe, is usually intended as a criticism of psychotherapy. The force of it derives from the supposedly morally repulsive idea of paying for something - in this case a human relationship - which, just through this very fact of payment, allegedly degrades the character of that - the relationship - which is bought. That 'you can't buy love' is, it could be said in a Wittgensteinian spirit, a 'grammatical' remark about the concept of love. (But then, people don't go to prostitutes for love - they go to them for sex. And they get it.)

In any case, I don't terribly mind being thought of as a prostitute - if that's just what it is to offer psychotherapeutic services. But in fact the comparison seems a little weak to me. For it isn't that one is (impossibly) buying the friendship of the therapist - that is never on the cards. What is rather being bought is a service which, if it goes well, will make possible the establishing, say, of meaningful friendships again - or for the first time - or friendships of a richer quality - by the patient. What is being paid for, then, is a certain kind of relationship of a different order which serves to clear the way for friendships of the usual order.

The good therapist will be boundaried; they will not excuse bad behaviour in the name of psychological distress or trauma. They will 'call' the patient if they act disrespectfully; they will not do them a disservice by letting them 'get away with' dishonourable acts towards the therapist. Yet again, they work to clear a space for regression, they tolerate it to the utmost, they strive to locate the humanity of the patient within or behind his or her hysteria. First regression, then progression anew. Troubles are 'worked through'. Conversations which arouse defensive anxieties and all the difficulties these generate are positively encouraged, made space for. In friendships troubles are shared; therapeutic relationships are designed to (re)establish the embodied conditions of possibility of such sharing.

The patient is an adult who is paying another adult to function in ways akin to a parent. In ways akin to a parent, but also in ways akin to another non-parental adult at the same time. That is the trick of therapy - to pull off both those roles simultaneously. That is what is being paid for. (Perhaps we could even argue that to not pay for therapy would be odd, potentially reducing it to the status of an attentive and oddly asymmetrical adult-adult relationship.)

The sex therapist will sometimes call on the services of a 'surrogate' - i.e. of a person experienced in sex with whom the patient can practice as they develop their confidence in their own sexual performance. Payment here is essential to the meaning of the interaction for the patient. They are buying the surrogate's patience, they are buying their non-intimacy. Unlike the prostitute the surrogate functions as a way-station for someone who is trying to emerge from solitude into an intimacy they find overwhelming. Sexual relationship, and not sexual relationship, at the same time: that is what is being paid for.

I believe it is more accurate to describe my own practice as surrogacy rather than prostitution. The person who visits a prostitute is just getting a quick fix of something to satisfy their immediate desires. I hope I do not function as an emotional palliative for my patients. Sometimes, in fact, the session may be more painful than pleasurable. To function as a therapeutic prostitute would be to engage in giving the patient the temporary illusion of an adult-adult relationship - in other words, to collude with their narcissism - only to leave them just as vulnerable as ever in those real-world encounters from which they will typically shy away. To function as a prostitute would be to try to merely bolster their self-esteem, make them feel better, let them (even despite their better selves) get away with bad behaviour 'because they are paying for it', etc. To function thus is to function anti-therapeutically, and this is the real failure of the 'prostitute' analogy.

To function as a surrogate, however, is to provide something which is explicitly understood as on-the-way to elsewhere - as an inbetween of defence/phantasy and reality, as a stepping stone to real relatedness. That role is not best captured by the literal meaning of 'surrogate' - a mere stand-in for the real-thing, but rather by an appreciation of the surrogate's role in an ongoing, therapeutic, adaptive process.

psychotherapy and the ethics of acknowledgement

2009-08-20T15:04:00.040+01:00

For a talk at the forthcoming 'Fifth R. D. Laing Conference'...

1. In his paper Pat Bracken charts the unwitting suicide of the evidence-based medicine (EBM) paradigm in psychotherapy. Large-scale studies have found evidence that, when we consider the psychotherapy of people judged 'depressed', therapeutic success has far more to do with the putatively 'non-specific' - than with the specific, technical - factors in the therapist-patient relationship. What really matters, that is, are not so much the model-driven 'interventions' of the therapist - 'interventions' which the EBM paradigm has done so much to assess - but rather the quality of the therapeutic relationship, as well as client-specific factors. So: whilst so much of the evidence-based paradigm is concerned with documenting the efficacy of this or that specific intervention, the research as a whole itself shows us that it is not these technical interventions that are doing the majority of the work.

Perhaps I should start by voicing my own perspective on this. I want to note first that the research Pat cites is research on the therapy of patients judged 'depressed'. It is not concerned with patients struggling primarily with circumscribed anxiety difficulties, for example. My own clinical experience is that patients 'with depression' seem to benefit less from an approach in which therapeutic techniques are derived rationally from models of psychopathology than do patients diagnosable with discrete 'anxiety disorders' such as OCD or panic/agoraphobia or various phobias. My own limited experience is that (CBT and mindfulness) techniques can be very useful for a substantial majority of this latter group of patients, especially when they are otherwise secure and intact in their emotional functioning, whereas they seem to add little to a person-centred, dynamically informed, therapeutic stance - a stance characterised by the listening therapist's restrainedly making their own humanity maximally available to the patient - for those who struggle with depression.

In what follows I want to pursue a line of Pat's presentation further, and to consider whether - and if so in what sense - it may not be merely a fact, but a necessity, that good therapy often cannot be reduced to the performing of technically good interventions. I shall prosecute this through first considering the significance of the therapist's ability to recognise the patient's individuality. (The philosophers Raimond Gaita and Cora Diamond will be my philosophical guides in starting to unpack what such recognition and such individuality amount to.)

The patient's individuality is often put forward by psychotherapists as a reason for the inapplicability of therapeutic approaches based on the application to the individual of generalisations derived from research on groups of individuals. I think that such arguments, while (probably, usually) representing attempts to articulate a perfectly apt intuition, often end up making a mistaken empirical point (for the details as to why this point is indeed mistaken, see Gloria Ayob's (2008) Do People Defy Generalizations?: Examining the Case Against Evidence-Based Medicine in Psychiatry in PPP, 15, 2, 167-174). The articulation goes awry because the arguments have often already unwittingly conceded too much to the EBM paradigm - conceded too much through making use of what I shall call 'empirical' rather than 'ethical' conceptions of the patient's individuality and its recognition by the therapist. What this all means will be explained later in my presentation.

2. The standard 'but everyone is unique!' argument against using an EBM approach in psychotherapy goes as follows: "You want me to apply this research-based bit of advice in my clinic. But in my clinic I see a lot of individual cases. As such they have their own unique difficulties and their own unique historical trajectories. Therefore it's meaningless to try and treat this person as an instance of a general type. That misses out what is particular about them - and their psychopathology is inevitably bound up with their particularity. To understand the individual person we must use an idiographic mode of comprehension, to see how they uniquely have been formed, and how they uniquely can be helped. It would be unethical to apply EBM approaches since these are not tailored to the individual, and as such would just not be effective in helping them achieve their own goals."

I will come on to the question of ethics later on. For now I want to note that the argument as presented depends upon a (to-my-mind dubious) empirical premise: People are just too dissimilar to one another in their personalities and in their troubles to warrant the application of general methods. But is this true? And how often is it true? After all, the EBM pundit is not claiming that using their technique for someone who meets a particular diagnosis will always lead to success. What they are claiming is that it will lead to success often enough - let's say, 7.5 out of 10 times. Unless we can claim better success rates for our idiographically derived treatments, then we should just shut up and practice evidence based therapy.

Furthermore, if this really is the argument, then why not just compare a version of therapy designed to tackle particular problems against a version which relies on individual clinical judgement derived purely from particular case formulations? The idea that one would come out tops is a perfectly empirical postulate, and readily testable. What it isn't is something that should just be evident from argument alone - something that can just be said by way of defence of one's own practice, for example, during a conference.

I want to note too that it had better not be the case that idiosyncratically tailored treatments - treatments designed to accommodate this particular individual with his or her particular difficulties and particular history - function just as well as, but no better than, the EBM treatment. If our argument is that the EBM techniques do not attain to the requisite level of specificity to meet the individual needs of the individual client, then it ought to be the case that an individual-case-formulation-based approach should meet those needs better. That is a direct implication of the above argument which treats what it is to be an individual to be an individual case - even if a case of a class which has only a few - perhaps only one - member.

On this 'empirical' approach to the individuality of the patient - this approach which takes the form of individuality which matters to us here to consist in the idiosyncrasy of the patient's history, character, beliefs, etc. - the connection between the ethics of the psychotherapy relationship and the patient's individuality can only be construed as 'external'. What I mean by this is that the only significant reasons why it would be considered morally better to treat the patient 'as an individual' are, on this approach, to be located in the prior framework for, and the posterior upshot of, the therapy.

First the framework: follow your professional code of conduct, be respectful to the patient, do not abuse your power, and treat them as you would treat anyone. This provides a background moral framework against which treatment is to be provided: it isn't itself typically understood as a piece of distinctly clinical advice.

Second the upshot: treat the patient in such a way that their presenting problems will be most speedily and successfully remitted. Here the best analogy would be with medical practice: provide that treatment which has the best chances of success. The therapy is morally good or morally bad depending on how it leaves the patient. A doctor or therapist who practices forms of therapy that don't work, or don't work very well compared to ones which do, is practising in a straightforwardly unethical manner.

I do not wish to criticise either of these moral principles: of course we should be generally humane, and of course we should not provide treatments with less than optimal outcomes. What I wish to say, however, is that this 'professional ethics' reading of the connection between ethics and psychotherapy is banal. It fails to explore the possibility that there is a more intimate connection between therapy and ethics - fails to explore the possibility that it might be illuminating to consider whether there is a sense in which one might meaningfully and truthfully say "therapy is ethics".

There is, I believe, something very convenient about this exclusion of the ethical from the heart of psychotherapy for the practitioner. The convenient implication is that to act ethically all one has to do is to act professionally (follow your professional body's code of conduct, aim for optimal outcomes, and there you are). Therapy itself now becomes all technique - practised in a humane way, of course - and the moral probity of the practitioner becomes a straightforward matter requiring little or no reflection. Knowing that we have met the ethical standards of the code of conduct and the technical standards of the therapy manual is knowledge that is not too hard to come by. (Good therapy, I want to suggest by contrast, constantly has the practitioner calling him or her self into question. Did I really understand, did I really offer acknowledgement, did I really make myself available or take myself out of the way? If anyone thinks such questions can be answered with any confident certainty they have probably just missed the trick about what it is to live an examined life.)

I shan't pursue the following thought in detail here, since I believe it better honours Laing's memory to use a paper at an 'R D Laing conference' to pick up his themes anew than to retrospectively mull over his thought or his person. But - briefly - it strikes me that much of R D Laing's work and thought can be seen as an enacted repudiation of this professionalised approach to the ethics of psychotherapy. (Importantly, Laing also repudiated the idea that therapy consisted in any set of techniques - I shall ***???*** return to this in the final section.) Laing's trickster identity led him to counter the banalising effects of professionalism by acting in deliberately unprofessional ways. This, I believe, served to highlight - for those with ears to hear - what I am arguing is an aspects of the ethics of therapy which professionalised approaches leave untouched: the ethics immanent in the authentic therapeutic encounter itself, an encounter which professionalised approaches tend to render merely humanely and technically managed. For those without such ears, all that was heard in Laing was his unprofessional manner, the GMC investigation, and so on. (This, it seems to me, is the danger of deploying the trickster approach - its failure to save those who most need it - those damned by their own institutionalised banality.) At any rate, in what follows I start to unpack the 'who' of this authentic ethical therapeutic encounter.

