Monday, 31 March 2008

Panic and the Intentional Order

panic piccy

David Clark's panic model is well-known, and provides a perfect foil for the philosophical critique of certain strands in contemporary clinical psychology that is gradually unfolding in this blog. To pre-empt, this critique has it that:

  • Cognitive psychological models of psychological disorders often aptly describe the kinds of psychopathological processes involved in these disorders.

  • However they can often tacitly assume as a condition of normality what is actually a condition of abnormality.

  • That is, they can tend to assume a conception of our mindedness as, fundamentally, our being disengaged representers of reality. They can assume that what fundamentally grounds our understanding of our world is our thinking and modelling and hypothesising about it.

  • They may thereby cover over the real nature of much neurotic psychopathological disturbance - which can be summarised as the disruption of everyday, pre-reflective, intentionality, and the emergence of disengaged attempts to predict, reason, think, and control one's interactions with the world.

  • This everyday intentionality amounts to the kind of understanding that we carry around with us in our interactions, dispositions, bodily habits, affective responsiveness, praxical capacities - an understanding that is not grounded in, but which instead itself grounds, thought and representation.

  • Cognitive models of clinical disturbance tend to present the disturbed subject as someone in the grip of a faulty hypothesis, and in need of a better one.

  • Alternative hypotheses (provided in cognitive therapy) may challenge the catastrophic thoughts which maintain psychopathological disturbances. Yet whilst they challenge the catastrophic thoughts, and hence prevent run-away anxiety, much of the real work lies elsewhere.

  • It consists, in particular, in the strengthening and activation of behavioural and emotional modes of everyday intentionality. These modes do not primarily involve thought, but rather involve a pre-reflective engagement with, and unthinking trust in, the world.

  • In order to adequately understand psychopathology, we need to attend to the disruption of the underlying intentionality, and see this as the condition of possibility of catastrophising cognitions actually having a genuinely psychopathological impact.

  • That is, it is because of this disturbance of pre-reflective intentionality that we get trapped in a distinctive state of mind, typically untheorised as such by the cognitive clinical psychologist, which makes us prone to anxious rumination.

  • Thus, whilst the cognitive clinical psychologist describes what takes place when the subject is in this state of mind - the rumination for example - they do not theorise what it is to be in such a state of mind, nor provide us with the foundations of a theory as to what is disturbed or neurotic about this way of functioning. This, I suspect, is why we have a prevailing tendency within contemporary clinical psychology to 'normalise' much psychopathology. Because the 'norms' (everyday pre-reflective intentionality) are not themselves adequately theorised, it becomes impossible to understand why what can now start to look like merely quantitative variations in content should be pathologised.

So here's the nuts and bolts of the cognitive theory of panic disorder, as presented by David Clark (from chapter 6 of Science and Practice of Cognitive Behaviour Therapy.

  • People who experience panic attacks have an enduring tendency to interpret their own bodily sensations in a catastrophic fashion.

  • They interpret normal anxiety responses (e.g. palpitations, breathlessness, dizziness, muscle pains, and paresthesias (body sensations like tingling or pins and needles)) as signs of a serious health problem (e.g. heart attack, stroke, collapse, mental breakdown).

  • This misinterpretation causes further anxiety.

  • This anxiety inspires further anxiety responses, thus driving the vicious cycle.

Here's a pictorial example (taken from this GP training website:

Let me say first of all that I'm not here to deny the truth of what the model says - it seems intuitively in order. (An interesting aspect of the model, incidentally, is the way in which it challenges people (like me) who think it is often unhelpful to invoke efficient causality when providing psychological understanding, to see how that which appears to be in psychological order can be reconciled with philosophical anti-causalism.) What I want to question, however, is the comprehensiveness and sufficiency of the model. For it seems to me that, whilst it may let us know part of what is going on for the panicking person, it does not itself seem to feel the need to account for the panicking state of mind. It takes for granted the CBT premise that our affective responses are "cognition" driven. Because "cognition" (a possibly pseudoscientific term of art which covers a vast range of phenomena in a far less scientifically precise manner than do cognate English terms like 'thought', 'idea', 'rumination', 'understanding', 'opinion', 'belief') can do duty for both the catastrophic notions that occur to the panicking person, and for the understanding immanent within our everyday praxis (albeit that it often actually encourages the notion that such praxis is to be explicated in terms of an underlying order of tacit cognition extrinsic to it), the term covers over the phenomena which need to be understood. It presents us with a nice picture of 'getting in a state' or 'getting wound up', but simultaneously fails to theorise what the state is and what it is to get into it, leaving us all too often with only with a bland psychology of bodily reactions, cognitions, and mediating embodied emotional responses.

