Tuesday, 20 March 2012

Beck and Psychoanalysis

Aaron T Beck
In the last few years I've come upon a couple of rather lazy papers that try to challenge an opposition between CBT and psychoanalysis by pointing out the Aaron T. Beck - the founder of cognitive therapy - started life as a psychoanalyst. Some even claim that CBT was 'rooted' in psychoanalysis.

The real story is rather different. But what interests me here, mainly, is just how lame Beck's rejection of psychoanalysis looks from today's perspective on what psychoanalysis actually amounts to. The story is told by Paul Salkovskis, arch critic of analysis, in the epilogue to his edited volume Frontiers of Cognitive Therapy. Whilst Beck certainly started life as a psychoanalyst, his theory of the causes of depression grew in direct opposition to his own psychoanalytical convictions. These convictions apparently included the view that depression always or at least typically arose from self-directed hostility. (Even when we consider Freud's Mourning and Melancholia, with its talk of reproaches of the object being directed onto the self once the identification with the ambivalently regarded object has taken place, we can see how simplistic Beck's psychoanalytical (ego psychological) theory really was. To say nothing, that is, when we compare it with more recent psychoanalytic formulations - see, for example, Trevor Lubbe's Object Relations in Depression: A return to theory.) Beck looked at the effects on the self-esteem of depressed people on their doing well in various tasks. Apparently he reasoned that if psychoanalytic theory were correct then depressed people who hated themselves ought to be distressed by doing well, and was then surprised to find that depressed people actually cheered up when they did well!

Paul M Salkovskis
What today appears as the extraordinary naivety of Beck's psychodynamic theorising goes unmentioned by Salkovskis, but this is perhaps not surprising given Salkovskis's own well-known animadversions concerning psychoanalysis. (btw, hear his contribution to this year's Maudsley debate on psychoanalysis here.) Beck writes to Salkovskis: 'I went back to my dream studies and I thought "Maybe there is a simpler explanation [of why people espoused critical views of themselves in their dreams than the idea that they are motivated to by self-hatred] and that is that the person sees himself as a loser in the dream because he ordinarily sees himself as a loser. ... If you take motivation and wish fulfilment out of the dream, this undermines the whole motivational model of psychoanalysis. I started to look at the motivational model all the way through, and its manifestations in behaviors, everyday slips, and so on. It seemed to me that the motivational model did not hold. Once that collapsed and I inserted the cognitive model, I saw no need for the rest of the super-structure of psychoanalytic thinking.' (Frontiers, pp. 535-6)

So, firstly, so much for the idea that CBT is 'rooted' in psychoanalysis. But more interestingly, how extraordinary to think that the content of dreams might not reflect the patient's general self-concept, along with all the patient's conscious and unconscious wishes, fears and drives. That at any rate is the general idea of analytical approaches such as Jungian dream analysis (see Marcus West's Understanding Dreams in Clinical Practice). Another question one might ask is whether or not someone's conception of themselves as a loser - both in their waking life and their dreams - is born of a defensively motivated identification with a childhood aggressor (a bully at school, for example, or a critical aspect of their father). Are we to believe that dreams never contain wish fulfilling elements? Only yesterday I dreamt of going to shut the curtains to get the sun off my face, only for the curtains to keep reopening - and then awoke to find the sun shining hotly on my head. Are we to believe that people who are depressed never suffer from harsh superegos, that they have not felt the need to suppress their id impulses for fear of their social unacceptability - for fear that love would be withdrawn or that they would go painfully unrecognised? Clearly, I believe, Beck would today be the last to deny that motivational dynamics such as these have any part to play in the psychogenesis or maintenance of psychological distress - whatever he might make of the value of psychoanalytic therapeutic technique.

It therefore remains a bit of a puzzle what we are to make of the birth of cognitive therapy out of his rejection of psychoanalytic therapy. I am however reminded of nothing more than the dramatic conversion experiences of rather literalist-minded devotees of a religion or of atheism into their opposite number. They always seem to be the ones with the dramatic backstory of 'I used to believe minus X but now I believe plus X'. We are supposed, it seems, to be more persuaded by the authenticity of their belief by the fact that they once held so closely to what is touted as its opposite. The real rhetorical effect, however, to my mind at least, is always to incline the reader to wonder whether the author had originally accumulated quite all the sensibilities necessary to fully grasp what was meant by X in the first place. If you start by thinking that unconscious self-hatred would invariably cause a sufferer (who is presumably a stranger to ambivalence, and hence a rather unlikely psychoanalytic subject) to be disappointed if they met with success in their life, it is perhaps no surprise that you end up a cognitive therapist...