3. I now wish to outline an account of individuality - I shall call it an 'ethical' account - an account of 'individuality' as an ethical concept - which lies in contrast to the above-described 'empirical' concept of a numerically distinct individual with qualitatively distinct psychological attributes. (It is here that I shall be drawing heavily on the work of the above-mentioned philosophers Cora Diamond and Raimond Gaita.) I shall start by considering philosophical considerations before moving on to consider psychotherapeutic ramifications in section 4.

To rehearse a point made above, what it isn't to be an individual human being, in the (ethical) sense of 'individual' which concerns me here, is to be a particular member of the species homo sapiens, nor is it to have empirical characteristics which serve to distinguish one from one's conspecifics. Neither my numerical identity (I am this singular person here, not you, that one over there) nor my biological or psychological qualities (I have such-and-such skeletal or postural attributes, such-and-such a profile of neuroticism or extraversion, an IQ of 80 or 130, weak or strong ego boundaries, a poor self-image, this or that profile on the BADS or WIMS or TAT or Rorschach, these beliefs and those desires, etc.) constitute my individuality. But what then is it to be an individual in the ethical sense? What is it that we recognise when we show recognition of someone's essential individuality, and what is it to recognise this?

One unhelpful way to answer this question is to search for objective facts about people which constitute their individuality and which warrant our ethical recognition of one another. This is not to say that certain facts about us do not condition our practice of acknowledging individuality. Take the living bodies and faces of others, physiognomies capable of embodying character, faces capable of expressing emotion, faces which can show moral as well as physical wounds - - without these we should struggle to ethically encounter one another. (We struggle to show instinctive solicitude for those creatures which least embody the human form.) A certain unity of experience and memory - both autobiographical factual memory, and the 'memory' of sedimented habits of motion and emotion - provide some foothold for our ethical appreciation of one another. Yet there would seem to be nothing in such objective facts about us that compels us, in the way in which a demonstration of right- or wrong-headedness would wish us to be compelled, to offer one another recognition. (That, perhaps, is why ethical recognition is offered - it neither consists in, nor rests upon, our exercise of extra-ethical cognitive skill.)

Philosophers have tried various idioms for articulating our ethical individuality. For Kant it was an essential part of a viable (i.e. non-consequentialist) ethics that we untreat one another as ends in ourselves, and not merely as means to ends. "Act in such a way", he said, "that you treat humanity, whether in your own person or in the person of any other, always at the same time as an end and never merely as a means to an end." To recognise another's individuality, then, is not so much to become acquainted with some fact about them, but rather to act towards them in a particular way - to treat them not merely as means to ends, but as ends in themselves.

Gaita tells us that to see someone as an individual is, in part, to see them as an intelligible object of someone's love. We may not be able to love them ourselves (perhaps they have terribly hurt someone we do love), but we must at least, if we are to be able to acknowledge their individuality, be able to see them as lovable by someone. Gaita also draws out internal relations between the concepts of an ethical individual and friendship; to see a man as an individual:

he must be seen as someone who is subject to the demands which are internal to friendship, as someone of whom it is intelligible to require that he rise to those demands, no matter how often he actually fails to do so. That is compatible with him being such a nasty fellow that nobody could befriend him, for it is to see his nastiness from the critical standpoint of what is required for friendship. He is not like a bad-tempered dog.

Our offering recognition to one another shows itself in a range of further facts such as (those noted by Diamond:) that we give our children names and not numbers, and that we have respect for people, and treat them in a particular way, even when they are dead. It may also be brought out in talk of the moral preciousness of any individual's life, or of the essential irreplaceableness of any true person. By 'preciousness' here I mean the 'infinite preciousness' of a person - the fact that their worth is necessarily immeasureable. Individuality is reflected in the fact that if I wrong you, then what I feel remorse for, if I do, is not that I have broken some general moral rule, nor that I have decreased the stock of happiness in the world, but rather that I have hurt this particular person - you. Similarly with grief: a mother who grieves the loss of one of her four children may have grieved equally deeply if she lost any of the others. Nevertheless, in this instance, it is precisely for this particular child that she grieves - she does not grieve for her loss, but for this child. (Such examples bring out the meaning of Kant's above-cited categorical imperative far better, it seems to me, than any abstract formulation regarding 'ends' and 'means'.)

There is a further feature of our individuality to which I wish to draw our attention. This is reflected in the necessary limitations of the scope of psychological discourse, and has been expressed most cogently by the philosopher Ilham Dilman. If I am treating someone as an individual, then I am treating them as someone with an inalienable authority over their own motivations and intentions. This is not to doubt the applicability on occasions of explanations in terms of unconscious motivations or emotions or intentions, and not to doubt that, on occasion, we may be in error regarding our own desires. Nor - I believe - need acknowledging this authority saddle us with implausible theories of mind, such that we start to take it (as an 'epistemic realist' might) to arise either from putative direct introspections of our inner motivations and intentions, or (as a 'constructionist' might) from an alleged constructive power that the act of avowal has to shape the contents of our hearts. (Avowals neither report nor construct - but rather avow! - that which they express.) However it does require us to suspend the hermeneutics of suspicion that would have us see every utterance or action as a function of someone's psychology, and instead to see a good part of them as a function of their person.

To see someone as a person is, I suggest, to see her as somebody who, at least in part, or at least potentially, has her sight set on the true and her heart aligned to the good. To see someone as a person is to see their thought and action as (to redeploy some of Donald Davidson's terminology) potentially 'regulated by the constitutive ideals' of the good and the true. Hearts and minds may be corrupted, but what it is to have a mind or a heart is to be someone who seeks out the true or the good. To be able to offer someone recognition is to be able to hear what they say as a sincere expression of what here they have to say - as a sincere expression of their thoughts and feelings. Acknowledging their individuality is, then, acknowledging the necessary limit here to explanations of their behaviour which reference unconscious desires and motives.

None of this is to say that, were we to fail in this endeavour, the cause of the failure need be all our own. Perhaps we are confronted with such a despicable psychopath that we cannot - to use Gaita's criterion - discern how to view them as an intelligible object of anyone's friendship or love. Their heart and mind are so perverted and corrupt that we struggle to locate their humanity, struggle to know even how to offer them recognition. The above brief sketch of what it is to offer someone acknowledgement does however lay out the task ahead of us, in any encounter worthy of the designation of 'ethical'. In what follows I shall consider the extent to which a pursuit of the ethical, thus understood, lies at the heart of the therapy relationship.

4. In his paper, Pat Bracken describes how it is that what the EBM paradigm purports are the 'non-specific' factors have been found,time and time again, to be by far the most significant therapist contributions to therapy for people diagnosed with 'depression'. In what follows I shall suggest that these factors - which are I believe often thought of rather vaguely as something to do with the warmth of the therapist's manner - how friendly they are, for example - can be better understood as reflecting the therapist's capacity to offer ethical recognition to the person who is their patient.

Such a perspective suggests itself in the writings of Carl Rogers, who provided us with a set of ('non-specific') factors concerning the attitude that the effective therapist takes towards his or her patient. In fact he considered these to both be essential elements of any genuine human and humane relationship, and he considered too that the formation of such a relationship was the key to therapeutic success.

The factors Rogers cited were:

congruence: ‘It has been found that personal change is facilitated when the psychotherapist is what he is, when in the relationship with his client he is genuine and without “front” or façade, openly being the feelings and attitudes which at that moment are flowing in him.’

acceptance / unconditional positive regard: ‘when the therapist is experiencing a warm, positive and acceptant attitude toward what is in the client, this facilitates change. It involves the therapist’s genuine willingness for the client to be whatever feeling is going on in him at that moment – fear, confusion, pain, pride, anger, hatred, love, courage, or awe. … he prizes the client in a total rather than a conditional way. … without reservations, without evaluations.’

empathic understanding: this is ‘when the therapist is sensing the feelings and personal meanings which the client is experiencing in each moment, when he can perceive these from “inside”, as they seem to the client, and when he can successfully communicate something of that understanding to his client’

Now there were elements of humanistic psychology at which Laing baulked, and at which I find myself baulking too. (It's version of self-realisation, for example, as well as degenerate versions of empathy (i.e. parroting what the patient says back to them).) But, so long as we do not offer an uncharitably trite interpretation of what 'unconditional positive regard' amounts to, nor demand that it should be present more than the therapist's 'congruence' could allow, then I suspect that there is little that could reasonably be said against these factors as significant elements in what makes therapy therapeutic.

But what I wish to urge here is that these factors are precisely what it means to offer ethical recognition to the patient. In other words, to be in touch with a patient as a unique and 'infinitely precious' individual, to do genuine justice to their individuality, just is to engage with them with the kind of solicitude outlined by Rogers' three factors of empathy, honesty and unconditional acceptance. The unconditionality Rogers mentions, for example, might at its worst be merely a suspension of judgement where judgement is due. This, it could be said, is a way of taking 'unconditionality' as an empirical feature of a therapeutic relationship: I think you're being unreasonable but I prevent myself from saying it. Or I would think that you were being unreasonable were it not for the fact that I've learnt to suppress my own judgements, shut down my own critical faculties, to the supposed - and misguided - end of 'being therapeutic'. But at its best, 'unconditionality' will not represent any such merely empirical function, but rather function transcendentally to constitute whatever it is to acknowledge another's individuality. The question is: can I allow myself to view you under this aspect - under the aspect of a uniquely and infinitely precious human being? Can I find this in you - but more importantly, can I find what allows for this perspective in myself? Can I bring myself to be fully alive and present - to bring myself spontaneously and unguardedly online - in this moment, to offer a recognition of your humanity by means of drawing fully on my own? Offer recognition of what you spontaneously offer me by responding from my own capacity for spontaneity?

Rogers acknowledged that when he put aside all thought and especially all theory, and approached the patient with wholehearted devoted attention, his therapeutic powers were enhanced (. He talked of his 'complete subjectivity', of how he 'let my self go into the immediacy of the relationship where it is my total organism which takes over and is sensitive to the relationship, not simply my consciousness. I am not consciously responding in a planful or analytic way, but simply react ... based on my total organismic sensitivity to th[e] other person. I live the relationship on this basis.'). Martin Buber, reflecting on what it is to meet someone as a 'you' - as another subject rather than as an object, comments that

The relation to the You is unmediated. Nothing conceptual intervenes between I and You. No prior knowledge, and no imagination. And memory itself is changed as it plunges from particularity into wholeness. No purpose intervenes between I and You, no greed and no anticipation. And longing itself is changed as it plunges from the dream into appearance. Every means is an obstacle. Only where all means have disintegrated encounters occur.

Bion put it more pithily: our task, he suggests, is simply to 'listen without memory or desire'. This mode of listening was, for him, a way of affording him a faith in his own unconscious - in its capacity to respond directly to the unconscious of the patient. By 'unconscious' here Bion meant not a sphere of repressed desire, but rather, and amongst other things, a mode of mental functioning which dares to be playful and associative.

For all three authors, albeit with their different understandings of the work of healing in therapeutic relationships, therapeutic listening involves: listening with one's whole being, attentively, in a manner unmediated by thoughts of case formulation, without deploying special techniques, without explicitly trying to recall what was said before, in the absence of desires to have the patient reach a certain goal. It means meeting the person of the patient in that moment, and meeting them from a point of maximal involvement with them rather than with one's own thoughts.