This, at least, is the critical idea I am exploring here. Let me say in advance why I think it matters. It matters scientifically, of course, just because as psychological scientists we want to get the phenomenology right (that is just what it means to be scientific here - to be careful, accurate, truthful, etc.). But it matters clinically because we need a way of tying together the clinical observations of the in-the-moment maintaining factors of anxiety with broader developmental concerns - e.g. insecure attachment - and biological concerns - e.g. vestibular disturbances - and psychodynamic (relational, personality-based, transferential and clinical) observations - that become apparent in the clinic with panicking populations. And we need to understand why some people may get better through non-cognitive treatments - in a way which does justice to this as a real phenomenon (rather than explaining it away in terms of cognitive changes that were nevertheless occurring unawares).

The phenomenologist's beef with the cognitive model of panic concerns two junctures which may at first appear contradictory. On the one hand, the cognitivist seems to suppose that an understanding of what panic disorder is can be had without understanding the disruption of normal intentionality that occurs in the condition. What I have in mind is the fact that the person who panics develops an intentional relationship with their own body - they take it as the object of their thought. It no longer stands as that from which they attend to the world, as the pre-reflective foundation of their experience, but becomes auto-paralysed when questioned by the mind. The body, or the functioning of the brain, can no longer be trusted. It becomes an object of fear, of attempted control - it becomes a ground or foundation which can no longer be trusted. Yet where are we to stand if the ground is shaky? Perhaps we avoid that bit of ground (safety behaviours), or perhaps we jump in the air and try to reconstruct the ground beneath us (magical thinking). In truth, when the structural disturbance of the ground is fairly pervasive, there is nowhere to stand (perhaps the sufferer stays inside the house). The cognitive theorist describes the catastrophic contents of the person's thoughts about their body, but misses the disturbed intentional relationship with the body. They do not discuss what we might call isssues of 'structure' or 'form'.

On the other hand, the cognitivist's conception of the sufferer's relation to their bodily symptoms as 'evidence' for an 'interpretation' (or rather, a 'misinterpretation') which has a catastrophic content, distorts the character of the sufferer's 'cognitions'. What I have in mind is that the kind of cognition that goes through the sufferer's mind hardly has the characteristic of an interpretation. It can of course be useful in therapy to frame the thought as an hypthesis - this gets the therapeutic process of substituting alternative interpretations or hypotheses off the ground. The decisive step, here, however, is not simply that which is described through the alternatives at the level of the content ('anxiety symptoms', not 'heart attack symptoms') of the thought, but the very move from an imaginal to a rational form of thought. The first was run through with primary processes; the latter, supported by the therapeutic relationship, has the character of genuine secondary process cognition. What gets lost here is not only the character of the catastrophising, imagistic panic cognitions, but also the conditions of possibility of secondary process, rational, reflective, hypothesising, interpretative thought.

Perhaps another image will help to make this clear. Here is a phenomenological image of everyday intentionality:

  1. Ground level, unanxious, bodily being.

  2. Supports our intentionality - i.e. our pre-reflective, affective, motoric, relatedness to the world.

  3. This supports our rational cognition, interpretations, hypotheses, etc.

In panic, we may surmise, we have:

  1. Disturbance of bodily being.

  2. Disruption of everyday intentionality, and emergence of self-focus.

  3. Self-directed cognitions which are catastrophic in not just content but in form: unstable, totalising, exceptionless, imagistic, etc.

