Wednesday, 23 December 2020

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

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

Cooper's Argument

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

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

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

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

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

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

Cooper finds this reconstructed argument invalid:

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

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

Critique

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

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

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

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

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

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

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

Sunday, 20 December 2020

relational psychiatry

 I've posted my latest piece on Duncan Double's 'Relational Psychiatry' blog instead of here. In it I articulate different senses of relationality and urge that we don't weaken relational thinking in psychiatry by conflating them.

Saturday, 21 November 2020

why we panic

A classic CBT formulation of that panic which is met with in panic disorder - a formulation owed to David Clark - looks like this: 

clark's cognitive model panic attacks

The idea, I believe, is that we're to read the arrows as meaning 'and then this leads to...' We might say that they're perhaps intended as 'causal' relations.

For clinical purposes the model is helpful. The clinician can share the model, and then, with the model now there to help organise a terrifying runaway experience, the patient can start to stand back from her experience too, put it into words, etc. (More on this later.) But does it mean anything to suggest that the model is empirically accurate? How, say, do we know the wheel really spins clockwise rather than anticlockwise? What tests could we run to show that misinterpretations lead to anxiety lead to symptoms, rather than these all being epiphenomenal products of some other underlying circular causal mechanism? 

The thing is, I don't think the questions I just asked are actually good questions. My point in asking them is to suggest that if the model is to be understood as it rather invites us to understand it - perhaps in 'mechanistic' terms - then they should be good questions.

David Clark
I mean, sure, you could say 'Well, I'll block out the interoception with a drug, and show that this reduces the frequency of misinterpretations'. Or 'I'll offer an alternative interpretation of the symptoms and we'll see if that reduces the anxiety'. But, well, so what? I mean, can we even understand what 'anxiety' is in the absence of physical/cognitive symptoms? Could we even have someone who is truly anxious, but who has neither anxious thoughts nor the physical sensations of the relevant sort? Can we really separate out the components of the panic experience into different domains so as to consider them as separable phenomena situated in bona fide causal relations? And are we really in the business of 'interpreting' our own symptoms? Is that the word we'd choose? Do I normally, when not afflicted by panic etc., interpret my bodily sensations as signs of anxiety? (It's certainly true that I understand them that way. But the criterion for me so understanding them is just that if, say, you asked me why I was feeling them, I'd say 'it's because I'm anxious'. And here I'd not be giving you a cause so much as situating them in their rightful place within that state we call 'anxiety'.) And when I misinterpret something, is it perspicuous to say that the thing I misinterpret leads to my misinterpretation of it? Or is this to confound the intentional relation between the interpretation and that which it interprets as a causal relation in the opposite direction?

Here's another thing. The value of the cognitive model, as I see it, is that it captures something of our ordinary understanding that panic involves getting in a spin. What the model doesn't explicitly thematise, but what it nevertheless aptly suggests, is that the panicking person has also lost a grounding contact with and in reality, and instead now hyper-reflexively takes what's normally the mere medium of his intentional relatedness to the world (his thoughts, feelings, bodily states, etc.) for its object. (I don't say that by way of offering a causal hypothesis, but instead offer it as a phenomenological articulation of what we already understand.) And we really don't need to think of anxiety as 'leading to' cognitive and physical 'symptoms'. Instead it 'includes' them; they 'constitute' it. And we don't need to think in terms of 'misinterpretation', as if normally we have a different, perhaps saner, interpretation in our minds. Instead what we have is the person becoming involuted, getting in a right state, anxiously worrying that he's having a heart attack or stroke or what have you, and not really being able to think properly any more. What the model misses here is the qualitative character of the state of mind the sufferer is now in: it's a state in which, because healthy exteroceptive reality contact has quite diminished, involves a loss of the capacity to clearly distinguish between fearful fantasies and realities. In the language of Minkowski, this mind has 'short-circuited'.

Viktor Frankl
This, in fact, is the state of mind in which young children and neurotics are not infrequently in, and it makes them very vulnerable to self-ratcheting troubles. And it's the state of mind for which a soothing, rationally grounded, sanely competent, consistently mentalising, parent or therapist can be very helpful. For the child or neurotic adult can, by experiencing the 'holding' that the therapist or mother etc. provides, enjoy the boons of their hyper-reflexive state now being down-regulated. In part they enjoy the benefits of what Viktor Frankl called 'dereflection': their intentionality, the directedness of their attention, is now properly focussed outwards again, onto the environment and life projects, rather than spinning about on its own axis and ratcheting itself up. They allow themselves to be reassured: the therapist seems to know what she's talking about. (It might not matter too much if she does or doesn't, so long as she seems to.) Ordinary mentalising returns; 'I'm feeling anxious' becomes available as a thought. And that thought itself performs its ordinary 'containing' function. ('Holding', 'containing': not parts of empirical theories; just words to describe what we all - I mean, those of us who have performed such functions for children and neurotics (including ourselves) - already know.)

In many ways, as I acknowledged in the second paragraph, none of this matters. It doesn't matter if the model doesn't quite pass muster. It doesn't matter if it inclines somewhat towards the pervily boxological and inhumanly scientistic offerings of the 'cognitive sciences'. It's at the least part of a techne of care, a way to help restore inner order. All that I really want to take a stand against here is the impression it might give us, and which I think it often does give us - that the kind of knowledge that really matters, to help the patient, is of a scientific or quasi-scientific or largely reflective sort. When really that's not the thing at all. What really matters - it seems to me - is the therapist's 'containing' and 'mentalising' function, and their natty pictures take their place in supporting the occurrence of this. (Again, I'm not offering these as empirical claims, but just as ways of describing what we all already know once we clear out the misleading causal claims and just try to describe the situation honestly.) It's their know-how, which is ultimately not something other than their very humanity, which is in play. Can they make themselves truly available for the patient, here, as a receptive mind, one that wants to understand the patient in his own terms, yet one which also brings an additional grasp of our possible human predicaments to bear upon the patient's experience? That's the question.

-----------

Just a quick postscript for trainees. I remember being so struck by the cognitive panic disorder model when training that I somehow thought that it was a model of all panic. But it's really not. People often panic - in a more one-off fashion, rather than in the panic disorder manner, either when the defences against unconscious anxieties break down, or when anxieties bubble over as the severe strains of life aren't adequately 'mentalised'. 