In characterising the nature of that meeting it is far easier to say what it doesn't involve than to say what it does. I think this is not to psychotherapeutic theory's detriment. When Rogers, for example, tries to be more explicitly positive in his characterisation of therapeutic listening, he tends to risk becoming off-puttingly, humanistically, cloying. Rather than simply having an unconditional regard for our patient, we are invited to have an unconditional positive and warm regard. (This appears to risk contradicting his own emphasis on the significance of 'congruence'.)

By sticking to Bion's 'listening without...' formula we do better. The goals of therapy involve being able to 'relate without...' i.e. to engage with others without using defences. They involve too being able to 'be oneself', which means, again, simply an absence of certain neurotic fears which incline us to the use of contrived self-presentations. Some of the means of therapy - the listening without: trying to be clever, trying to explain, keeping an ear out for the data which will confirm one's theory, theorising what is being said - have a similar logic. In the final section of this talk I shall discuss this logic further, and explore analytically how it resists codification.

5. I started this talk with an appreciation of Pat Bracken's critique of the idea that specific psychological techniques provide the means for treating individuals struggling with depression. Over against such techniques Pat stressed the importance of the non-technical therapeutic relationship. I now want to finish by considering what could be said to someone who wished to attempt to turn the provision of that relationship itself into a technique. I (perhaps inaccurately) recall a passage in a book on Treating Affect Phobia I have that recommends going 'mmm' at certain points in the interview to convey understanding and empathy. That will strike anyone with ears to hear as righteously absurd, but I wish to ask now why this is so. Is it merely because, if we are thinking about what we ought to be doing, then we are less likely to be really listening to them? That is, is the uncodifiability of relationship merely a function of the contingent limitations (in attentional resources) of human psychology? Or is there something more principled at stake here: that the provision of true relationship cannot be codified, as a matter of what it means to enter into such relationship?

This at any rate is what I should like to suggest. In Buber's words, to attempt to codify relatedness would amount to attempting to reduce an I-Thou relationship to an I-It one. (I do not mean to say that one should not engage in both forms of relationship with one's patients, nor that a certain kind of movement back and forth between the two will not be highly productive at times, nor that I-It thinking may sometimes be helpful to clear the way for I-Thou modes of relating which have become thwarted. What I am concerned with here, however, is with the question of whether human relatedness could itself be codified.) I suggest that this is impossible, and this is not because we can't imagine deploying some set of rules which if the therapist deployed them, the patient would feel recognised, but because to deploy such rules is just not to respond to the patient, but instead to respond only to what they say or do. It is not to meet them as a person, but to (somewhat immorally - cf Michael Morris, The Good and the True, p. 116) build an explanatory or predictive model of their behaviour.

Buber writes, in defining what it means to relate as to a Thou: 'The relation to the You is unmediated. Nothing conceptual intervenes between I and You. No prior knowledge, and no imagination.' By 'imagination' here I suggest that Buber means: no imaginative projection of myself into your shoes. When I listen to you qua Thou, I discern straightway what it is like for you to be you - not what it would be like for me if I were in your situation. I do not, that is, first imagine what it would be like to be me were I in your shoes, then ascribe the output of this 'simulation' to you. I stress this here because I do not believe for one moment that Buber meant to deny imagination an essential place in our understanding of one another - only to state that such imagination should not function as a mediating, intervening, step between listening and understanding. To suppose that it would do is just to view you as another instance of a being like myself - and to do this is to fail to respond to your individuality.

Again, the relevance for the present discussion is not the likelihood of any such imaginative simulation-gained understanding being true or false. I may be correct 100% of the time in my making of such sympathetic inferences. Or perhaps I rely instead on 'prior knowledge' of what people in situation Z who report X are likely to feel or think or do or say, and I use this to explain or predict your behaviour with perfect accuracy. Again, I do not believe for one moment that Buber meant to deny our accumulated knowledge and prior experience of humanity a role in our understanding of one another. The point is whether such knowledge is to function as an intervening or mediating factor in my relationship with you when, truly listening to you qua Thou, I hear the meaning of what you say. Rogers' point, to reiterate, was not that listening to someone as if to an It made for poor individualised formulations and hence poor therapeutic interventions. It was rather that listening to someone as to an It made for poor therapy, since good therapy just is listening to someone as to a Thou.

Let me follow up this point regarding the relevance of the accumulation of knowledge to the therapist's activity, as a way of concluding, and summarising some of the main themes of, this presentation. In his essay 'Paradox and Platitude' (quoted by Ilham Dilman in his essay Science and Psychology), the philosopher John Wisdom wrote of how

It is, I believe, extremely difficult to breed lions. But there was at one time at hte Dublin zoo a keeper by the name of Mr Flood who bred many lion cubs without losing one. Asked the secret of his success, Mr Flood replied 'Understanding lions'. Asked in what consists the understanding of lions, he replied 'Every lion is different'. It is not to be thought that Mr Flood, in seeking to understand an individual lion, did not bring to bear his great experience with other lions. Only he remained free to see each lion for itself.

The same, I believe, can be said of the enterprise of therapy. Of course the therapist brings to bear his or her experience with other people in the encounter with a particular patient. This, however, does not mean that the encounter need be mediated by this knowledge. And if the therapist is offering genuine solicitude to the patient then, I suggest, the encounter cannot be so mediated. The accumulated experience has informed who the therapist is, in their spontaneous engagement with the client, in (to use Winnicott's term) their carrying-on-being and this, I have been suggesting, is precisely what makes possible the carrying-on-being of the patient. To really meet the patient out of who one is, and not from what one knows, is just what I have been calling 'offering them recognition'.

metaphysics 0.101

2009-08-10T19:43:00.013+01:00

How is it that metaphysical debates get generated and sustained? Here's my abstract grasp of the essential character of metaphysical thought.

...I'm aware of how ridiculous that sounds, of course. Let's put it more modestly: here's my abstract grasp of the essential character of whatever fits the forthcoming characterisation...

Using the conceptual resources of some particular 'discourse' or 'language game' we can raise empirical questions regarding the viability of some or other judgement regarding an instance of it's subject matter. I say "Katie seems sad", but you question my grounds for saying this, and I come to see that I had jumped to a premature conclusion. In fact she was crying out of relief, ecstacy, or boredom.

But now a certain doubt strikes us - not regarding the viability of some particular judgement, but of the whole discourse in its truth-stating deployments. Not: how do I know I was right about Katie? But rather: how do I know that I am ever right about what people think or feel?

With that kind of sceptical doubt in place, we all too readily find ourselves imagining that we now need to find a way of holding up this language-game against reality. To find some vantage point from which the moves made within the game can be shown - or shown not - to tally in toto with the facts about the thoughts and feelings of others.

This leads us, then, quickly to a position called 'Realism'. Realism wants to tell us that it not only makes sense to talk of particular judgements corresponding to the facts (or not), but also makes sense to discuss whether an entire domain of discourse corresponds to the nature of reality. Not just: is this judgement made using this concept a good one, but: are these concepts themselves good ones - do they 'pick out' (or whatever other dead metaphor you prefer) anything 'real' in 'reality'? (That's right - you also have to be prepared to talk not just about regular things like tables and cats, and how solid or furry they are, but also now about some super-thing called 'reality' which too is thought to have some or other character.)

We struggle with this for a while, and find it hard to occupy any vantage point that doesn't tacitly presuppose, for any affirmative answer, our entitlement to the conceptual resources which are here being sceptically questioned. By accepting the Realist's answer we seem to have unwittingly preserved our ontology (if you like) at the expense of our epistemology. We find ourselves attracted to phrases like 'mind-independent reality' but simultaneously at an anxious epistemic remove from precisely that reality.

So perhaps we oscillate into another position - lets call it 'Constructionism'.

As a Constructionist we find ourselves wanting to reject Realism's epistemic immodesty. Rather than attempt to answer our question by reference to the world, we instead try to answer it by reference to the discourse itself. What I, or what we, say or think determines the answer to the sceptical question. So, there 'really are' cows because we speak of cows. And so on. Language or thought determines the nature of reality. Oh, no, we don't mean to say... er... anything too drastic ... er, transcendental idealism all comes good in the end ... er... Or does it? Haven't we now substituted ontological immodesty (now we're world-makers) for epistemological immodesty (claiming to know stuff that we don't seem to be able to reflectively accommodate within the Realist worldview)?

As I see it, metaphysics is all-too-often the practice of jumping on to this see-saw of Realism and Constructionism, of trying to load the weight all on one side, of hoping that if we manage this well enough we can get it to touch the ground of both our epistemological and our ontological needs. But accept the sceptical question, and the game never ends.

How to dismount the see-saw? Well, we find ways to reject the sceptical question in good faith. For example, we remind ourselves with Ryle that 'existence' is not a generic word, but one tied to the logical space opened up by some particular discourse. From within the sceptical fantasy we imagine ourselves and our language games standing over against some super-thing called 'reality'. But 'reality', 'existence' and the like tend to be philosophical hypostasisations of perfectly good existential terms which have their scope of application individually set by the rules of the diverse language-games which deploy them. Or - another example which takes us away from hypostasising generalisations - we remind ourselves with Wittgenstein of the 'paradigm case' character of deployments of particular terms. So that it just isn't clear what is being asked when someone says, in the vicinity of a ripe tomato, 'Yes, but does 'redness' really exist?' Because to be red is to be just like that tomato, and so on.

So yes, we use such particularising examples to help to free us from the metaphysical impulse. We also develop, perhaps this time with Austin, a less tinny ear when it comes to spotting the philosopher's (the philosopher-inside-us's) decontextualised (and thereby de-meaning-alised) uses of terms such as 'reality' and 'appearance'. With Wittgenstein we 'bring words back to their everyday use'. But more than this, we need to keep a handle too on our diagnostic formulations. We have an account of how the sceptic has unwittingly alienated themselves from the world, or from the mentality of others, before they even ask their question, and of how their question bears the logical traces of this alienation, an alienation which is now inscribed in the question's every iteration.

I would like to add one further suggestion, this time lifted from psychoanalysis. It might be thought that neurotic defences are typically and for-the-most-part deployed against the real anxieties that confront us in the midst of our lives - managing our relationships, illness, injury, death, work, etc. And as a result we inhabit a phantasy land in which the mind tries to narcisistically ground itself within itself - to (impossibly) be an other to itself, rather than rely on the vicissitudes of the availability of the love of others, or of meaningful employment. To generate a phantasy object which then gets treated like a real object (compare what Wittgenstein's private linguist tries to do - how he tries to get real normativity out of imagined normativity) within the mind, which can now stand (it is fruitlessly imagined) as something to which the mind can be in relation - something which can ground its representations.

Well, that may sometimes be true. Life is hard. But what makes it much harder, what continually inspires the need for the further deployment of defences, is not so much - I believe - the original pains and fears of life. Rather it is the ongoing oscillation of the defence/anxiety cycle. For the phantasy objects that are narcissistically installed as if genuine others to thought are always threatening to reveal themselves in their fantasy status. And by inhabiting the domain of phantasy we become further estranged from whatever sources of love, reality contact, engaged work, there are in our lives. The defences, in other words, generate further anxiety. The cure becomes a poison.

The same, I believe, obtains in the metaphysical context. What sustains, and sometimes makes increasingly desperate, the metaphysical impulse is, I believe, the vicious cycle of metaphysics and scepticism itself. Once caught up within it, and responding to the needs of the sceptical questions, we find it hard to put it down. That would seem, from within the ambit of this metaphysical vortex, to amount to a capitulation to scepticism and a loss of the world.