The cognitive theorist aims to break the vicious cycle of panic by encouraging replacement of the content of the anxious 'cognitions'. And this, of course, is fine, since the effect is all well and good. Yet what is covered over is the dual sense of 'cognition' in play here - in the one case, imagistic, in the second case, rational. No cognitive therapist worth their salt would encourage the simple substitution of catastrophic with peaceful images. That hypnotherapeutic intervention fails to raise the quality of the thought to the rational and fails, furthermore, to provide the patient with a long-term solution. What they need is the capacity to draw on a resource of rational thought about their own panic reaction, to have some understanding of the nature of anxiety reactions, to be able to effect the cognitive manouevre of re-casting their bodily sensations as symptoms of anxiety rather than heart attacks or strokes or what have you.

What is also disguised by any approach which simply urges us to change the content of the cognition is a real understanding of the power of distraction (or, better, what Frankl used to call 'dereflection'). Once we understand the self-focus in panic as being an instance of disturbed intentionality, rather than of thoughts which a content which just happens to concern the self or body rather than the world, then we can come to understand the importance of re-establishing everyday intentionality again. We encourage the person to carry on with their business regardless of their sensations; we encourage the lived body to maintain its living intentionality. We encourage the patient to pick short-term goals, so that their temporality will not be hijacked by catastrophic cognitions. We understand, then, how a strengthening of pre-reflective intentionality can serve to prevent panic.

There are those who appreciate the simple-mindedness of the cognitive formulation of panic. This simple-mindedness is the appeal of the idea that we can practice psychology with a combination of learning principles and with a cognitivist's focus on the content of cognitions. What dismays me about this state of affairs in clinical psychology is not only its banality and breeziness, not just its explicit downplaying of the therapeutic relationship as anything other than a vehicle of the positive or negative therapeutic effect, and not just the existentially trite view of human beings as proto-scientists sustaining their connection with reality through rational inference-making. What dismays is the way in which so much of this is made to seem possible, reasonable, sensible, ethical through the un-negotiated premises of the theory. That is, once we have in place a view of the subject's comprehending relation to the world as grounded in representation and reasoning, it is hardly surprising that a focus on the ethical and relational and personal and embodied and affective aspects of personal being will come to be seen as distractions.

I've noticed I'm starting to rant, so had better draw matters to a close. To finish, however, consider the way in which the above-described banalised vision of the human mind and accordingly of the therapeutic relationship revealed itself in a recent episode of the excellent Radio 4 show 'Am I Normal?' (you can also listen again to this show, which will also enable the tone of the following exchange to be grasped). The topic was social phobia (sorry to change the subject...), and at one point there was an exchange between a young female CBT therapist (T) and a young male patient (C). Part of it went like this (verbatim transcript):

  • C: Mm.
  • T: So now we’re going to start challenging that [cognition of yours].
  • C: Mm.
  • T: Is it true that your saying one or another thing to the shopkeeper means that you are inadequate, odd, or stupid?
  • C: Erm … no.
  • T: Even if someone says something stupid, does that make them a stupid person? Is there such a thing as a stupid person?
  • C: Mm … I think, I think there is … But that’s obviously if someone does something that’s really embarrassing...
  • T: So there’s behaviours that are stupid.
  • C: Yeah.
  • T: But all of us do stupid behaviours.
  • C: Yeah.
  • T: So … is there such a thing as a stupid person?
  • C: [long pause]. Not really, no. Because I don’t look at other people and think ‘You’re stupid’.
  • T: Good [said in a tone of voice indicating the meaning: ‘You have answered correctly’].

I have no idea if this was a real or an acted encounter. But in either case, consider first the rational failures that T (the therapist) perpetrates. We have T and C both agreeing that everyone does stupid behaviours, and that doing a stupid behaviour does not make one a stupid person. Then T jumps to the extraordinary conclusion that there can't therefore be such a thing as a stupid person! (Whether or not the 'conclusion' is true or false, it is clear that no evidence for it is presented in the transcript. Just because non-stupid people can do stupid things doesn't mean that stupid things can't also be done by stupid people! It also obvious that this conclusion is not necessary for the apt challenging of C's putatively pathogenic beliefs: if C's belief that he is stupid is based in behavioural evidence, then challenging the evidence from the behavioural evidence should be enough to be getting on with...) C holds out for rationality for a while, but eventually gives in. In the process he is forced to come up with an alternative (equally bad) reason to believe that there is no such thing as a stupid person (he (claims he) doesn't look at people in such derogatory terms).