Monday, 19 March 2012

What is Madness? 6
Lacan on the Oedipus complex

In this sixth post I continue reading Leader's What is Madness? and look at his explication of Lacan's version of the oedipus complex. My intention, to repeat, is not to critique the reading of Lacan (about whom I know next to nothing) but to try to understand what I can, and note what can't be understood by me, of Leader's Lacanian text. At the moment we are still on the preliminaries, in chapter 2, and will have to wait till chapter 3 to arrive at the Lacanian theory of psychosis.

Unlike Freud, Lacan 'sees the initial relation with the mother as problematic and uneasy. Closeness to her may be valued, but it is also a source of anxiety. She has the power to dispense love and care at her will. This gives her a real dominion, echoed in her delivery of nourishment.' (p. 59) My reaction on reading that is, I think, mainly one of sadness - that it is sad that Lacan - as I now imagine it - had such an experience of his own mother - and sad if this experience became universalised into a conception of an infant's love for its mother such that closeness may (but the contrasting and yet implicated may not speaks louder) be valued but may also give anxiety. I notice I'm having a similar counter-transference to this as I do to some of R D Laing's writings on love, seeing in them a troubling experience, born out of his own disastrous relationship with his mother, but then projected (in the non-dynamic sense) onto human love relations in general.

'Anticipating her responses', Leader continues, 'a basic trust may be established between mother and child, which involves repressing the very idea that her actions depend on her will.' What this means is not yet apparent to me. Leader continues 'This is a faith in the symbolic order as such, a fundamental foothold that makes the mother-child relation subordinate to the symbolic law that we care for our offspring.' What I think Leader is saying is that the child finds it scary that the mother can dispense love and care at her will because this means that it is only a contingent fact that the infant is cared for - it is terrifyingly possible that she may not be (if the mother wills otherwise). I don't yet see quite what this has got to do with the symbolic order though, but perhaps it is the following: that the trust that the mother will not abuse her power is to be thought of as coming about by the child's taking the mother, in her behaviour towards the child, to herself be subject to a general rule: love your children. The moral appears to be: it isn't enough even for a normally developing child that he comes to trust in the good-enough-ness of their mother, trust that he is loved. Rather he needs to back this up to himself with a normative guarantee: it doesn't matter if the mother might, merely under her own steam, be less than ideal - since she has to, is obliged to, love him. Again, I don't know what Lacan's evidence is for thinking this way, or why Leader follows him in this; we aren't told.

Leader tells us next (p. 59) that we can link the experience of an infant, who fails to get a clear sense that the mother is restricted in her (potentially abused) exercising of her will (perhaps because the mother does abuse this power and is intrusive; perhaps because the 'paternal function' / 'symbolic law' does not kick in), to the experience of a psychotic for whom things happen because of someone else's will... but says (correctly) that we will have to wait till a later chapter to understand this. 'The plane is flying overhead or the wind is blowing due to some plot or conspiracy, as if the basic situation with the caregiver had been generalized to the whole of one's reality. There is no mediation to show that the mother is herself subject to laws and constraints.' (p. 59). I don't yet grasp the link here. A child's bad relationship with a mother who is experienced as having an unchecked will becomes generalised into a paranoid experience of the world beyond as willed? A failure to repress the truth - the truth that the mother could exercise a withholding power over the infant if she didn't love him - leading to an experience of untruth - the untruth that unwilled events which have no relation to the subject, are in fact willed? We aren't yet shown how to understand the one as a generalisation of the other.