Sunday, 8 November 2020

inherence

Andy Clark
Does anyone know what - if anything - extended mind pundits mean by the mind's inherence in this or that part of the brain or local environment?

Here's the kind of thing they tend to say:

Is the mind contained (always? sometimes? never?) in the head? Or does the notion of thought allow mental processes (including believings) to inhere in extended systems of body, brain and aspects of the local environment? The answer, we claimed, was that mental states, including states of believing, could be grounded in physical traces that remained firmly outside the head.

That the mind is sensibly said to inhere, or be contained, or be grounded ('residing' and 'being realised' in, or 'supervening on', this or that are other favourites), is something the text just takes for granted, and we move quickly on. The only questions then on the table appear to be 'in what?' and 'can the mind really be grounded in that which is partly outside the head?' But what we're not told is what's here being envisaged by 'grounding' or 'inherence' or 'containing'. 'Consisting in' is another such term, and since reading Teichmann on Wittgenstein (Investigations §304) on sensations being neither 'somethings' nor 'nothings' (because it's not clear what 'consisting in' even amounts to when we're thinking of sensations), I've also become suspicious of the notion of the mind's 'inherence' - suspicious that we have more than an illusion of sense here.

Roger Teichmann

What does someone have in mind when she thinks of inherence? Dictionaries tell us that 'inherence' in metaphysics means "the relation of attributes, elements, etc, to the subject of which they are predicated, esp if they are its essential constituents". Well, we predicate thoughts and feelings of people, not of brains or parts of the local environment, so that doesn't help us here. Or it ends the discussion too soon, since those who know how to use the word 'person' properly distinguish people from their peri-personal environs (the clue's in the words 'peri' and 'environs'). 

A side is predicated of a triangle, happiness of a happy man, and legs of a chair. What does it mean to say that the same relation is enjoyed by all of these? Or that happiness 'inheres in' the happy man, the chair leg 'inheres in' the chair? The answer I propose is simply that inherence obtains whenever the attribute or element in question is properly predicated of the subject in question - that (in other words) it truly is 'of' it. To return to the above extract, can 'believings' (whatever they are - I suppose they're the moments of our coming to our beliefs) inhere in the body, brain, or local environment? Well, no, not on this understanding of 'inhere' - since it's only people (or certain animals), and not their parts nor features of their peri-personal environments, that can come to believe anything. (And mental processes just aren't properly predicated of our organs; to think thus is just to commit the mereological fallacy.)

Online philosophical dictionaries don't have entries for 'inherence' or 'consisting'; Stanford however has one on 'grounding' - perhaps this will help? "Frank is sick in virtue of having a cold"; "an act is lovable by the gods in virtue of its being pious"; "complexes exist because simples exist": these are examples it provides of grounding statements. So might these 'because's and 'in virtue of's help us here? Might Frank believe that he's sick in virtue of certain processes obtaining either or both inside and outside his head - in the same sense of 'in virtue of' as is met with in 'Frank is sick in virtue of having a cold'? Well, no. These Stanford-provided 'in virtue of's seem to me to have their primary role in the order of justification: they tell us what we can appeal to if we're to justify our judgements that Frank is sick, that an act is loved by the gods, etc. (Statements not justifiable by reference to anything else are what we call 'brute'.) This, however, is surely not the sense of 'grounding' which the extended mind pundits who wrote the above extract had in mind. The ascription to me of remembering to buy eggs is not justifiable by reference to states that obtain, or processes that go on, in my brain or body or shopping list.

In Defense of Otto

Perhaps we'd do better to approach our problem from the other end. It is clearly true that my occurrent thinking about eggs bears some relation to events in my brain. We might say: the brain activity enables the thinking, and have in mind by 'enable' some kind of causally necessary condition for the happening of this singular event. Our question now becomes: is the sense in which my shopping list enables my recall of the eggs relevantly similar to the sense in which this or that in my brain enables my remembering of the eggs?

The authors of the above-quoted extract tell us "yes, sometimes", and this in part relies on their suggestion that the sense in which the information is stored on the shopping list is the same as that in which information is stored in the brain of he who does not rely on a shopping list. But what now does it mean to say that information is stored in the brain? It's not as if we store anything in our brains, in any normal sense of 'store' (as when we talk of a drugs mule storing cocaine up his butt). All it means here, I suggest, is that having a brain is causally necessary for retaining and recalling what one needs to buy from the shop (so that destroying some part of the brain will also result in the memories being lost). And for some people - forgetful people like me - a shopping list is equally necessary. 

So shall we now say that the answer is 'yes, we can make sense of the idea of the extended mind, and it seems a highly plausible idea'? Well... no. For it's news to nobody that some of us need shopping lists to get the right things from the shop. What motivated the extended mind pundit was not the notion that our need of shopping lists can be equal to our need of brains when it comes to getting the right produce. What motivated her was rather the idea of thought equally inhering in, being grounded in, being realised in, supervening on, residing in, brains and shopping lists... and we've still not arrived at any clear idea of what that is. The only clarification of some such relation that got us anywhere pertained to grounding, and in the sense of 'grounding' that then became clear, our recollections are properly said to be grounded neither in the brain nor in shopping lists.

This is why it seems to me that the thesis of the 'extended mind' ultimately amounts to nothing. Not, to reiterate, because really the mind is all safely stashed away in the head. But rather because we've not yet had a sense of 'stashing' ('being realised in' etc.) be put on our conceptual table that does any meaningful work, whether we're envisaging it to obtain only inside or also outside the head.


Monday, 2 November 2020

why is 'sorry' the hardest word?

I was recently asked this question, and found I didn't have a good answer. But it's a good question, and deserves a good answer.

The answer, I think, is that saying 'sorry' involves a double whammy of painful moral emotion. It essentially involves both guilt and shame. We feel the pain of our guilt in the acknowledgement of our wrongdoing: we 'feel guilty'. And then, when we say 'sorry', we feel the shame of being known for a wrong'un. 

Learning to say 'sorry' is a central achievement of such a childhood as goes well enough to produce someone who could be and have a friend. (That remark looks empirical but, given the inevitability of our failing those we love, is basically a 'grammatical' remark on the concept of 'friend'.)