Now, perhaps unlike the prototypical CBT therapist, I don't myself believe that the global irrationality of this exchange need pose much of a problem for the progression of the therapy here. (What matters is the relationship, the gradual unfolding of shared understanding, and the genuine re-shaping of the patient's non-relective self-understanding in the context of the relationship.) What I want to note, however, is what can happen to the therapeutic relationship when the idea sets in that it is just the content of the patient's thinking that causes them their problems. The therapeutic relationship seems to go out the window, or is at least preserved mainly by the client who tries to accommodate to the therapist's forced-choice format. The therapist sets the agenda, the client tries to answer their school-mistressy questions as best he can.

The example is perhaps unfair. It hardly qualifies as an example of the cognitive therapist's beloved Socratic method. But it is not just the leading tone of the therapist that I am considering here. It is not just the method, but the goal. The goal is to change the cognitions which are supposedly underlying the social phobia. The perversities of the method are undoubtedly not all caused by the goal, but they are surely the kinds of hazards we can imagine once such goals are adopted. And what rationalises the goal is, I am claiming, a view that it is the content of the cognitions that must be changed. Once the view is taken that it is the content (and not the structure or form) of the cognitions that is driving the psychopathology, then it will be natural to adopt methods that aim to change this content. The categorical character of the cognition, the relevance of the subject's pre-reflective intentionality, and so on, is just covered over.

This post is straying rather wide of its remit, so permit me one further such stray. 'Third-wave' cognitive therapies often present themselves as having overcome the typical CBT therapist's focus on content. It is not the content, they say, but rather the person's relationship with this content, that matters. The goal, accordingly, is not to change content, but to change the way that the person entertains their thought. Do they see it as a thought which happens to pass through their mind? Do they see it as revelatory, absolutely disclosing of the truth - do they inhabit it or consider it? Can they be brought to a mindful detachment from it? And so on.

I feel sure that this is an advance over content-focused CBT, but am unconvinced that it provides a truly adequate phenomenology for understanding the psychopathology. (This may of course not be the goal of the ACT therapist, who is rather concerned to promote skillful means.) (Nor am I convinced of the merely facilitative conceptions of the therapeutic relationship that abound in ACT and other third-wave behavioural therapies.) For what we do not have is a seemingly free-floating notion of 'content' - conceptualised perhaps as 'inner word presentations' - to which we may adopt different relations. What I am wondering is whether or not a sleight of hand may be being played here by this notion of apparently free-floating content the form of which is provided by a simple relationship to it - a sleight of hand similar to that perpetrated by the generic notion of 'cognition'...

Friday, 28 March 2008

Shame and the Body

There are certain schema of explanation which pretty much define contemporary clinical psychology; schema which are inscribed into the very structure of what 'psychological' has come to mean; schema which come very easily to minds raised in individualist and modernist Europe and America; schema which pretty much trip off the tongue with an ease which itself should make us suspicious; schema which, I want to claim, only provide the illusion of understanding; schema which are hyper-banal; and schema which are bizarrely suited to to many of the phenomena they are used to theorise since the pathological features of the phenomena are (in a way unacknowledged by the theorist) mirrored in the theoretical sub-structure of the psychologist's schema.

Take bodily shame as an example. We know that shame is very much a bodily thing. We go red in the ears or in the whole face, we feel very awkward and clumsy, we look down. Perhaps we are also shamed by our bodies (acne, big nose, awkward gait, small or big breasts, you name it). Sometimes this shame reaches pathological levels (think of body dysmorphic disorder, or certain cases of social phobia and paranoia).

Here's the typical clinical psychological 'explanation' of shame. (No particular theory is being referred to - the focus is on the kind of theoretical substructure which I suspect would be in play framing pretty much any of the psychological theories one might look at.)

1. Bodily shame is understood as a two-part phenomenon. On the one side we will be offered mental representations. On the other side we will be offered bodily reactions.

2. The mental representations will be representations of my body and of the environment (including the representations in the minds of proximal others). My shame will be said to consist in my cognitive representation of my body as being a certain way.