In setting aside the metaphysical impulse, however, it is precisely the world that we find. (This, I believe, was what Wittgenstein was on about when he talked about looking for that which would enable him to give up 'philosophy' - i.e. not an expression of an anti-reflective impulse, but an expression of a desire to in good faith lay to rest his sojourns into the phantasy world of sceptical questions and metaphysical answers in endless symbiotic hock to one another.) Or to put it better - what we find are the diverse particulars that show up in the diverse byways of our days. To acknowledge that we need and can do nothing, cognitively, to hold on to these - that we cannot earn our worlds but must accept them as gifts, as instances of grace - now that is the real challenge. Can I tolerate relinquishing the phantasy that I could sustain myself if my world is taken from me?

character and causation

2009-08-05T11:22:00.006+01:00

I think there's a widespread confusion between two types of cause in psychology. One (cause1) has to do with precipitants, and is the sort we are interested in when we are trying to intervene in causal pathways. The other (cause2) has to do with character, with a pattern in which some particular example is situated, and is the sort we are interested in when we are trying to understand what it is that we are dealing with.

CBT models frequently muddle these together. Take the famous 'downward arrow' technique in CBT. The idea is that we keep on interrogating a negative thought with a question like "Well, what's so bad about that, what does it say about you?" and then we can get to the 'core beliefs'. These are presented as deep-rooted precipitants of lots of surface automatic thoughts, when they are better understood as the broadest possible meaning-organiser of the thought in question.

For both types of cause, we can anticipate that, on the whole, the causes function as sine qua non's. Yet here I think we need to be careful - and this is because the 'ceteris' in the ceteris paribus explication of the causal necessity refers in each case not to causes in general, nor to the other type of cause, but only to causes of the same form. That is to say: when I say that the cause2 of a certain behaviour is a certain mental state, I am saying that in the present context it is not similarly a function or cause2 of another mental state also present. (This is not to say that a certain behaviour cannot be multiply causally2 determined, but only to say that the logic of the causal2 explanations necessitates the explicit ruling in of such multiple determinants which otherwise are simply ruled out by the explanation in question's functioning as such.) And similarly for cause1: if I say that the man's arm is shaking because1 of Parkinsons, I am implying that it would not shake were it not for the Parkinsons. An arm may shake both because of Parkinsons and because of anxiety/depression - i.e. if either were singularly removed we would still expect a tremor - but that would need to be said when enumerating what the cause of something is. We can talk about what a cause of a behaviour is, meaning a contributing cause1, but this does not itself amount to a causal explanation of the behaviour unless it is wrapped up into a more complete story about what the cause/s is/are. Anyway, the limit of the sine qua non character of the causal story is - I want to suggest - that we can't rule that a particular behaviour or emotional state would not have been caused1 even if the cause2 we posit for it had not obtained.

The necessity of distinguishing causes is particularly potent in psychosomatic medicine. By treating a physical symptom as a communication we are, I believe, saying something about its character. We are not saying that it is caused1 by that which it communicates. But we can also, I believe, view physical symptoms as effects1 of causes1 which happen to be psychological. So: I have a bad shock, and my body goes into cortisol or adrenaline or what-have-you production mode. This then causes1 a physiological change in me, which may in turn cause1 a certain psychological state, etc. etc.

Psychotherapy typically works on the assumption that an investigation of meanings will result in a change of behaviour or emotion. In order for this to work we must presume that self-understanding involves a translation of an appreciation of causes2 into a reconfiguring of causes1. We guide our own activity according to our self-understanding, and our agency is that meeting point of the two causes 1 & 2. We come to realise that many of our behaviours and experiences do indeed conform to (are caused2 by) a certain pattern. This allows us to think of alternatives, and to understand that we do indeed have a mind (a perspective), and to guide our behaviour anew. The behaviour now gives rise to different experiences, and our experience of the world is altered. Yet this is only one possible mechanism for therapy. Another version is contained in the Kleinian idea that, in therapy, there is a direct communication from one unconscious to the other. I believe that this commuincation is of a cause1 form.

At its worst, psychotherapy either degenerates (psychodynamically) into a search for merely possible causes2 of behaviour and feeling, or (behaviourally) into a search for precipitants (causes1) of behaviours. In the former case the patient is understood, or at least potentially understood, but a fat lot of good it does them. In the latter case they are not even met as a person.

applying theory in the clinic

2009-07-22T11:23:00.005+01:00

For the last year I've had the privilege of working in a primary care setting and working with a wide variety of people with a wide variety of problems. Some people have struggled with bereavement or other losses, others have struggled with managing sporadic anxiety or panic, others find it hard to manage their relationships without frequent explosions of anger, others (often those who have experienced childhood sexual abuse) turn to physical means (cutting, pills, medicines, suicide attempts, alcohol, exercise, too much or too little food) to manage feelings that are experienced as overwhelming and intolerable, others struggle to motivate themselves or to hold onto hope, and so on.

Given this wide variety of problems, it is perhaps not surprising that I've not found any one clinical perspective, theory, or model which helps me both to understand what is going on for each and every one of my patients, and to know what to do. There have been times when I've thought that an accelerated psychodynamic perspective, or a CBT approach, or a narrative therapy model, or a solution-focused method, or a mindfulness-based approach, or a person-centred stance, or a purely behavioural tack would do the trick. Sometimes this happens after I've just been on some relevant training in, or read the latest book regarding, the particular model in question! Thankfully my clinical experience soon prevents the development of an unhelpful manic theoretical omnipotence.

This is not an easy situation to manage, and I want to start by exploring the reasons for this. One has to do with getting to grips with the different 'instruments' of the different theories. Imagine that we are asked not only to play the violin in an orchestra, but also to be able to pick up the oboe or trombone at any moment. This is not easy, because the techniques and the learnt habits are really quite different - the embouchure may require different strengths and weaknesses in the lips and cheeks in the different cases. But the situation with the therapy situation is even more complicated. For in the therapy situation, and especially for the less behavioural therapies, the instrument is the therapist him or her self. It is then not merely that I must do something different, but perhaps that I must also be something different, when working with different people with different problems. Of course there is a sense in which the most important thing is that I be myself, in the room, with the patient. And the fact is that some therapeutic modalities simply don't come very naturally to my nature. However hard I practice, it will always be the case that I take much more naturally to the violin than the tuba.

This, however, is only a small part of the answer to the original question. And to say of the relation between model and patient/problem that it's merely a matter of 'horses for courses' seems to radically underestimate the conceptual complexity regarding what a 'good fit' amounts to here. As already suggested, this is partly because the therapist must not only know, but in some way embody, the theory in question: we do not then have simply a matter of an objective matching of theory to data. And living the theory - what in any particular case this will look like - depends in part on the sensibilities of the therapist. But it is also, I believe, due to the status of the models not simply as presenting different hypotheses regarding the origins of distress, but also as presenting quite different perspectives.

Much has already been made of the different values embedded in the different therapies - symptom relief or characterological change, etc. I'm not too fussed about that, and prefer to get my own values from my own life and to make the patient's values the drivers of the therapeutic process. At other times the multiplicity of perspectives provided by the different therapeutic models seems to me to inspire a too-quick retreat to a theoretical constructivist position. As if the theories were just different and incommensurable ways of making sense of the same data. My experience counts against this: It seems that some theoretical perspectives just do work better and can also meaningfully be said to fit better in certain kinds of cases. Nevertheless it also seems unrealistic to me to take the possibility of talking of 'fitting' here as indicative that, after all, the theories really are best thought of as different hypotheses.

So what more can be said on the relation between theory and 'data'? Here's how I've come to think of it. I've always been struck by the way in which some models seem to bring alive understanding in the midst of certain cases, but to merely redescribe others in a way that adds little (other than a smug sense of continued professional expertise in the uni-model practitioner) to what was already known. The concept of repression brings alive the phenomenology of hysteria; the concept of thwarted mourning works very well for certain cases of depression; the CBT perspective on anxiety disorders works rather well for those of my clients who are middle class, generally well-adjusted, but struggle with episodes of panic; ideas developed in the midst of attachment theory (to my surprise) seem to have their day in thinking of cases of health anxiety; a Rogerian focus on authentic listening and the provision of recognition never goes amiss but again seems particularly apt when working with patients who have had too little of being accepted for whom they are in their earlier life; a focus on behavioural activation seems to work wonders for the more biologically depressed patients who just do not have enough 'life' in them at the time; a focus on intrapsychic conflicts nicely does the trick in others; catharsis is sometimes hugely pertinent but often only of initial and short-lived therapeutic value; offering and thinking in terms of 'containment' seems very helpful for those who frequently feel overwhelmed; 'mentalisation' cuts the conceptual mustard for many 'borderline' cases... and so on.

To simplify even further, it might be suggested that the different models are conceptually organised around different core emotions. CBTists are driven by 'anxiety', Kleinians are motivated by 'guilt', Counsellors are preoccupied by 'loss', etc. And for any one patient it will always be possible to redescribe their inner life and their difficulties in such terms. After all, there are complex inter-relations between these experiences when they are situated in the ramified lives of any one individual. But it also remains true that some perspectives bring alive and speak more to some cases than others. Some cases are more ready to be spoken of in terms of, say, loss - this readiness is itself part of the phenomenology of the patient. And some concepts start to become tired and fray when over-applied outside of their zone of maximal unconcealment. Some therapists, too, have an ear best poised to hear narratives of guilt or loss, and can locate these in life stories in which we might otherwise feel they feature as sub-plots at best.

Attentive readers will notice that I've not-so-subtly distanced myself from (realist notions of) either truth-apt representation or (idealist notions of) incommensurable conceptual schemes, only to end up with a set of expressivist (speak of or to, bring alive, etc.) metaphors. Well, that's fine by me. Admittedly I should like to be able to say more about what it is for certain uses of language to resonate with, rather than aptly represent or conceptually organise, their intentional objects. That however will have to wait for another day.

before mind and body ... again

2009-06-06T21:20:00.010+01:00

I'd like to start to flesh out, just a little, the idea mooted in a previous post that so-called 'psychosomatic' disturbances may sometimes be a function of a failure of 'mind' and 'body' to co-emerge as they normally would out of a pre-differentiated 'id'.

Why tackle this topic? Well, two sets of reasons - one set theoretical, one clinical. Theoretical reasons first: Several supposedly enlightened perspectives on psychosomatics strike me as ultimately rather hopeless. I'm thinking for example of attempts which depend upon what I find to be one of three rather unpersuasive metaphysical pictures.

The first picture has it that we can unproblematically 'sum' independent contributions from mind and body in some rag-bag 'bio-psycho-socio... model' which uses hyphens to synthesize what our genuinely theoretical imagination baulks at. The second has it that 'minds are really brains' or some other more inclusive portion of the material world - and so simply finds it ultimately unremarkable that 'mind' and 'body' are of a piece with one another. (First unthinkingly entify the mind, then 'identify' it with (part of) the body, is the idea here.) The third has it that the mind and the brain are 'two different sides of the same coin'. Goodness knows what the coin is supposed to be, but the moral anyway is that we can once again dispose of the necessary theoretical work just by reference to 'double aspects'. The truth is however that whilst we perfectly well understand the idea of 'two aspects of the same thing' in other contexts, we don't (I believe) really know what we're talking about when it comes to 'mind and brain'. It's just odd to think of a substance (the brain) as an aspect at all...

When all I've got is the above, I feel that I'd rather just stick with the non-theorised notions of 'conversion' and 'symbolic manifestation', although these too can be cheap tricks when they pretend to an explanatory value they simply can't muster.