By wronging you I rupture our relationship. (This is true regardless of whether you know what I've done: the relationship is still broken - because it now involves the living of a lie, however unwitting.) By seeking you out and apologising, the possibility of relationship (if you accept my apology) is back on the table.

In order to apologise meaningfully I need a secure enough sense of self. It can't be that the shame I feel utterly undoes me. And having a secure enough sense of self involves trusting that I'm lovable despite my failings.

A good parent coaches and supports the child in the above-described relational repair routine, showing an accepting love at the shameful moment of the child's guilty confession. A poor parent either does not accept apologies - if they continue to hold the wrongdoings against the child, weaponising the acknowledgement of guilt - or brushes them off as if the child hasn't really wronged them - thereby breeding a narcissist.

If you're well-rehearsed in the saying 'sorry' routine, you can benefit in addition from a dignity boon - of knowing that you've (at least now) done the right thing. Rather than holding your head in shame you can, if not quite hold your head up high, at least not be lost in endless self-recriminations. You did wrong; you've tried to put it right; you've owned your bad; and because you're even so a lovable human being, life can go on.

Saturday, 31 October 2020

psychosis, violence, and the fear of madness

The psychological community often attempts to combat the stigma suffered by the mentally ill by challenging the view that people suffering schizophrenia and other psychotic conditions are physically dangerous. We're often told, for example, that schizophrenic subjects are more likely to suffer than to commit violence. In what follows I'll unpick some examples of this destigmatising message from section 4.4 of the professionally representative 2017 BPS report Understanding Psychosis and Schizophrenia.

To spill the beans, I'll be arguing that this section of the (generally good, if excessively normalising) report underplays the dangerousness that schizophrenic subjects can present when unwell. However I'll also argue that the widespread fear of actively psychotic people is only partly due to a fear of the (real or imagined) dangerousness of their actions.

what the BPS report says

In contrast to media stereotypes, in reality few people who experience paranoia or hear distressing voices ever hurt anyone else. It is very slightly more common for people with psychiatric diagnoses to commit violent crimes than for those without such diagnoses. However, the difference in rates is extremely small: far less, for example, than the increased risk associated with any one of: being male, being young, having consumed alcohol or used street drugs, or having been violent in the past.28 

The reference (28) given to support this assertion leads us to a paper on the 'measurement and reporting of the duration of untreated psychosis' which has nothing at all to say about violence - presumably it's just a mistake. That no valid reference at all is given for this central claim is, I think, rather striking. The above quote is also potentially misleading: 'people with psychiatric diagnoses' is a very large category, and what we're surely interested in is whether people who have such mental illnesses as involve psychosis - in particular: schizophrenic illnesses - are significantly more violent than those without. (If you're anti-psychiatric by inclination, and disposed to read talk of 'mental illnesses' as somehow all by itself implying a biomedical approach, then help yourself out at this point by inserting 'diagnoses of ' before 'such mental illnesses'.) After all it could be that people who, say, suffer from depression are too apathetic to be violent, and so bring the total violence of the mentally ill down to the population average. In fact even limiting our interest to schizophrenic individuals may be misleading, since 8 out of 10 such individuals may be significantly less likely to commit violence than non-schizophrenic individuals (perhaps violence is significantly negatively associated with negative symptoms or the use of major tranquillisers, for example), whilst 2 out of 10 (perhaps the acutely unwell ones - i.e. the ones that people actually fear) may be significantly more likely to commit violence than those without schizophrenia. This potentially vitiates the suggestion a little later in section 4.4 that 

specific diagnoses like schizophrenia do not predict dangerousness.31

The reference (31) given here is to a paper on the link between violence and mental health (and drug and alcohol use) which found that 'if a person has severe mental illness without substance abuse and history of violence, he or she has the same chances of being violent during the next 3 years as any other person in the general population.' Limitations of this paper, however, are that it relies on self-reports of diagnosis and of violence towards others (might not people under-report their own mental illnesses and might some people who have been psychotic and recovered not recall their violence?), and that it includes both medicated and non-medicated individuals in the sample. (When we're thinking about the relationship between mental illness and violence, what we're surely wanting to know about is the relation between untranquillised currently psychotic individuals and violence. That, after all, is what we intuitively understand the alleged stigma to relate to.) Once again, perhaps young tranquillised schizophrenic men are less likely than an average young man to commit violence. That, however, doesn't touch on the worry of the uninformed member of public which is that actively psychotic individuals are dangerous. In fact the BPS report rather backs up this worry:

Most violence is committed by people who have never been in contact with mental health services and the overwhelming majority of mental health service users have never been violent.

For all we know so far (I turn later to the actual data) this could be because untreated individuals who are having a first episode of schizophrenic psychosis truly are likely to be violent.

The report also tells us that 

as a result of people’s fear and prejudice, mental health service users are much more likely than others to be victims of violence.36 

The supporting reference (36) given here is to a report written by Victim Support on 'the criminal victimisation of people with mental health problems'. This report, which looked at the experiences of a total of just 81 individuals with varying diagnoses, found (inter alia) that people with severe mental illnesses were five times more likely to be a victim of assault than people in the general population, and up to four times more likely to be victimised by their relatives or acquaintances. What this report doesn't show, however, is that being the victim of such violence is (to quote the BPS report) actually 'as a result of people's fear and prejudice'. (It does detail however that 25% of those interviewed - i.e. 20 people - felt that they became victims of violence specifically because of their mental health status.) Thus perhaps the reason why people with severe mental illness suffer more violence than those without is in part because they're more likely to be living with relatives or peers who are themselves mentally ill, or in part because they're visiting or detained in psychiatric facilities and are there more likely to be victims of violence from mentally ill subjects (9 individuals reported suffering violence on the wards), or perhaps because they're more likely to act in such a way as would, regardless of who was so acting, provoke violence. It's worth noting, too, that only 15 of these 81 individuals suffered schizophrenia; 40 suffered depression, 8 PTSD, 10 personality disorder, etc.