3. The bodily reactions will in some not-quite-specified way (but doubtlessly somehow mediated (oh don't you just love that causal rhetoric in psychology of distinct states 'mediating' one another) by an emotion) be said to be caused either by environmental triggers or (when the problem is more entrenched) by the mental representations of the body. In the latter case we will probably get the beloved CBT-style vicious cycle: cognitive representation causing shame causing bodily reaction causing increased representations etc...

4. We will expect there to be predisposing factors in the body - tendencies to go red very easily, etc. Some kind of evolutionary explanation will be trotted out to account for bodily shame reactions in general, and which will also provide the theoretical resources (unfortunate gene inheritance etc.) for excessive shame responses.

5. And the rest of the explanation will sit with the cognitive factors. If I have body dysmorphic disorder or anorexia then this will be explained in terms of 'distorted cognitions about my body'. Or perhaps I have distorted representations about the extent or nature of my own bodily shame reactions. I'm not really going as red or sweating as much as others think I am. (I'm going to - oh-so-conveniently-for-my-own-critique - leave out reference to hypervigilance, body scanning etc., since these seem to me to be genuinely interesting and theoretically cogent postulates, and irrelevant to the conceptual critique I want to mount.)

6. If I am wanting to make some kind of a name for myself and get on with my career, I will elect to spend years collecting correlational, synchronous and longitudinal, data on the tendency of patients with different diagnoses or different symptoms to have distorted cognitions which have, as their intentional content, (aspects of) the patient's own body. I will also develop a theory which posits that these distorted cognitions have a causal relationship to the symptoms and to the emotions. If I'm scientifically minded enough, I'll spend years and cash performing regression analyses on the data. Hopefully I'll come up with a 'model' of the disorder, and this will probably be representable in a diagram, with component boxes joined up nicely by arrows etc. I'll sleep well when my inputs and outputs and intervening variables all line up right. I'll be able to adapt the model by 'positing' different 'mediators' or 'intervening variables', thereby keeping the research project alive for several years.

And, da-da!, there we have it. This is, I take it, the kind of sleep-of-reason pseudo-theory that passes for real psychological understanding in contemporary psychology. It's surrounded by enough sciencey language and practices (data gathering, model-making, those regression analyses) and formal rhetoric (talk about 'representations', 'cognitions', 'information processing', 'cognitive processes', and all those sharply drawn powerpointish boxes and arrows) to look respectable. We have the lovely old we're-so-post-behaviourist "input - intervening cognitive processes - output" conceit structuring the model. And so on. Familiarity with this way of representing psychological difficulties also gives the psychologist some sense of professional identity - in particular, this way of bringing together the technological (those boxological diagrams and regression analyses) and the clinical (pathological shame or what have you) fills out what the 'scientist practitioner' model might be all about.

So, well, what's actually wrong with it? Here's the bit I'm struggling with: it isn't completely hopeless; and its pundits are clearly sincere. Furthermore, because it all - at the surface - seems to make such perfect sense, there is a strong pull to cleave to it and resist any problematisation of it. And, worse still, because the form of thinking which such cognitive models rely on itself becomes so utterly totalising (I mean: it becomes paradigmatic for what counts as evidence, what counts as justification, what counts as reasonable critique, and so on), objections which come from outside are liable to simply look confused.

Nevertheless, I want to claim that these kinds of cognitive models: i) chronically distort the phenomenology (Response: "no I'm not, I'm just saying what really must be going on underneath the naively described experience"!), and ii) deploy unawares an indefensible philosophical framework (Response: "what, no I don't, this is a purely empirical model"!). i) and ii) work together symbiotically, the distorted phenomenology fitting together perfectly with the philosophical framework, thereby disguising the ultimate wrongness of the model. iii) fail to even consider what we could call 'existential' concerns - i.e. the person's changed relationship with the world. iv) correlatively, fail to theorise at all, the personality or self. v) accordingly, theorise any phenomenon which we would naturally understand in relational or self-oriented terms as due to underlying cognitions, and thereby get the cognitive horse before the existential cart.

These are big claims, and I'm not going to justify them all in one post. Let me start, though, with the first two. (The phenomenology of shame I deploy here is I suspect largely drawn (in memory) from Thomas Fuchs' excellent paper The Phenomenology of Shame, Guilt and the Body in Body Dysmorphic Disorder and Depression.)