Finally, a clinical reason for positing a foundational disturbance in the co-emergence of mind and body at the foundation of certain difficulties: that in encountering people who are struggling with so-called 'psychosomatic' conditions one sometimes finds something so fundamental, profound, outside-of-consciousness in its character, and ultimately baffling, hard-to-think, and hard to engage with, that normal psychological or biological approaches - or any combinations of these - just don't seem to work. The clinician can end up feeling like banging their own head, since the patient's mode of being-in-the-world somehow leaves no room for a mindful or emotional engagement with their difficulties.

Well, to step back a paragraph, I would stick with talk of 'conversion' etc. if that was my only choice. But I do think there's a chance of an alternative - which involves the idea that our experience of ourselves as having either physical or psychological experience is a function of the ongoing enactive structuration through differentiation (here of the mental and the physical) of the bodily source of the intentional field. Not a matter of conversion from mind to body, then, but a matter of a disturbance of the balanced co-emergence of mind and body in the first place.

So, the theoretical claim still sounds fairly mad at the moment, and a little too close to the double aspect theory to boot. What can be done to give it some plausibility and determinacy? First, I want to make it clear that I'm not talking about the body qua physical being mysteriously unfolding from the background id (that would be, like, weird, right?). It is the subject's experience of their bodies on the one hand, and the subject's mindedness on the other, that interests me. (I do think these experiences fold over into the constitution of the lived body, as non-'mentalised' experience becomes sedimented, in the body, in character (bodily habits, frown lines, stoops, a constant quizzical look, etc.) - but that's another issue.)

So for the moment let's just consider bodily and emotional experience. Where the 'of' in 'experience of the body' or 'experience of the emotions' is not to be taken as specifying the intentional object of an experience, but rather the form of the experience itself (bodily, or emotional).

In the posts on self and other I considered whether psychotic forms of identification could be considered as due to a shift in the placement of the 'chiasm' such that the normal existential unfolding of self and world becomes skewed to one side, leading to a hypertrophy or atrophy of the experience of the self (that which is 'inhabited' and so precisely not experienced) or of the other (that which is not inhabited and thus can be genuinely experienced). Here I want to consider whether the same thing may not happen between mind and body, such that there may, in psychosomatic conditions, be a skew in the unfolding of the source of the intentional field such that what normally would find itself taken up into freedom, inhabited as emotional suffering, lived from, becomes instead something of the non-lived body which oppresses the lived body, something one suffers from rather than the suffering.

The notion is familiar from psychoanalysis that the goal of therapy is to help the patient be able to find activity where previously we had but passivity. That is the goal of the interpretation - and it would not be too far stretched to say that, whilst the doctrine is often presented in epistemological terms - as if it were the subject's self-knowledge which is here at stake, the real goal is often a transformation of the self itself, and not merely in its representation. (Rather than it being 'really the case' that we have an emotional feeling disguising itself as a bodily symptom.) We aren't concerned to merely help out patients have a correct perspective on themselves, but to engage more meaningfully with their worlds by increasing their agency, ownership and responsibility for their experience.

So, the idea under play is that our experience of our feelings qua emotions and our experience of our bodies qua patients of their abnormal functioning are constructed as the bodily pole of the intentional field unfolds into mental and bodily experience. In the former we have genuine emotion or thought, and the lived body is in this mode inhabited, pure subject, seen from, and our ongoing emotions or thoughts are the form of this embodiment. In the latter we have a hiatus, an experiencing of one's body which becomes both subject (experiencer) and object (experienced). In the former the lived body suffers, in the latter it is suffered.

It is I believe quite hard to think clearly about whether there is any correct way in which the limits of one's subjectivity, or the limits of the impingement of one's unowned embodiment, should be drawn. We do however have uncodified norms for what amounts to a healthy degree of ownership, and we sometimes feel we know when our patients are experiencing a skew in the existential underpinnings of their agential self - either with the obsessive taking too much responsibility for that which 'really' is just happening to them (in an attempt to make themselves feel less at the mercy of a world which impinges on them, they take on a terrifying amount of responsibility), or with the somatiser taking too little ownership for that which 'really' belongs to their subjecthood.

An example may help. Helen has what to many people would be a traumatic break-up with a partner, and she does not become angry where many of us might. (Furthermore we notice that she is quite alexithymic, and that feelings of anger are experienced by her as quite unbearable whenever they do arise.) Instead she develops a chronically disabling condition which is experienced by her as physical in character. (The doctors don't seem to be able to find anything wrong with her, though, and she ends up with a dustbin diagnosis like CFS.) The idea that her experience is 'all in the mind' rightly infuriates her - she is not imagining her symptoms after all. (A striking feature, I believe, of patients with (what I will continue to misleadingly call) such 'psychosomatic' conditions is that they feel very sure about what is and what isn't psychological - as if their experience itself could be thought to reliably disclose to them its sources. The very idea of a condition being 'psychological' becomes instantly equated with the idea of it being factitious ... which is no less unreasonable than the typical psychological theories of the 'conversion' process.)

Helen experiences as happening to her various physical sensations and disturbances (such as pain, weariness, spasm, paralysis, weakness) which she then describes herself as suffering from. For someone else whose subjectivity was differently constructed (and I'll come back to the word 'constructed' below), these may instead have been constituent components or vehicles of an intentional relation to the ex, where the relation in question is an emotion such as anger or sadness. In the latter case the person would not say 'I feel such and such physical feelings', but rather 'I feel such and such emotions', since they would, as it were, be attending from the physical feelings to their object (the ex). In the former they instead attend from an attenuated body subject to the remainder of their embodiment now experienced as happening to - rather than as constituting - their selfhood.

Finally, a word on 'constructed'. The term is often used to denote a psychological process or the products of one. But here I am not referring to a certain reflectively available understanding or interpretation one may have of oneself. The construction is more existential than psychological - it is the delineation of a transcendental field within which psychological phenomena - emotional and physical experience - can arise. I am unwilling to say that this process does not occur through discourse, nor that it is never a product of interpretation (cf Charles Taylor's conception of humans as self-interpreting animals) - although care would need to be taken over what is meant by 'interpretation' here. What I believe is an unhelpful way of understanding the issue is to posit an undifferentiated experience which then through interpretative acts gets elaborated as either emotional or physical. Nor, I believe, is it helpful to describe us as normally engaged in the business of interpreting our own sensations.

To conclude I want to think about the clinical merits of some such ontological / existential account of 'psychosomatic' conditions. First, we understand the impasse between clinician and patient. Both coming from and presupposing different backgrounds or frameworks of experience, they talk past one another. The clinician may tacitly assume, as it were, the normal placement of the chiasm, and so cannot grasp why the patient cannot understand the connection between their physical experience and their past and present interpersonal situations. The patient cannot understand why their own experience is so often apparently not being respected. Second, we can move beyond potentially unhelpful notions like (the metaphysically inflated) 'psychosomatic conversion' idea, or (the metaphysically deflated) 'mind and body are one' idea (the former pretending to an understanding and referring to a mechanism which remains unknown to it, the latter pretending that the need for understanding can be obviated by a materialistic or dual-aspect metaphysics of dubious coherence). Third, we can begin to grasp how the therapeutic focus must be on the background, on the structuration of the intentional field. Focusing on the symptom may just reinforce the existing background; developing a relationship in which the intentional field - and hence the foundations for the patient's own emotional experience - is mutually structured may be far more helpful. The aim may be, as with delusion, to non-reflectively encourage (i.e. encourage through active spontaneous emotional reinforcement) modes of being-in-the-world within which the symptom will have little place and the preoccupation with the body will simply drop away.

2009-05-24T13:18:00.012+01:00

I was recently asked to give a 12 minute presentation on mental health difficulties in adults. Quite a tall order! I thought it might now be instructive to set down in writing the thoughts I used to structure my somewhat off-the-cuff talk. I'm writing off-the-top of my head, using the concept of 'anxiety' to structure the presentation. What interests me is whether some such basic scheme could survive my own and others' critical scrutiny in the future.

1. Anxiety is the experience of a threat to the self. A healthy self is internally coherent, continuous over time, well delineated from others.

2. The development of a healthy self depends upon background neurological and environmental factors. Of the former a well developed CNS is essential, a CNS which can then selectively degrade (apoptosis) as required by development (to not be overwhelmed by too confusing a diversity of experiences), which is not too chronically dysregulated, and which is responsive in its development to environmental organisation which eventuates in self-regulation.

3. The most potent environmental organiser of basic selfhood is the attachment relationship with the primary caregivers. Through an adequately containing and mirroring attachment relationship, I develop a sense of the boundaries of my selfhood (the scope and delimtation of my physicality, my agency, moral responsibility). Having a caregiver who can hold me in mind over time also allows me, gradually, to develop a sense of myself as continuously existing over time as a self-same subject. A stable physical environment is of course also essential (although we can take this for granted far more frequently).

4. These factors allow for the development of selfhood, without which I will not even be able to experience anxiety (since there would be nothing which could be feared to be damaged). They also allow for the development of a stable sense of selfhood - without which I will be prone to recurrent anxiety.

5. Psychological disorders are principally due to anxiety - i.e. due to a sensed threat to the self. This can arise either because of an insecurely developed self to start with (for biological or attachment-based reasons) and/or because of environmental trauma (in which the self has come largely under threat. Very shameful experiences are good examples, or physical traumata in which one thinks one is going to die, or rape or other such extreme experiences of violation of the self, etc.).

6. Different psychological disorders result from different ways of managing different kinds of anxiety. (By 'different kinds of anxiety' I mean: the felt threat to different aspects of selfhood.)

7. Agoraphobia results when, to prevent the feared damage or death of the bodily self or of the self's psychological continuity (i.e. its sanity), the sufferer stays in a safe environment (their home). Panic attacks are cases of runaway anxiety where what is feared is actually the anxiety experience itself (although it is often not recognised as such).

8. Social phobia (extreme shyness) results from a disturbance in my social going-on-being-with-others. I fear that my social self will fall apart - I fear that I will no longer be able to go on being someone. Self-consciousness further disrupts the going-on-being of myself.

9. The obsessive-compulsive attempts to compensate for basic anxieties by inhabiting a semi-delusional alternative reality. In this world they can control outcomes with the power of their own mind, and are not therefore so subject to the vagaries of fate and its impacts on the self. Bad happenings can then be imagined to be magically prevented through performing rituals. However the self which takes itself to have more power than it does is left with a sense of hyper-responsibility; this causes its own further worries, which usually constitute the presenting problems.

10. Many specific anxiety disorders that appear to concern the subject in relation to him or herself (e.g. some health anxieties, or some obsessive compulsive anxieties, etc.) typically cover over - provide substitute foci for powerfully anxiogenic - more basic anxieties regarding the self in the context of interpersonal relations.

11. Depression results (at least sometimes?) when the sufferer retreats inwards, away from their situation, and away from their future, in order to keep themselves safe from destabilising experiences (such as major disappointment) which would otherwise threaten to plunge the self into crisis.

12. The person with psychosis so greatly fears the loss of the self boundary that they create an alternative reality to inhabit (hence delusions, hallucinations, etc.).

13. The person with a personality disorder finds intolerable the vulnerability of their self to the impacts of others. They either withdraw or merge with others, and often unconsciously 'project' or 'selectively disown' their disturbance into/onto others. These are then encountered in these others who are experienced as fearful. Intolerable anxieties may also be treated in a highly concrete way rather than be allowed to be felt, and so the patient may try e.g. to physically cut or eat them away. (We are all a bit personality disordered.)

14. Addictions to alcohol and heroin and barbiturates are attempts to manage anxiety through self-medication.

15. The task of therapy is to strengthen the self. The therapist trusts that, although when they are terrified their self may indeed be falling apart, the patient will return to themselves - that the anxiety will pass by itself. They convey this to the patient, as much through their attitude as through what is explicitly said. Over time, and if therapy works, the patient comes to internalise at least some of this confidence.

