Sunday, 24 May 2009

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.)

Saturday, 23 May 2009

before mind and body

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'.

Sunday, 17 May 2009

don't ask why

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'.


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.