The final piece of the BPS report which I want to touch on notes that

The reason that people associate a diagnosis with violence is most likely a result of negative and stereotyped media reporting about mental health.32 A survey found that homicide and crime were the most frequent themes in media coverage of mental health.33 Films and television dramas also often depict people with mental health problems as violent and unpredictable.34, 35 

The supporting reference for the claim of the first sentence here is to a piece on the media's depictions of mental illness hosted on John Grohol's 'PsychCentral' website. Yet whilst this information piece does indeed aptly survey the negative and stereotyped media reporting about mental health, it doesn't provide evidence that people's association of diagnoses and violence is likely due to that reporting. In fact it doesn't even consider any other reasons. (Perhaps the reporting and the stigma are effects of another common cause?) The piece also makes the above-mentioned claim that "Studies have found that dangerousness/crime is the most common theme of stories on mental illness ... But ... research suggests that mentally ill people are more likely to be victims than perpetrators of violence."

 Here I want to re-emphasise that the 'But' is misleading - it tempts us to infer from the putative fact that mentally ill people are more likely to be victims than perpetrators of violence to a conclusion about how violent mentally ill people are likely to be compared to those who are not mentally ill. (Compare: "Racing car drivers are more likely to be victims than perpetrators of car crashes on the track". Yes, true... because it's more often that one person causes several others to crash than several others causing one person to crash. But that tells us nothing about how frequent or infrequent it is that one of these drivers causes a crash.) I rather suspect that there's something about this widely repeated claim that somehow stops us thinking clearly about the issue at hand.  

the literature on psychosis and violence  


I now want to consider a little of the data we have on the rates of homicide and violent assault by people with schizophrenic and other psychotic conditions.

Here's one data source relevant to the UK psychiatric scene. Every year the University of Manchester produces what is now called The National Confidential Inquiry into Suicide and Safety in Mental Health. This considers (inter alia) the homicide rates by 'mental health patients' over the preceding decade.

The 2019 report tells us that between 2007 and 2017 there were 732 mental health patients convicted of a homicide offence, and that this represents 11% of people convicted of homicide (i.e. there was a total of 6597 homicides - an average of 599/year - during this time). (Some good news: during this period the number of homicide convictions per year for mental health patients reduced from 74 to 38, and this was a more or less steady decline.) Recent reports no longer provide much detail about the psychiatric profile of these homicides; the 2015 report however tells us more. Thus between 2003-2013 there were 630 homicides by mental health patients (an average of 57 per year). This was out of a total of 5,835 homicide convictions (an average of 530 per year) and 6,141 victims (an average of 558 per year). In short, 9.3% of these homicides were committed by the mentally unwell. 55% of the homicides by the mentally unwell were committed by people with a history of schizophrenia (and other delusional disorders). Of these, 81% had symptoms of psychosis (delusions and/or hallucinations) at the time of the offence. 203 (59%) of those with schizophrenia were extant patients.

Consider now that the point prevalence of schizophrenia in the UK is between 2 and 5.9 per 1000 - let's call it 4. That's to say, that at any one point in time, 0.4% of the population suffers schizophrenia. (The rate of acute schizophrenic psychosis - which is what we're really interested in, I think, when thinking of stigma etc. - is considerably less than this. But I don't know what it is, so will ignore it for now.) Turning back now to the 2007-2017 data, we can reasonably estimate that between 2007 and 2017 there were (732*0.55=) 402 homicides committed by schizophrenic individuals. If I've got my maths right, this means that 6% of homicides are committed by people with schizophrenia despite the fact that only 0.4% of the population is schizophrenic.

To try and zoom in on the issue of acute psychosis, let's now consider the 2008 meta-analysis by Nielssen & Large of rates of homicide during the first episode of psychosis and after treatment. The paper notes that although 'the prevalence of schizophrenic disorders is usually estimated to be below 1% of the population, patients with schizophrenia comprise between 5% and 20% of all homicide offenders.' This tallies with the findings of the University of Manchester reports. To summarise, what Nielssen & Large find is that 4 in 10 of the homicides committed by people with a psychotic illness occur before treatment, that 1 in 700 people with psychosis commit a homicide before treatment, and that 1 in 10,000 patients with psychosis who receive treatment will commit a homicide each year, so that the rate of homicide in psychosis before treatment is 15 times higher than the annual rate after treatment. (It's not germane to the argument, but I think it telling to compare this 1/700 figure with the fact that as many as 1/10 of schizophrenic subjects die at their own hand within 10 years of diagnosis.)  

In the above I have focussed only on homicidal violence. But what of aggression that doesn't result in homicide? For now I'll consider just Milton et al's paper on aggressive incidents in first-episode psychosis. These authors considered 168 consecutive patients 􏰀􏰀(aged 16-64 years) with a psychotic illness making first contact with psychiatric services in Nottingham 􏰀􏰀UK between 1 June 1992 and 31 May 1994. 9.6% of these subjects demonstrated at least one act of serious aggression (weapon use, sexual assault or victim injury) during at least one psychotic episode, and a further 23.5% demonstrated lesser acts of aggression. (It's worth noting, I think, that􏰀, unemployment and comorbid substance misuse had independent effects on risk of aggression.) In short, 1/3 of the patients in this sample suffering a first episode psychosis were aggressive.

What of the rates of mental illness in the population of individuals who commit sexual assault? According to Sorentino et al's 2018 review paper on sex offenders, the evidence on the prevalence of psychotic disorders in sex offenders is mixed. Some studies found low rate of psychotic illnesses in this population. One small study found no evidence of a psychotic spectrum disorder in 113 men convicted of sexual offences. Other studies found psychotic illnesses to be associated with an increased risk of sexual reoffending. One found psychosis to increase the risk for sexual recidivism in sex offenders with mental illness; another found that sex offenders were 4.8 times more likely to receive a diagnosis of schizophrenia and 3.4 times more likely to have bipolar affective disorder. The 2017 review by Lewis and Dwyer cites studies finding that 5-10% of sex offenders have psychotic disorders, and that male sex offenders were 5 times more likely to receive a diagnosis of a psychotic disorder than non-offenders. We should also consider the possibility that the disinhibiting effects of psychosis can amount to more aberrant sexual activity in the home which parents and siblings may not report for fear of their mentally unwell child or sibling being branded a sex offender.    

what does it mean?