16. The therapist provides an external support to the patient as the patient allows herself to drop conscious controlling modes of managing themselves - which modes have previously massively constrained their lives - and instead to immerse their selves in non-reflective encounters with their expanding worlds. Some of the new experiences which consolidate the self take place between patient and therapist (e.g. I risk not controlling my feelings when with my therapist; I risk looking at them and thereby fail to avoid potentially (but not actually) seeing them scowling at me, etc.); others take place in the patient's world; the exposure to these is however facilitated through discussion and goal-setting etc. in the therapy sessions.

17. Patients who have a fairly stable and well developed sense of self, or who only suffer a disturbance or weakness in one limited aspect of their identity, can often be helped with a more discursive, shared-formulation-based approach. Patients with a more fundamental disturbance will require a longer and more 'in depth' therapy. This does not mean one which explores 'deeper into the psyche', but one which works more through an implicit quasi-re-parenting approach (the tacit containment of anxieties by the therapist etc.).

18. Much effective therapeutic theory and practice consists not of techniques to positively influence the patient, but instead of the exercise of skills in using internal reflection to resist being drawn into the patient's anxieties and into the defences they use to manage them. Ordinary conversation - the meeting of civil minds offering one another recognition - is itself curative. This ordinary conversation is what is often impossible for the patient who has erected powerful interpersonal defences. The therapist's - often largely intuitive - skill consists in negotiating these defences so that ordinary conversation, play and symbolism can once again become real possibilities. ("Medicus curat, natura sanat": it is nature that cures, the doctor merely facilitating nature to do its normal work in abnormal circumstances. Well, that's the kind of thing - but transcribed into the psycho-social setting - where the therapist's job is to make it possible once again for (human) nature to restore itself to itself.)

before mind and body

2009-05-23T21:06:00.007+01:00

In trying to understand psychotic disturbances of ego boundaries - rather than disturbances in the mere representation of ego boundaries - the psychologist must, it seems, make recourse to a theorisation of interpersonal interaction which holds to an equiprimordiality of i) intersubjectivity and ii) of the identity of the selves in the interaction. Psychotic identifications arise when there is a failure in the separation out of two selves in the expected manner within a dialogical and intercorporeal relationship. The order of explanation cannot be, as would be normal for a psychologist attempting to grasp less profound psychological disturbances, that we have here any kind of failure merely in the relationship, or failure in the understanding of one of the participants in that relationship. To be sure, the pathology usually lies with the one individual, but not 'within their mind'. It lies rather in the background intercorporeal processes by which such a 'mind' crystallises out of the intercorporeal field, with the delimitations it possesses, in the first place.

That theme is one which has preoccupied me considerably in other posts and work elsewhere in the last year. I wish to consider now whether a similar form of explanation can be applied to what are misleadingly thought of as 'psychosomatic' phenomena. I do not mean to suggest that there aren't certain phenomena which can best be understood as due to the influence of mind on body. But what I want to consider is whether it would be possible to think the relationship between mind and body, as it obtains in profound psychosomatic disturbances, in a more primordial manner.

Here is the suggestion, which at present remains in desperate need of empirical phenomenological detail to render its content and scope perspicuous. That first and foremost we have our existence as embodied-beings-in-the-world, and that psychosomatic disturbance is a function of a failure of 'mind' and 'body' to co-emerge as they would normally do. Note the implication here: the mind and body, just like self and other, need one another, and can only reach ontological determinacy in a process of mutual negation.

So, we experience certain aspects of our 'existence' as bodily, and certain others as mental. Or to put it better, mind and body co-emerge equiprimordially from our ongoing lived-bodily being-in-the-world. Just as self and other co-emerge, so too do mind and body. The primordial goods are divvied up, as it were, in such ongoing enacted existential auctions. And what we may have in certain psychiatric conditions are cases of a 'skew' in this 'divvying up' either in the direction of the body, or of the mind. Such that the mind and body are either hypertrophied or atrophied relative to one another. It may accordingly be easy to talk of 'conversion phenomena' where really there is no conversion taking place, but rather a more primordial disturbance in balance of the co-emergence of mind and body. Some fatigue, some skin complaints, some paralyses, rheumatisms, allergies, etc. may then form a kind of mirror to complaints involving a kind of hypertrophy of cerebral identity (e.g. schizoid conditions). And given that the very categories of 'mind' and 'body' are dependent upon a certain reliable equity in this existential divvying process, when we confront certain extreme so-called 'psychosomatic' conditions we may be reaching an aporia in our very capacity to talk meaningfully here of 'mental' or 'physical'.

don't ask why

2009-05-17T17:48:00.012+01:00

621. Let us not forget this: when 'I raise my arm', my arm goes up. And the problem arises: what is left over if I subtract the fact that my arm goes up from the fact that I raise my arm?

628. So one might say: voluntary movement is marked by the absence of surprise. And now I do not mean you to ask "But why isn't one surprised here?"

Ludwig Wittgenstein, Philosophical Investigations

In these later paragraphs of part I of the Investigations Wittgenstein explores the idea that what may be 'left over' when I subtract arm rising from arm raising are a set of kinesthetic sensations that are equivalent to an act of willing. There is no evidence that he intends to take his own question seriously (to suppose so would miss the entire ironic tone of the entire Investigations), any more than he wishes to take the answer seriously. For what he appears to wish to reach is a point where the question 'how do I know that I raised my arm?' when I raised it has no traction for him. Where its own roots in an estranged conception of the human subject can be exposed, and the question laid to rest.

627. ... I do not say "See, my arm is going up!" when I raise it.

The person who has such a relationship with their body has clearly become alienated from it. They, perhaps, have become an interiorised will-er of exteriorised actions. No longer identical with their own living bodies, they become the intender of their bodies' movements and the perceiver of the consequences of these movements.

We might imagine that arm rising is a constituent ingredient of arm raising. That we could add some other ingredient to arm rising to arrive at arm raising. That we normally have some awareness of this ingredient when we engage in arm raising, and this is why we aren't surprised when our arms rise when we raise them (but are surprised when they rise when we don't raise them).

But wouldn't this be misguided? Might instead it not be the case that there is no reason why we are not normally surprised when, raising our arms, our arms rise. We might say: We are not surprised just because we are raising our arms ... which is of course not to answer the question but just to re-state one part of it - although it is nevertheless (I am suggesting) the only answer that could be given.

The notion that knowledge amounts to an identity relation between a subject and an object sometimes surfaces in the history of philosophy. It never appears terribly plausible when stated quite so baldly. But the present case provides us with the kind of example that might have inspired its original formulation. When I am raising my arm, my knowledge that I am raising my arm is nothing other than my raising my arm. I do not know it on the basis of anything. The 'how' question ('how do you know?) gains no traction. My knowledge and my arm raising are of a piece with one another. There is then no need for the assigning of epistemic intermediaries - sensations, conative introspection, etc. - to fulfil this mythical function for us. There is no need to posit some supposedly self-evident - but actually redundant - immediate experience of self-agency. No need to posit some 'ipseity' by means of which our consciousness supposedly knows itself.

We are not surprised because no malfunction has occurred. Arm raising is happening as it should. When it happens thus I the knower am of a piece with I the bodily agent. In exceptional cases the two may come apart. Sometimes I may be surprised by my body's movements, in which case I am not their agent (although we might need to do some fancy conceptual footwork to accommodate John Hyman's nice example of (from memory) a violinist being surprised when they pull off a particularly difficult performance without hiccup). On the whole, I am not. And why should I be - since my knowledge and my action, my anticipation and my intention, are of a piece with one another.

Alienated from our own lived bodies, the question 'how do I act?' naturally provokes an answer of 'by trying, causing, ...', and the question 'how do I know I act?' also provokes an 'by inward mental or somatic perception'. Leave behind this alienated conception of the self, and we can leave behind the questions, the answers, and the very idea of an 'experience of agency'.

Postscript

Someone might ask why I am blathering on about this in a blog about the philosophy of psychopathology. The reason is simple: It is tempting, when confronted with cases of, say, 'made action' (passivity experiences of the body) in schizophrenia, to imagine that here we have a case of self-consciousness gone awry. As if there is some normal psychological mechanism which affords us access to our own bodily intentions, and on the basis of which we can reliably anticipate our own actions. Whatever the strengths of such an account (like Chris Frith's) at a purely subpersonal level (using notions like 'intention' in 'motor intention' in a metaphorical sense in neuropsychological discussion), there are, I believe, no such merits to be gleaned at the personal level.

By demonstrating alleged philosophical ingenuity and developing an 'account' of 'agential self-consciousness' which posits a inner act of self-consciousness which allegedly makes possible our normal self-anticipation, the philosopher appears to be in a position of ingeniously explaining 'what goes wrong' in the psychopathological case. Schizophrenic passivity experiences get explained in terms of a lack of the phenomenal experience of 'ipseity' or what have you. The costs of this: the falsification of the grammar and phenomenology of everyday intentional action, and the making-too-much-sense of the necessarily-bizarre phenomenon of passivity experiences themselves, simply go un-noticed.

not master in my own house

2009-04-17T08:52:00.009+01:00

I've been too busy finishing up my clinical psychology doctoral dissertation to indulge in dreaming up blog posts. But I did think I'd note a disconcerting experience that has come up in the writing process; I wonder how many others have had it too?

My current (extra-academic) work has me having to take my writing work around with me, to different places, on different computers, to tackle it in odd moments. Unsurprisingly I have just occasionally got into a muddle with drafts, accidentally adding material to an old draft, so that I now have to go back and compile a further new draft.

What I also find when looking back at both is that I have often made very similar alterations or additions - even in the use of particular turns of phrase or idiosyncratic adjectives or metaphors - in the two documents.

Considered in isolation neither of these phenomena (ending up with two drafts, and making additions using the same phrases) are really very surprising. Taken together, though, they are (to me at least) really quite startling. When working on the second document I have no recollection of having already made the alterations in question. Nevertheless I go ahead and make exactly the same alterations.

The resulting feeling is that it is not me who is writing my own work. (A better way of putting it would be to note that I seem to have an overly restricted self-representation - of who 'me' is. Whilst I naturally think of the self as unified through and in its self-narrative, I may do better to think of it as unified in its distinctive character and continuous sensibility.) In Georg Groddeck's terminology (but not following Freud's redeployment of it), it is not the ego but the id that writes.

neither top down nor bottom up

2009-03-28T17:58:00.006Z

Reading the psychological and philosophical literature on delusion, one may sometimes be offered the following two choices:

i) either delusions can be understood in terms of the abnormal content of the experiences which they thematise

ii) or their delusionality is a function of formally aberrant features of the understanding used in this thematisation and not of the experience itself

Neither seem adequate to me, to capture the strangeness of delusional perception and its relation to delusional beliefs. A better approach would seem to be to insist that

iii) the delusionality of delusions can be understood in terms of the abnormal form of the experiences which delusional beliefs thematise

This could perhaps still be called a 'bottom up' as opposed to a 'top down' account of delusion, but I think I might want to follow the grand old duke of york in proposing an additional alternative:

iv) that the delusionality of delusional beliefs and of delusional perceptions is a function of their joint emergence from a delusional mode of being-in-the-world which makes both for formally aberrant perception and for formally aberrant belief.

holding our nerve

2009-02-22T09:58:00.012Z

Several texts in the 'philosophy of psychopathology' arena invite us to make the following kind of choice:

Either we should acknowledge that what appears to be some perfectly natural description of certain psychopathological facts ought to force us to reconsider our prior philosophical belief that the domain which has been affected by the psychopathology had a purely transcendental unity.