The experience of bodily shame is, surely, an intrinsically bodily experience constituted by my embodied feelings. I feel - not, at first, think or believe - that I am the object of other people's gaze. Furthermore, my whole relationship with my body becomes disturbed. I no longer inhabit it unreflectively as a living centre of my experience, attending outwards from it to the world. Rather I become alienated from it, I become clumsy, I start to try to control it. I am beside myself.

Moreover the experience, whilst intrinsically rooted in the embodied self, is itself an experience of disembodiment. I become alienated from my lived body, a body which becomes an object of attention rather than the medium of my relation to the world. I start to experience myself as another might experience me. My entire existential relationship, both to the world and to my bodily self, is turned in on itself.

The meaning of this experience is carried in the experience itself, and not in associated beliefs about it or about the body or the gaze of the other. Any such associated beliefs get their distinctive meaning not from thought but from the embodied experience.

The cognitive theory theoretically pulls apart the normal body and mind, in order to set them up again as two causally interacting phenomena. Thus the thinker is theorised as a combined representer of their own body and as a cause, via the biomechanics of the emotions, of certain bodily reactions (picture certain bodily shame as a runaway reaction cycling between body and mind). Yet this isn't how we normally experience our bodies. The whole phenomenon of our actual embodiment - the fact that we are our bodies is missed. Our essential animality and corporeality is lost. The intentionality of the body - the way we are directed bodily towards our environment, in our skills and habits and postures - the way in which our bodily skills and habits disclose a world to us - the way in which the affordances of this world, the basic way it strikes us as holding significance, are fundamentally bodily in nature - the whole praxical fit of the embodied self with its lived environment - this is all lost in the theory. We instead become disembodied representers, all meaning being created in the mind out of the deliverances of the senses, deliverances which might happen to include the subject's own body.

But what is most striking to me, in the present instance (and in many other cases such as psychosis - as Louis Sass has demonstrated), is the way in which the underlying existential presuppositions of the cognitive theory (the disembodied mind containing all the meanings, the body left out as a kind of dull mechanism) so nicely map onto the psychopathology. For this is just what happens in shame: the body becomes un-lived, the mind becomes dis-embodied, and a merely causal self-reinforcing feedback relation can get set up between the two. What the cognitive theory hides from us are the very conditions of possibility (i.e. the disembodiment of the bodily self) of this happening. These conditions are abnormal by their presence. It is through an understanding of these conditions of possibility that we actually start to understand shame. But the cognitive theory ignores these, since it brings them along in its general and in-apt alienated theorisation of human nature.

If we just automatically deploy dualistic frameworks in which meaning and intentionality are relegated to an interiorised mind containing mental representations which picture the world for the subject, and the body is relegated to playing a merely mechanical part in a natural world, a body under the motor control of the representations in the mind, then all sorts of lifeless pseudoexplanations of psychopathology appear possible. Lets take a look at how it happens. First we theorise normal human nature in terms of this framework. Then we reduce a psychopathological condition (chronic misplaced bodily shame reactions) to that of normality, albeit normality tacitly theorised in the alienated terms of the standard model. Then of course the psychopathological condition starts to look as if it makes sense. It looks like a perfectly intelligible response a person would make if they were unfortunate enough to be given (at the bodily end) the genetic starting point and (at the mental end) the mistaken mental representations that are posited to obtain in the pathological case. Yet once again pathology is reduced to mistaken cognition or to bodily hypersensitivity. We fail to understand the logos, the real meaning, of the psychopathology. It eludes us because human nature itself has eluded the underlying theorisation of normality within which the psychopathology is understood.

Once we grasp how the cognitive model distorts: the unity of the healthy lived body, the environmental meanings and bodily understandings, the lived intentionality of the subject who at one with their lived body attends comprehendingly with their reactivity, feelings, dispositions, to the saliencies of their lifeworld - then we can start to recover a sense of what our normal existence consists in. And once this is in place, psychopathological conditions can be understood as disturbances of our normal existence, abnormal forms of relation to the world, to the self, to the body. Disturbed cognitions can in turn be understood to arise out of the prior disturbances to the intentional field in which they are rooted. The banal pseudo-understandings offered by the cognitive models can be set aside. And the logos, the meaning of the symptoms, can finally be understood.