One of the questions with which we started was whether it's rational to be frightened of being attacked by someone who has a schizophrenic illness. Given that 'only' 6% of homicides are committed by people with schizophrenic illness (11% with mental illness), then - if you're imagining going for a walk and being worried about being assaulted or killed - you should be more worried that someone without a mental illness will kill you. And, recall, there's only a 0.00088% chance of your being homicidally killed by anyone in a year - and so only a 0.00008% chance of being killed by someone who is mentally ill, or a 0.00005% chance of being killed by someone who is schizophrenic. But you might consider matters rather differently if you're living with someone suffering a first episode psychosis and you are worried not about homicide but about being violently attacked. (There's a 0.003% chance of being killed in a car crash in any given year. ... But if you're standing right in front of a car speeding towards you, there's perhaps a 100% chance of being killed.) In that case, keeping in mind that perhaps 33% of people experiencing such an episode may understandably become violent, and that 1 in 700 will kill someone, may be helpful.

why are we frightened of serious mental illness anyway?

Now, an interesting fact about anti-stigma campaigns regarding mental illness is that they don't really work. One possible reason for this, of course, is that the media continues to spew stigmatising or otherwise exaggerating messages about the dangers posed by people with significant mental illnesses. But reflection alone reveals, I believe, that it’s the psychotic individual in his psychosis who is feared, and not simply such of his acts as would be fearful whomever commits them. We’re disquieted by his acts under the description of ‘psychotic’, not simply under the descriptions ‘violent’ (or ‘sexually perverse’ or what-have-you); we – and he when sane – are disturbed by his delusional peculiarity, by his unrelatability of expression, by his baffling admixture of comprehensible humanity and what can seem like an inhumanity which is, other than (sometimes) motivationally, as such incomprehensible. Whilst the formation of delusions and other psychotic experiences may be motivationally intelligible, this speaks not at all to their rational intelligibility – to our ability to really ‘find our feet with’ or ‘get’ them – which is what we cannot do with the truly delusional subject. It is such foot-finding failures that are intrinsically jarring and deeply disconcerting.

It’s worth recalling that we’re not inexorably disquieted by what we don’t understand or relate to, or by what we find unpredictable. We’re typically emotionally disturbed neither by quantum physics, nor by the birds of the air, nor by the normal vagaries of the weather. Instead we blanch at that which is both close yet alien, i.e. we’re phobic of such phenomena as appear to us under the aspect of the monstrous. We fear what invites our efforts at understanding but then pulls apart our minds in the attempt. Thus we tremble neither at the dead nor at the living but at the undead. Thus we fear the psychopath all the more because of the extent to which he is, despite his deathly inhumanity, largely humanly intelligible. Thus we fear the beast who is half human, half animal. Throughout history our cultures have thrown up endless icons of the monstrous, from the minotaur to Frankenstein’s monster – to help us articulate, and thereby gain some small degree of purchase on, such otherwise thought-stopping terror. 

With respect to psychosis, now, what we fear, I suggest, is that unreason which is no disturbance of inference-making or truth-telling but rather a more primordial disturbance to thought’s footing; we’re made anxious by this jarring disconnection between us; we tremble at this unmooring within the psychotic individual – an unmooring which, when we attempt connection with her, threatens to also unseat our own basic orientation in the world. We fear this reminder that it’s but a contingent fact that we too aren’t also trapped in a waking dream, that insight can’t be secured through reasoning or will, that the anchor chain of our mind does not break and the ship of reason be flung about on the dementing wave. And if we're afraid thus, we should remember what far greater terrors beset the psychotic individual herself. We might not be able to enter into them - and there's an important sense in which neither we nor the psychotic subject herself can comprehend her psychotic experience - but we can surely understand something of how terrified she is, and agitated, and fragile, and how likely to lash out she is because of that.

Why am I banging on about all this? Well, to overcome stigmatising reactions I believe we do well to first articulate our concerns, and understand their basis, so they may then be faced with understanding. This prevents our ignoring them by misarticulating them as, for example, being due to our overestimating the risks of the physical dangerousness of those with psychotic mental illness. This work of understanding inevitably involves work on oneself, and work on oneself is typically not a matter of learning further facts about the afflicted, but rather a matter of one’s own gradual moral transformation, the careful deactivating of one’s own defences, the growth in one’s own tolerance for the alien, the owning rather than the projecting of one’s own monstrous aspect, and the growth in one’s ability to hold onto that in the other to which, despite all that is awry, we can yet offer recognition. It is perhaps no real surprise that it's properly knowing someone with mental illness – not simply being acquainted with them – and certainly not just learning some general new information about mental illness, that is one of the best predictors of a greater tolerance for the mentally ill.


Monday, 19 October 2020

depression's causes

What causes depression? The question looks simple, doesn't it? But it occurs to me - on reading the newly minted BPS document "Understanding Depression: Why Adults Experience Depression and What Can Help" - that it really isn't.

The reason is that proper causal questions are always 'situated'. Their situation constrains what shall be counted a good answer to them. And what counts as an apt situation is not itself something explicable independently of the interests and values of the questioners. And the thing is, just asking 'what causes depression?' utterly in the abstract, as I just did above, is to ask the question without any situation at all. I would like to say that, so far, it's only really the bare outline of a question, one that still needs to be given a determinate context of use before anyone could meaningfully set about answering it - perhaps before anything much can even be meant by it.

Here's a non-causal example of what I mean by 'situation'. I take it from the Preface to the Scholium of Newton's 'Principia'. A chap's walking along a ship. And now for the seemingly innocent question: How fast is he moving? Well, he's walking at 4 miles per hour from stern to hull. But then, consider, the ship is going at 10 miles per hour across the sea in the opposite direction as the man is walking. So relative to the sea, the chap's going at 6 miles per hour. Ah, but the water and the planet of which the sea is a sea are moving through space, relative to the sun, at 10 gazillion miles per hour.... So... etc etc. Newton thought there was some 'absolute' velocity that the chap had ('through absolute space' as it were), but at least since Einstein we've clocked that such talk of 'absolutes' is meaningless. We always need a frame of reference - i.e. a situation - for our questions before they even enjoy a sense. Asking 'how fast is the chap moving?' without specifying a frame is not yet to ask anything. And so too, I suggest, is asking 'what causes depression?' Consider the following 8 perspectives:

  • Perhaps in a social utopia, one in which everyone feels valued by society as a whole, in which everyone has the opportunity to take up deeply meaningful labour which utterly satisfies them, in which everyone has the opportunity to make deep socially cohesive ties, there is no or very little depression. Does this mean that we should count social factors as the real cause of most depression in our non-utopian society?
  • Well, now we notice that, in our society, some people with shitty or no jobs, and some loners, are in fact not particularly unhappy, and certainly not clinically depressed. Does this mean that it's not the miserable social and economic situation that makes the others depressed? Perhaps, someone now suggests, it's just the way that some people interpret or cope with their admittedly non-ideal situations that makes for depression. Does this mean that the real cause of depression is psychological and not social?
  • But now the socially-minded questioner comes back in. She asks: well, where do these interpretations and coping strategies come from in the first place? Might it not be that the reason why some people have dismal ways of looking at their situations is that they were raised in dismal conditions, that they didn't have the opportunity to internalise loving self-relations and so form such self-esteem as can carry one through a difficult time? So perhaps the real cause is social after all - or at the least, familial? 
  • But then someone else asks: why are you setting utopia as the apt situational context against which these questions are to be raised? Why not instead deploy the fairly tough situation that many serfs suffered over the last thousand years as the relevant situation? If you can't cope with that without getting depressed - well that's on you, not on society! - or so they say.

  • Or, imagine now that we find that some people who basically have the worst possible jobs, and extremely dismal social opportunities, are as blissful as a Buddha. How do they manage this? Well, perhaps they have some rather unusual genes. Or perhaps they had incredible parents that gave them an invincible self-belief. Or perhaps they really are Buddhas. Shall we now say that the real cause of all depression is not having those genes? Or not having parents like that? Or not being enlightened?
  • Someone else joins the discussion. It turns out he's interested in what the 'material' rather than 'efficient' causes of depression are. Perhaps he particularly notices the slump, the downward gaze, the loss of energy, the low mood, the constant fluttering anxiety, etc, and he gets interested in what in the brain and body constitutes the 'flesh' (as it were) of the depressive reaction. He tells us a story about the gut, the autonomic nervous system, certain neurotransmitters, etc. These, he says, are the 'true causes of depression'.
  • And then a psychoanalyst comes along and notices how many of her depressed patients haven't yet developed certain ego strengths. They tend to capitulate. They don't know how to stand up for themselves. They don't really have a sense of what that would even mean. They lack self-possession. In short they have a 'depressive personality'. But then the question arises: what degree of ego strength shall be considered normal?
  • Or an evolutionary psychologist comes along - perhaps someone who's been reading about Jordan Peterson's blessed lobsters - and invites us to look at why such submissive traits were ever selected for. Here's the real cause, she says - it's in the natural selection of behaviours apt to promote the survival of the less powerful in dominance hierarchies. 

Now here's the thing. One very often finds that, looking at the above panoply of causes, broad-minded psychologists tell us that 'well, there are clearly lots of different causes of depression. Our model should therefore include all of them'. (The 'biopsychosocial model' rather takes off from there.) But - and here's my main claim - this is potentially just a real muddle. At face value it's almost as wrongheaded as someone suggesting that 'there are actually lots of different velocities of the chap on the boat, and our answer should contain them all'. In other words it makes a logical mistake. It confuses the fact that i) sometimes a causal question with a particular situation can receive more than one answer (Why is the floor wet? Danny spilt his water bottle; a pipe leaked; Sandra was bleeding the radiator) with the fact that ii) in different situations different answers will count as apt responses to the same question. (Here, by 'same question', I just mean: the same chain of words with a '?' on the end.) 

Note that I'm not, here, spilling an excessive amount of ink to make a point about (say) the difference between 'proximal' and 'distal' causes, or nomothetic vs idiographic explanations. The point I'm making instead has everything to do with what is the implicit or explicit 'situation' of the questioner's question. This situation, and not simply the facts, determines what shall count as apt answers to the causal question.

I want now to comment on the fact that people can differ a lot on what they consider an apt amount of ego strength in others. Those on the political right sometimes think that people can reasonably be expected to have more strength, and be held more accountable for their travails, than do those on the left. Someone on the right will think: 'lack of self-possession' where someone on the left thinks: 'lack of social support'; someone on the left bristles when someone on the right talks about a 'problematic lack of resilience'. Here I note that there's no straightforward factual answer as to which of these viewpoints is correct. They presuppose different 'situations', situations partly defined by different values. I don't mean that that's the end of the discussion between the pundits of the social and the individual causes of psychiatric difficulties, since there are further psychopolitical discussions to have at this point. (Someone on the right might convince someone on the left that his perspective was utterly naive, that he was holding double standards regarding the accountability and moral motivations of different groups of people, etc. Or perhaps someone on the left convinces someone on the right that she's been hardening her heart in a way that distorts her capacity to see the truth, or has been projecting her guilt or fragility into others. Welcome to the human conversation!)

To end, a little comment on the BPS depression report. I think it does an excellent job of showing us what becomes visible as the causes of depression when what we're looking through is what we might call the window on the left. (It states, without giving evidence - and so presumably what we have here is more a moral than a scientific perspective - that depression is never a moral matter, i.e. never involves accountability or choice. It focuses heavily on oppression, bullying, abuse, stresses of parenting, austerity, social disadvantage, gender, migration, marginalisation, prejudice, discrimination, even climate change.) But what in my view it doesn't do is sufficiently own that it's looking through the left window, and doesn't acknowledge that if we look through other windows, and so differently situate our causal questions, then a rather different set of causes become visible. And what really strikes me about this report from the Clinical Psychology division of the BPS is how it focuses rather more on the social than on the truly psychological. Again, I've nothing against looking through the left window, but it's a peculiar situation we're in when the impetus to do that rather disappears the profession's defining object of interest. (The only real place where the purely psychological gets a look in is in a section on 'schemas', and even here the relationship between schemas and childhood experiences are what is highlighted.) As a clinical psychologist working in psychotherapy - i.e. when I've that hat on from my hat collection - what I'm principally interested in are the workings of the psyche. I'm interested in how people unconsciously demoralise themselves, void hope before it gets a chance, close over to love before it can warm their hearts, sap the wind from their own sails before it could blow their ship into a conflictual course with close others, take their own minds apart in desperation at the pain that will be felt if they don't, even as adults keep flogging the dead horse of a hopeless parental relationship long after others can see that the parent never was up to the task of parenting, are stuck in unwitting and semi-witting cycles of miserableness which at least bring fate under their own control, have bought for whatever reason into depressogenic beliefs about their worthlessness and unlovability, and so on and on. I'm interested in how much of this happens in the grey zone between what utterly exogenously happens to one and what one culpably does. I'm interested in helping people recover their full agency and so take on more responsibility, or adapt (e.g. in grieving) to that over which they've no choice, or for the first time grow the parts of themselves that got stuck in childhood. That none of this was visible in the report tells us, I suggest, a fair bit about what today it means to be a psychologist, at least as the BPS sees it.