At any rate, Leader tells us that a key task for the infant is to come to understand and tolerate the mother's absences - to grasp what pulls her away from it (what pulls her away is called her 'desire'). 'Her absences show that there is something that draws her away. And this means that she is not omnipotent, that she is lacking: otherwise, why would she be so pulled?' (p. 60). The child may attempt to compete with this 'desire' of the mother, trying to seduce her, but will eventually come to see that the 'magnet beyond hte mother cannot be him or herself, but is linked in some way to the father.' (p. 61). Both boys and girls must now identify with the father. The boy stops trying to be the mother's love object, and instead accepts that he will become like his father. The girl stops trying to be her mother's love object, and instead accepts that she will herself be a mother one day. (I'm leaving out here talk of 'equations with a phallus' to stop my brain fron exploding.)

'For both the boy and the girl, this transforms the relation to the mother, as it establishes a horizon for her, a meaning that her actions are now linked to.' (p. 61) Such talk of a 'horizon' is at first obscure, but luckily Leader breaks it down for us. 'First the child registers that the mother is not all-powerful but lacking, and second, this lack is named'. I think the idea is that the child becomes able to think about their mother, rather than as it were be merely enveloped inside her mind. That sounds like an important part of individuation for the child. The fact of the father allows them to get some kind of emotional handle on their mother; she stops being the whole universe; she is in some important sense lacking and so cannot be all for the child, just as the child cannot be all for the mother.

Leader also gives us a clue as to what Lacan means by talk of the 'phallus': this term, apparently, is used not to describe the father's penis, but rather to signify that  without which the mother is emotionally incomplete. It signifies the mother's neediness, one might say, without specifying what exactly fills that need. Talk of the 'phallus' is, Leader says, talk of two things: one, the to-the-child saddening fact of the mother's limitedness; two, the welcome fact of a symbolic framework to enable the child to become emancipated from the mother's world.

These pages of Leader's text are exceptionally dense, with unfamiliar Lacanian idea after Lacanian idea tumbling after one another onto the page. As I read through the text very slowly my sense of the intelligibility of what is being said does however increase. Much of Lacan's version of the oedipus complex appears familiar to someone more versed in the Kleinian version. What appears different are largely the rather negative, 'uneasy', views of the child's first relations with the mother, of the view of the mother as lacking, the father (or other such third term) as mediating the child's relations with the world, the regimenting of the child's embodied desires, etc.

Thursday, 8 March 2012

What is Madness? 5
Lacan’s Name of the Father

‘Through language, the symbolic enters the real of our bodies and organises them for us. It inscribes the law within us, providing a principle of mediation.’ (p. 52)

I'll begin this fifth post on Leader's What is Madness by asking what to make of the above? Think of the ways in which the infant’s habits and desires are shaped – how their body is ‘organised’ – as they grow up. What do we normally think does this? Well, we think of the character of the attachment relationship, especially the emotional connection between mother and child, and then later father, mother and child, in the context of a particular culture. Language is a part of this, but the shaping of desire is not in any obvious way primarily organised by language. So, in reading the above 'charitably' we must take it to refer not to what gives shape to our embodied experience, but only to the way that the symbolic order gives shape to this experience. What is supposed to be mediating what (the ‘principle of mediation’) is not spelled out by Leader, so we must wait for it to emerge from the text to follow. But perhaps the mediation is between an individual’s instinctive desire and the interpersonal social world in which they become embedded?

Leader tells us that Lacan thought that there was a ‘privileged representative of this principle’ which with Heideggerian hyphenation he called the ‘Name-of-the-Father’. But when he tries to tell us what this amounts to, all we are given are a range of highly ambiguous descriptors with no clear rules of deployment or disambiguation. ‘Primitive’ people tended to attribute pregnancy to a woman’s encounter with a spirit at some sacred rock or spring rather than to coitus. Why?:

this ‘primitive’ lack of understanding in fact reveals for Lacan the true structure of paternity: that there is a difference between the real progenitor and the symbolic function of paternity that must frame reproduction. The spirit and the sacred space form part of the symbolic context of reproduction, necessary to symbolize it, to make it part of that person’s world. Without such a context, it is hardly possible for a human being to understand that they are at the origin of a biological process.

Yet without the specification of a context to help disambiguate the meaning of this necessary symbolism it is hardly possible for us to understand what the 'name-of-the-father' amounts to. Leader goes on to talk about the father as a symbolic being without which we are unable to 'situate' or 'organise' or 'make sense of' the reproductive act and its consequences. I am left feeling that there is something very important being talked about here, but as yet have no feel for what it is.