Or we should stick to our philosophical guns and acknowledge that what appears to be some perfectly natural description of certain psychopathological facts is purely that - a misleading appearance - and that all we have really is a nonsense with no apt articulation.

To give just two examples, we find this kind of forced choice (and a plumping for the second option) in work on delusion and rationality (Davidson must be wrong about the constitutive principle of rationality because delusional beliefs seem to be both irrational and beliefs), or in work on disturbances of self-consciousness (passivity experiences show that what we might have thought was constitutively inalienable - our knowledge of our own minds - is only empirically so. Reflection on the alleged psychopathological facts forces us philosophers to admit of distinctions between the ownership and the agency of thoughts which would not otherwise have occurred to us).

My short objection to this forced choice is that it fails to consider adequately a third alternative:

That what we confront in psychopathological conditions (especially psychotic conditions) are phenomena that simultaneously and naturally invite, yet also thwart, the application of certain concepts. That what we are dealing with are necessarily exceptions to a rule, phenomena the psychotic character of which is precisely of a piece with the ways in which our language starts to fall apart in the phenomena's articulation. That the background preconditions for the sensible application of our concepts are what falls apart in psychosis. That what we must however learn to tolerate is a situation in which the most apt characterisation of the phenomenon is also and nevertheless one which aptly fails to make it intelligible - since, being psychotic, it is precisely not intelligible in the way in which non-psychotic phenomena are. And that the aptness of this characterisation is not one which can be demonstrated through the application of criteria but is sui generis - is, possibly, one which draws more on intellectual sensibilities that have their most direct expression in, say, poetics.

cbt ain't so bad after all

2009-02-06T06:06:00.007Z

I've been fortunate enough to experience, recently, three perspective shifts on CBT (you know, the popular psychotherapeutic, not the sadomasochistic, practice), aided in part by my convincingly CBTish, and even more so convincingly humane and therapeutic, supervisor. The shifts have simultaneously helped me to develop a more apt, and in some ways less literal, understanding of both the theory and practice of CBT, and also brought that understanding closer to a 'one take on just what decent generic psychotherapy is all about' perspective on the very notion of cognitive behavioural therapy.

The first shift concerns the status of 'beliefs' in CBT. It's easy to knock CBT for containing an overly intellectualist psychology - as if it really did hold that all feelings and behaviours - especially those which we see in the clinic - are driven by doxastic states of the belief variety. Doubtless there are some die-hard, signed-up-to-good-old-fashioned-epistemology, CBT pundits out there who really do imagine that the everyday notion of 'belief' or 'idea' is, as it stands, with the kind of cognitive penetrability and intrinsically linguistic criteria for individuation that beliefs typically enjoy, apt for describing the foundations of psychopathology.

But the truth is that CBT beliefs are far more akin to semi-conscious automatic structures of anticipation or expectancy than they are to workaday hypotheses. My supervisor said something like 'beliefs are the kinds of things that, when the client is able to arrive at their articulation, typically provoke tears'. That by itself shows something of the distinctive characteristic of beliefs in CBT. The process of the articulation of a so-called 'belief' is not one of simply identifying that which, through the process of identification, retains the same form. The articulation process is one of itself giving increasing structure and differentiation and consciousness to forms or habits of expectancy that hitherto have lurked in the background, as constraining structures of experience. The foregrounding, in its way, creates rather than simply voices what we normally think of as beliefs. A murky from-where of attention becomes something which now, in its very status as belief, acquires an optionality for the believer.

I have a half-lingering doubt that says: perhaps even what we ordinarily describe as 'beliefs' have much more akin to semi-conscious background structures of embodied anticipation than I am here admitting. In other words, perhaps my prior prejudice against CBT's talk of beliefs was more a function of my own overly intellectualist conception of what genuine belief is, rather than CBT's overly intellectualist conception of the foundations of our emotional lives. But I'll leave this whole 'learning', as Rogers would have said, here for now.

The second perspective shift turns on the mechanism of belief change in cognitive-behavioural therapy. For it seems to me that the typical idea of CBT in the wider academic and clinical circles in which I move is one of a verbal technology of merely or at least primarily rational disputation - as, say, Ellis' REBT is typically and perhaps more correctly viewed. Even the hallowed behavioural experiments in CBT can be described, within and without the discipline, as ways of simply 'testing hypotheses'.

This seems to me to be almost entirely wrong. For the entire point and continued relevance of the 'behavioural' in cognitive behavioural therapy is that the underlying structures of expectancy driving the psychopathology (the 'beliefs') are, by their very nature, far less opaque to active experiential challenge than they are to verbal discussion of however forceful a hue.

The process of much decent CBT seems then, to me, to work something like this: We invite the client to discuss their difficulties and their formative experiences, so far as they understand them. Together with them we reach an admitedly rather intellectual (i.e. cognitive, representational, schematic) understanding of what distortions may obtain in their relations to the world. For example, they automatically expect on the basis of some unfortunate yet unrepresentative experience that, say, men will be dangerous rapists unless precautions are taken against them. The counter-productive or, at least, problematic expectancy-maintaining, character of these precautions is mutually explored. At this stage the alliance with the healthy ego of the patient, and the content of the discussion, allows for an idea of how change might be possible. However the emotional change - the change in affective expectancies - has not often yet occurred. What now does the real work, in terms of changing the shape of the underyling structures of anticipation, is the behavioural activation - the tentative dropping of the safety behaviours - the learning not merely from, but within, experience.

CBT, as I see it, can then best be understood as a kind of cognitively-, and therapeutic-relationship-, stabilised behaviour therapy. Where by 'behaviour therapy' I don't mean some mechanistic, dry and dusty simple-phobia-exposure treatment, but a therapy which involves active immersed experiential change of the sort that allows for learning within experience to take place. (The relevant behaviour might, for example, and admittedly in an extention from mainstream CBT, even be taken to involve trying to drop both internal and external defences to avoided emotions and thoughts to which a greater tolerance would be therapeutic.) This active element is, it seems to me, one of CBT's greatest strengths; rather than run the risk of simply talking about change, or accruing merely intellectual insight, the therapy promotes real experiential transformation through alteration of bodily praxis.

Rather than explore this further, I want to comment on my third 'learning', which involved me in what I now see as an unwarranted devaluation of CBT at the expense of ACT or other third-wave (cognitive) behavioural therapies. ACT tells us that what is most therapeutically effective is often not thought-challenging - i.e. not trying to alter the content of thoughts - but rather the comprehensive distancing from them - i.e. an alteration in our relationship with our thoughts, or an alteration in their form. To engage in questioning thoughts was, I thought, potentially to invite people into arguments with themselves which were, possibly, ultimately counter-therapeutic.

Well, I now suspect that this may be based in part on an oversimplification of the relationship between form and content. Moreover, though, I suspect that it is based on a failure to appreciate how one of the best ways of changing one's relationship with one's automatic thoughts is through questioning their truth. Furthermore, questioning their truth can be a darn sight more therapeutically easy than learning mindfulness techniques! Done sympathetically, and with an encouragement to the person in their sympathetic treatment of themselves, the questioning of the content of a thought which has hitherto been treated as a fact is a great way to turn that thought into a mere hypothesis. From being something which presents itself as a bit of world disclosure, we get something that acknowledges itself as a possibly mistaken take on the world. And that is itself a significant transformation in our relationship with the belief itself.

None of the above three recantations are meant to suggest an acquiescence in, say, modes of therapeutic practice or theory which devalue therapeutic ingredients not explicitly recognised in the above - say, the power of the therapeutic relationship itself. Nor do I wish to condone forms of therapy which seem to fail to appreciate the intrinsic significance of the ethical - of the power and the bloody hard work of offering true recognition to someone else. CBT is doubtless as guilty as many other therapies when it comes to underestimating the value - and the practical difficulty - of the human/e encounter. I also don't mean to condone the therapeutic fundamentalism that obtains in often highly visible sections of the CBT (and, for that matter, psychoanalytical) community. But these are concerns for another day.

need projective identification be unconsciously motivated?

2009-02-03T11:32:00.008Z

There is a commonplace understanding of projection and projective identification according to which it doesn't make sense to think of them as unmotivated. Why project - why even call it 'projection' - when we don't have to do with the functioning of defence mechanisms?

And that's fair enough. I want to suggest, however, both that some - many? - ersatzes of the phenomena referred to in these ways need not be defensively motivated, and also that, even when defences are brought into play, we can understand the basic process on which the defences are working without essential reference to the motivational dynamics themselves.

The significance of this possibility was only brought home to me after I was asked, following a presentation at the Tavistock, whether I didn't think that projective identification always has to be 'active'. I guess I hadn't noticed an implication of my own account - that perhaps 'it' (or rather - the mechanism at play in the cases I was referring to) need not be motivated.

Providing an account of (what I'm going to, albeit confusingly, insist on still calling) projective identification as not intrinsically motivated would bring it into line with, say, the psychoanalytic theory of phantasy and the primary processes. If I understand the matter correctly, such basic mental processes constitute the functioning of the mind, but are best understood as exploited by, rather than created by, the defences for their own purposes.

So here goes:

We start with an existential phenomenological conception of selfhood and it's relation to experience. This involves the following key claims:
The self boundary arises neither prior to, nor posterior to experience.
It arises equiprimordially with experience.
In experience we have arising, all together, a self, an object, and an experiential relation between the two.
It may be more helpful to speak of 'aspects of the self' rather than 'the self' per se. It is not that the whole person is reborn in every perceptual act.
Rather, that, in perception, I am separated off from this or that object - this perceiving aspect of myself is differentiated from this perceived aspect of my lifeworld.
And now that this separation has arisen - or better put: equiprimordially with this separation - we have the possibility of a perceptual relation.
Better put still: the separation, and the experience, are of a piece with one another.
Sometimes there will be disturbances to this separation/perception process.
These disturbances may or may not be motivated. We may nevertheless explain, teleologically, why they arise again and again for someone, inscribed into their character and interactions, by reference to the operation of defences.
The disturbances involve a failure of adequate separation of subject from object (i.e. a kind of identification occurs). Either the boundary between self and object (the 'chiasm', as Merleau-Ponty describes it) is placed 'too near' the self, or 'too near' the object.
If the former, then what would normally belong to the self is experienced as belonging to the object. Part of what would normally be the self now belongs to the object. In these cases we talk about projective identification or (with Bleuler) 'transitivism'.
If the latter, then what would normally belong to the object is experienced as belonging to the self. Here we would speak of 'introjective identification'. Identification with the aggressor might be another example. The object is witnessed as not having some of its essential properties - hence talk of psychological 'scotoma'.
There is an essential confusion in this discussion which must not be tidied away too quickly. The confusion concerns the possibility of talking, as I have done, of boundaries being placed 'too near the self' or 'too near the object' when we are talking about a disturbance in the very constitution of the self and of the object-as-perceived. It might seem like I want to have my ontological cake and eat it.
I think we just have to acknowledge this confusion. The truth is, there is no better way of describing what is happening in projective or introjective identification.
We cannot appeal to what is 'really' the case - where, say, a feeling 'really belongs', or what 'really does or does not' belong to the self. For we are talking about the very constitution of feelings themselves.
Neither is it apt to talk of, say, feelings as if they may genuinely transmigrate between people.
If we are employing an epistemological attitude, we will find ourselves wanting to say the former, misperception, kind of description of the processes. If we are employing an ontological attitude we will find ourselves wanting to say the latter. In practice we will probably wobble unsteadily between the two, sensing the inadequacies of both.
But the truth is that projective and introjective identification involve a disturbance in the very preconditions for the intelligible talk of selves and experiences. What remain are selves and experiences manque. We are drawn to use everyday terms to describe processes that could only, ultimately, receive an intelligible elaboration at the subpersonal level of description.
We can however note what people are inclined to say and do. We use an extension of our everyday psychological vocabulary, and talk of primitive mental processes of phantasy, although some of the preconditions for the intelligible application of everyday psychological discourse have been abrogated.
To return to the principle theme. To be sure, it may often be that (what I am forced to describe for now as) the displacement of the self boundary, the partial identification of aspect of self with aspect of experienced object, arises, is sustained, repeats itself, under the influence of a defense mechanism. Projection is a way of getting rid of parts of the self that are intolerable; introjection can be (as Fairbairn described) a way of getting rids of parts of the object that are intolerable (their apparent cruelty, for example).
But the very same instability in ego boundaries may itself arise for purely biological reasons - as part of the essential vulnerabililty in schizophrenia, for example. It arises in conditions of profound sensory deprivation too. The enactive processes whereby the self-boundary is normally maintained cannot operate so smoothly in such disturbed environmental or internal (neurological) conditions.
This is not to say that the disturbances in the self-boundary in schizophrenia might well not too have their motivating factors (defensive origins). With a weakened self boundary constitution, there will be all the more opportunity for defences to succeed in, say, ridding the self of intolerable aspects of itself. And so these primitive defences may have more of a chance of succeeding.
But this is not to say that disturbances in the constituting processes must only arise under the influence of a defence. To assert that would seem to be simply a prejudice: what could be its justification?