Saturday, 5 September 2020

being philosophical about it

A talk for Confer: Confronting Mortal Threat / Oxford Psychotherapy Society
5.9.2020 / 14.10.2020


‘Wisdom is a tree of life to those who lay hold of her; 
fortunate are they who embrace her’ (Proverbs 3:18)

Abstract

To be ‘philosophical’ or ‘stoical’ is in part to remain calm and able to think in the face of adversity. But how have the sages suggested we achieve this? And how can their deliberations be drawn on in the consulting room without therapy degrading into intellectual discussion? In this talk I discuss the relation of six virtues -
  1. the cultivation of healthy pride (dignity), 
  2. the development of ego strength (inner courage), 
  3. amor fati (getting with fate’s program), 
  4. the will to power (determination, outer courage), 
  5. receptivity to grace (the cultivation of gratitude), 
  6. and seeing life sub specie aeternitatis (the bigger picture) 
- to the life ‘philosophical’ and to the existential anxieties attendant on living a necessarily vulnerable, dependent, human life. Of particular importance for therapeutic practice is the distinction between i) embodying, modelling, and cultivating and ii) merely talking about such virtues. The embodiment of these virtues is what we call ‘wisdom’. The person who’s wise can take a step back and recall the longer-term perspective, can get the true measure of things, remember that anxieties pass, remain self-possessed - and thereby be less anxiously vulnerable in the face of life’s vicissitudes.


Introduction 


As psychotherapists we hear and talk a lot these days about the ‘regulation’ of emotion, affect, and anxiety. We’ve all learned about the importance of mother’s sensitive regulation - through empathic attunement and soothing - of her child’s affective experience. We’ve learned how this regulation is internalised in that healthy emotional development which allows a child to recognise, tolerate, understand, and appropriately guide his behaviour in the light of, his feelings. We’ve learned about how dysfunctional or semi-functional affect regulation strategies - strategies for ignoring or suppressing, projecting or denying, devaluing or converting painful feelings - i.e. superego function and ego defences - cause and maintain psychopathology. And we’ve hopefully also learned something about the significance of psychotherapy for the deactivation of such defences and for the provision of more adaptive affect-regulation strategies.  


What we psychotherapists don’t hear and talk a lot about, though, is the moral life - by which I mean, here, the life of our virtues and vices. Perhaps this is because psychoanalytic psychotherapy’s earliest understandings of that life were all too often of internalised social pressures acting to constrain the id, preventing it from becoming ego, and causing hysterical psychopathology. And not infrequently psychoanalytic psychology has, I contend, simply conflated superego functioning (inner fear-based prohibitions governing the animal soul) with true conscience (our awareness of when we act out of unloving selfishness). Morality, now, becomes equated to something like anti-liberal censoriousness, and psychoanalysis’s job becomes that of combatting it to the end of emancipation from internalised tyranny. A danger of over-reach here is that the emancipation of the psychological ego (i.e. of what psychoanalysis calls ‘ego’) becomes an enslavement to the moral ego (egotism) - i.e. that self-stifling becomes replaced with self-interestedness. At any rate, this is all by way of saying what I don’t mean here by ‘morality’ - I don’t mean governance by oppressive mores - and by way of introduction to what I do mean by it - namely the domain of the virtues. That is, I mean: caring, commitment, compassion, courage, courtesy, dignity, diligence, friendliness, gratitude, honesty, humility, joyfulness, loyalty, moderation, perseverance, reliability, etc. And their vice counterparts - bitterness, boasting, dishonesty, greed, sloth, vanity etc. 


Now, why am I talking, in this Introduction, together about anxiety regulation and the virtues?  It’s because I think that we psychotherapists have long been missing a trick. So focussed have we been on the importance of psychological self-understanding for regulating anxiety that we’ve ignored the power of moral self-understanding for the same end. I don’t mean that the point of the virtues is anything as banal as the regulation of anxiety - but I do mean to make some propaganda for the ideas that a virtuous life is a life in which we’re most fully human and humane, and that this life intrinsically regulates anxiety


Let me give you an example: Orval Hobart Mowrer was an American psychologist, one time president of the American Psychological Association. He suffered from periodic severe anxious depressions. Influenced by Harry Stack Sullivan, Mowrer comes to see these as the result of guilty secrets he carries within himself. On confessing to his wife Molly that he’d had an affair, he experiences considerable relief from his depressions. Rather than being stymied by neurotic guilt, it was - Mowrer concludes - real guilt from which he’d been suffering. That is, he’d been stifling the cries of his conscience, and this prevented the adequate formation of feelings of guilt, and this in turn prevented him from addressing his failings in his life - i.e. by making apt reparation in his marriage. (Integrity Therapy groups - a cross between an AA meeting and an Encounter Group perhaps - sprang up for a while in the 70s.) Stifling the guilt led to anxiety - the charge of the guilty feeling is there but the form which is required to make it truly intelligible as guilt is closed down. The routes for the feeling’s discharge, the paths of action which allow reparation and re-centering to take place, are all blocked. But when he takes the virtuous path, Mowrer can make reparation, orient himself toward the good again, and continue with a life of self-becoming that isn’t such an anxious issue for itself.