Freud and Little Hans
But perhaps an example will help. Leader first chooses Freud's case study of Little Hans and his dramatic horse phobia (p. 54). Hans, we are told, had a horse phobia from three and a half. In his preoccupation with the horse it either could or could not bite, fall down or remain upright, be attached to carriages etc. 'Hans was creating a system to reorder his world, creating prohibitions as to what he could or could not do, where he could go or not go, through the phobic object - the horse - that he was using as his instrument' (p.54). The idea appears to be that the boy was living in an anxiogenically rule-less world, and so unconsciously invented a phobic stimulus to provide a kind of order to bind his anxiety.

Why had he done this? Leader, following Lacan, singles out Hans' first erections mocked gently by his mother, and the birth of his little sister - both of which events disrupted his relations with his mother. In order to revise his relationship with his mother, the little boy needs his father's help. This father, however, was rather useless, and so the boy invents a father substitute - the horse - to reorder his world. Hans is 'busy appealing to the Name-of-the-Father, accessing the latter's function in order to move through the Oedipal involvement with the mother and to situate the new and disturbing bodily changes present in the erections.'

This, it seems to me, helps a great deal. Whether or not a real father is physically present, what Lacan is calling the paternal function is one of instilling order, rule, determinacy, and disruption of emotional symbiosis. What this has to do with language, per se, is not obviously clear to me. However when we think of how young children relate to language, sometimes obsessively categorising objects, needing to know what things are called, the powerful organising effects of language become clear. (When I was young I remember being obsessed with collecting stamps ('Oh it will improve his Geography': wrong,  I didn't give a damn where they came from), cataloguing words in lists, ordering knowledge in filing cabinets, collecting other neatly classifiable objects. The emotional wellsprings of the Victorian naturalist start to become apparent.) This in turn allows us to go back and interpret what Leader is on about when discussing how 'primitives' would attribute pregnancy to an encounter between a woman and a spirit at a sacred rock or spring rahter than to coitus. The 'symbolic function of paternity that must frame reproduction' is preparatory for the power of the paternal object, necessary for the child to develop and grow, and become himself, in the context of his family life.

Thursday, 1 March 2012

What is Madness? 4
Lacan's symbolic order

In this fourth post on Darian Leader's What is Madness? I continue my reading of his presentation of Lacan's ideas and their significance for understanding psychosis. My intention is to begin to get a handle on Lacan, distinguishing what makes sense to me and what isn't yet clear enough to grasp.

Leader begins his exposition of the symbolic order by describing it as a network of inter-related tacit rules (e.g. against incest) governing the family and society. This segues into a discussion of how language allegedly, and according to Levi-Strauss, introduces (p. 51) a 'certain negativity' into our experience of the world, 'building our worlds at the same time as creating a certain distance from them.' What this means isn't immediately clear, but the following ideas emerge from the text.

  • First, that entry into the symbolic order involves a transformation of lived bodily experience. The infant who is at first polymorphously perverse experiences a 'draining and restructuring of bodily excitation.' We learn when not to shit, touch ourselves, eat, talk, undress, etc. This symbolic system of rules 'clips the body, removing libido.' 
  • Second, that (what a Kleinian would call) the symbolic equations of a child, in which surroundings become fascinating because they are equated with bodily functions or parts (a hole in the wall evokes a vagina or mouth), need to be displaced by the symbolic order if terror is not to predominate. Without symbolisation, 'the world would just be one immense body and the hole in the wall might threaten to swallow up the child.' 'If too much of the body is present, we cannot enter a shared, social space.' 
  • Third, that psychosis can involve a failure of the symbolic order in the same way that Segal suggests (concrete symbolic equations of bodily functions and worldly events dominating over the system of symbolism proper).

For the moment I think I must just acknowledge that these ideas sound interesting, but give me far too little by way of determinate content for me to be able to adequately conceive of what would confirm or disconfirm them in the clinic. Perhaps Leader is not so much offering an empirical theory, however, as a way of thinking. About that I must as yet remain silent.