Postscript (18.2.09): It has occurred to me since writing the above that the question about the 'activity' of projective identification might not have referred at all to its being motivated or not. After all, it's a common enough bit of psychoanalytic understanding that projective and introjective processes are part and parcel of the very means of our emotional communication and empathy, and not simply the materials of defensive offloadings from or accretions to the self. Perhaps what was meant instead was simply the idea of a process of movement from pre-projective to post-projective moments - I start off in a non-identificatory relationship with you, and then move into an identificatory (of whichever sort) relationship, and then back again, in a dynamic pattern of fluid engagments. And these movements might have been what the questioner was getting at. Whereas my account is, admittedly, rather static. On reflection, I am attracted to the idea of such movement. What I suspect, now, is that it is the absence of such movement - back and forth between projective and introjective and non-identificatory moments - that makes for the possibility of normal, healthy, object relations, including the normal and healthy constitution of the self boundary. And that what I was describing was simply instances of 'frozen identification' in which the normal healthy dynamic dialectical motility - the fluid dance of merging and separation - has been lost.

mood

2009-02-01T05:09:00.005Z

My everyday psychological understandings and clinical practice give me little handle on mood. Yet it is mood which so often radically constrains and inspires those habitual actions that bring people to the clinic.

My psychologist's training certainly helps me think about emotion, and about thought, and about belief. It is through such notions that I formulate and address a client's difficulties together with them.

Lying in the background, however, is mood. And mood constrains the way in which anything, at any time, is understood. It constrains motivation. It shapes belief. It is a kind of total framework within which the whole of my experienced world shows up. It is more general than an emotional feeling.

I am thinking of pervasive states of boredom, agitation, numb neediness. I am thinking too of the kind of state of mind in which an obsessional person performs their compulsions, or of manic excitement. And, to put it simplistically, whilst emotions disclose the self and the other in relation to the self to itself, moods disclose the entire world to us. They are always 'behind' us, the from-where of our attention.

Perhaps there is a sense in which it is true to say that mood is, or can be, repressed emotion. It is what happens when emotions are not able to be felt; they are flipped inside out - and now they have us, rather than us having them. (It is we who are in moods, not vice versa.) Freud, for example, explained feelings of unfamiliarity - which are not simply the absence of feelings of familiarity but have a positive yet baffling content - as due to the repression of something familiar. (Freud, The Uncanny).

In the group I run for people trying to lose weight, it has become apparent that people tend to overeat when they are in a particular mood. It is often a kind of numb and compulsive state, an opaque neediness, a restless oral urge, a boredom. Everyone understands what they have to do to lose weight; everyone very much wants to. But the charioteer of their actions is at these times not their better self, but an uncomprehending mood. A different mood prevails in the group, and the difficulty of transporting the message home consists, in part, in the different mood-states in which good intentions and restless orality find their repose.

In the psychotherapy literature, I am only aware of two methods for tackling mood. The first is the psychoanalyst's interpretative endeavour: trying to condense out a mood into that emotion which has hitherto been 'held from awareness'. The second is Gendlin's focusing, where a mindful and respectful interrogation of the body invites the articulation of the felt sense operative in the self. I am not sure that either are readily applicable procedures in many therapeutic contexts. My challenge to my CBT colleagues is, now, to develop a new therapy of mood.

moral treatment

2009-01-30T20:14:00.012Z

Early psychotherapeutic endeavours were known as 'moral treatments', the category of the moral being drawn on primarily to contrast with that of the medical. The French alienist Pinel freed his psychiatric patients from their manacles and recruited helpers who would treat their wards with respect and kindness using a 'traitment moral'.Whilst 'moral', as Pinel uses it, seems to have more to do with the 'psychological' than the 'ethical', the fact remains that treating the patients kindly, with respect, as real people, remained an important part of that admittedly imperfect evolution of the human madhouse into the humane asylum which he helped to institute.

In this post I want to start to think about the relation between the moral and the psychological. It strikes me that many psychotherapeutic endeavours and psychological schemes treat the category of the moral as merely externally related to the therapeutic encounter. Psychological theory and technique can then (it is supposed) be developed and practiced as something intrinsically separate from - even if always necessarily contextualised by - ethical concerns. So, to be a therapist I must of course be a kind and warm-hearted person who abides by the code of ethics and conduct of my professional body. These are, so (what I believe is) the prevalent conception would have it, (merely) essential preliminaries, practical preconditions, for the therapeutic endeavour. But this endeavour can (it is supposed) be theorised in purely psychological terms which, as such, need make no further essential reference to the moral order. The two goals - to be a (morally) good clinician, and to be a (psychologically) good clinician - are two enterprises which accordingly may (allegedly) be thought to merely run in sequence or in parallel. And whilst the former may influence the latter externally (i.e. be a practical precondition for the efficacy of, but not be actually constitutive of, the psychological therapy), the practice of morality is nevertheless typically theorised as external to the therapeutic action.

There are I believe some exceptions to this from what might at first appear some quite unusual quarters. Kleinian theory, for example, and despite some of its occasional darkness, has particularly powerful things to say about the complex and interwoven relationship of moral factors, goodness, love, envy, etc., to psychological functioning and the development of the self. And Rogerian theory and practice, despite some of its occasional naievity, holds to a view of therapeutic endeavour which makes moral authenticity and openness into a primary therapeutic virtue. But on the whole the rule of a separation of the moral and the psychological seems to hold. One thing that strikes me is that (what I believe is) the typical psychological approach seems to view the moral factors as quite easily instantiated. Follow the BPS Code of Conduct - keep confidentiality, show respect, don't bring the profession into disrepute, don't sleep with the client, don't abuse your position of power - and you'll be alright.

The first 'argument' I wish to make is that this appears to be a very simplistic position on what it is and what it takes to morally relate to another. It seems to make out that it is far easier than it really is to be moral. It seems to take a particularly Old Testament, decalogue-ish, view of morality. Don't: murder, be adulterous, forget to pray, lie, slander etc., stick to the rules - and you're doing alright. (I don't mean to slander through absurd simplification the Jewish faith, and am not at all concerned with making a religious point, only with borrowing a certain, probably false yet popular, Christian conception of the relation of New to Old Testaments to make the ethical point at issue.) But the New Testament tells us it's not so simple as obeying principles such as not coveting your neighbour's wife's ass. Love your neighbour as yourself: is that an easy task? Can we even be confident what is to do it, or know when we've done it? Practicing open-heartedness is, instead, a never-ending challenge, whilst not stealing or murdering or sleeping with the patient is hardly such a burden. Christian writers, such as Rowan Williams, make clear how the spiritual life, understood in its moral dimension - as the cultivation of 'un-principled', un-conditional love - is something we have to continually work at, not simply through effortful self-discipline, but through the never-ending practice of openness, prayer, and humility.

So what about, say, respectful listening in the consulting room? Is it really so obvious when we manage to achieve respect? Is it just a matter of, say, not interrupting? Of course not! And what about treating the patient as a person. Is that an easy matter? To really, fully, acknowledge the otherness of an other? To not project one's own values or beliefs onto them? To achieve true humility in our listening? To locate the humanity in the most challenging of their endeavours or attitudes? To practice with integrity, to fully empathically respond to them, to convey to the client our recognition of their personhood - not in an interpretation but in, say, a spontaneous smile?

This kind of morality clearly speaks not to what massive abominations we refrain from doing, nor of or to a set of procedures or codes of conduct as to what is generally befitting of a psychologist. It speaks to what or who we are as human beings. Open-heartedness, genuine kindness, true compassion are character traits we have to work on, constantly, throughout our lives. It's often only when I'm back in touch with my better self that I realise the darkness in which I've been living - both inside and outside the clinic.

So my counter to a contrary temptation to say 'To be a good therapist it's not enough, you know, to be a nice person' is to ask: 'Are you so very sure that you have really appreciated, really tackled in understanding, the sheer amount of un-ending work it takes to manifest moral courage in the consulting room?' 'Are you sure that morality can be tidied away into injunctions and niceness, leaving the field open for a more purely 'technical' endeavour called, for example, psychoanalysis?'

Let me be honest: I think I can, truthfully, imagine a truly not-very-kind cognitive therapist, who in their personal life lacks integrity, nevertheless helping a patient to overcome their social phobia in the course of working their job through, say, both providing them with some knowledge about the maintaining influence of safety behaviours, and also by putting them through the paces of a desensitisation regime. (Computerised CBT also provides a good example, as do self-help books, of therapeutic strategies that lack any obvious moral dimension.) Or a hopelessly immoral psychoanalyst who nevertheless serves as a useful object for me to become conscious of the extent of my own disposition to project and of my typical unconscious assumptions about the way others will or should treat me. And I can imagine too that someone who happens to be nicer than the aforementioned therapists, and who has an equivalent merely technical capacity, will effect better results because they may, say, be just that good bit more approachable.

But it is also clear to me that, whilst the above-mentioned patient may have been freed from his phobia, he will not have achieved any change in who he is as a person. He will not have grown through the encounter; his self will not have changed. He will 'be better' in one sense only - in a quasi-medical sense of symptom-relief or change in underlying non-moral beliefs.

And I do not want to say, either, that the psychotherapist ought to be positioning themselves as a moral guide, or view their patients as wishing primarily to make moral progress. To simply collapse the psychological into the ethical would seem as misguided as trying to separate them out from one another in the manner I've been criticising above. What I am claiming is simply that, to help the patient to become themselves - to achieve some of their inmost potential and, through that self-becoming, to be able to relinquish their defences - it may perhaps be necessary for the therapist to be fully morally engaged in the encounter with the patient and for this moral engagement to be in no way be exhausted by, say, simply not being immoral. Achieving recognition of the other - through the receiving of which the other may now be able to change - is I believe not something we - those of us well educated in the theory and techniques of psychological therapy - can afford to take for granted as a straightforwardly cognitive endeavour. The depths of my own humanity are rarely readily accessible, and plumbing them seems to require a constant invocation of humility which, if I am honest, I frequently find hard to muster.