[I've just been alerted to another example, from Jung's essay 'Basic Postulates of Analytical Psychology': 'I am reminded of a case which is very instructive in this respect. It concerns a highly intelligent young man who had worked out a detailed analysis of his own neurosis after a thorough study of the medical literature. He brought me his findings in the form of a precise and admirably written monograph, fit for publication, and asked me to read the manuscript and to tell him why he was still not cured, although he ought to have been, according to his scientific judgement. After reading his monograph I was forced to admit that, if it were only a question of insight into the causal structure of a neurosis, he should in all truth have been cured. Since he was not, I supposed this must be due to the fact that his attitude to life was somehow fundamentally wrong, though certainly his symptoms did not betray it. During his anamnesis I had been struck by his remark that he often spent his winters at St Moritz or Nice. I therefore asked him who actually paid for these holidays, and it thereupon came out that a poor school-teacher who loved him almost starved herself to indulge, this young man in his visits to pleasure-resorts. His want of conscience was the cause of his neurosis, and this also explains why all his scientific insight availed him nothing. His fundamental error lay in his moral attitude. He found my way of looking at it shockingly unscientific, for morals have nothing to do with science. He thought that he could scientifically unthink the immorality which he himself, at bottom, could not stomach. He would not even admit that any conflict existed, because his mistress gave him the money of her own free will.']


Maybe I should say something now about how I understand anxiety. If you look this up in psychoanalytic dictionaries you will find something like: an unpleasant feeling produced by unconscious conflict. I think this too narrowly psychodynamic, however, for it seems to me we also sometimes properly describe ourselves as made anxious by that of which we are, at least in some ways, conscious. And also that anxiety can result from unconscious thought which doesn’t involve inner conflict. Nevertheless Freud’s first theory of anxiety gives a central place to the unavailability of routes of discharge for the tension caused by instinctual excitation. Physiologically oriented psychologists tell of how anxiety arises from sympathetic nervous system activation and the release of adrenaline and noradrenaline, and results in fight, flight, and freeze responses. So perhaps we can see anxiety as a ramping up of action-readiness in the absence of clear pathways for action. In the absence, that is, of such structured, meaningful patterns of emotion and behaviour and self-understanding as make for the living of a potent and meaning-making life. (Anxiety which results from being pulled both ways by unconscious conflicts can be seen as a subset of this.) In sum, much anxiety, it seems to me, is caused, in part, by a loss, or absence, of self-possession. Where by ‘self-possession’ I mean the state of knowing your own mind, rather than being in thrall to others. Where by ‘knowing your own mind’ I don’t mean: being aware (as opposed to being unconscious) of what you think or feel or want - but rather, having determinate thoughts, feelings and intentions in the first place - having a mind that’s made up - and taking such aptly decisive actions as naturally follow from that. 


I just talked of knowing one’s own mind, but I should also like to talk about something we could call ‘knowing your own heart’. I have in mind, here, clarity regarding: what it is to live the good life, what it is one truly believes in, clarity about what really matters. Remaining alive to love is, I believe, the crux of this matter, and pursuing a life which discloses everything of human significance by means of love’s lens is the surest routes to healthy self-possession. Without something of a securely installed good internal object, one which provides access to the very idea of love - access to the live sense of its possibility, that is - access to the world as disclosed under its colour-and-life-providing aspect -, one will be able to make little sense of the virtues I talk about today. To gender it: without a mother’s love warming the soil, the seeds of the more masculine virtues I will talk about today shan’t be able to take root. But, having said that, today I’m not going to talk about this crux of love, but will instead consider those latter virtues. For as I understand it, to know one’s own heart is in part to live a life where these virtues can fulfil their function as regulatory ideals for life. (I will spell out what a ‘regulatory ideal’ is shortly). Freud identified a form of anxiety he called ‘moral’ - i.e. a fear of violating the superego’s moral codes. As I implied earlier it seems to me that Freud conflated the superego and the conscience. But, that aside, what I offer today can be seen as a near-opposite of Freud’s suggestion, in that my thought is that anxiety can stem not from fear of the self-punishment resulting from not living up to one’s moral codes, but rather by having a lack of clear moral understanding in the first place. On this view, unless we clearly understand the virtues and attain something of wisdom (i.e. ‘ethical self-regulation’), we can be left adrift when facing anxiogenic situations. 


So - in what follows I hope to recover - that is to say, make newly perspicuous - six key moral concepts the clear grasp of which makes for the life less troubled. I’ll now turn to the first of these virtues which is: 


1. Dignit

Dignity isn’t something one reads a great deal about these days. In particular it’s not a concept which makes much of an appearance in psychotherapy texts. However, we do find it, in that form in which I’m here interested, in inspiring literature - embodied in Elizabeth Strout’s character Lucy Barton, say, or in Walter Mosley’s tough black detectives like Easy Rawlins. And we also find an emphasis on dignity in the pop-psychological writings and videos of Canadian psychologist Jordan Peterson. Yet even in these settings it’s rarely called by name (Peterson, for example, mainly talks about the value of taking personal responsibility, taking up the challenge of shouldering life’s burdens, and standing up straight with your shoulders back).

Perhaps the principal aspect of ‘dignity’ we meet with today marks how we feel we ought to be treated by others (we respect another's dignity if we treat her as possessing ‘intrinsic value’, i.e. as being - to use Kant’s term - an ‘end in herself’). But the (related) aspect of ‘dignity’ I want to focus on today is that which concerns our way of conducting and evaluating ourselves. In part: Do we act in such a way as we can hold our heads up high, or do we act in such a way that prevents that and instead feeds low self-esteem? But more than this: Do we so much as call to mind the concept of ‘dignity’ as a regulatory ideal - i.e. as an inner rule for conduct which, when we think on and attempt to act in accord with it, beneficially regulates our action, self-esteem, and anxiety? Consider: Your external life may be in ruins, your friends and parents are dead, you’ve been persecuted and tortured in your country of origin, you struggle to access good housing or appropriate employment in the country you now live in, you’ve very little money. But, here’s the question: how are you going to act today? What can you do that will result in self-pride? What exactly are your values and how, in these limited circumstances, can you act in accord with them, and how can you get the satisfaction that living in accord with them brings? How can you act, today, to bring yourself more in line with your ideal self? For example - and now I’ll borrow some examples of the sort that have made a huge difference to those young men influenced by Peterson to pick themselves up - are you overweight or physically weak in a way that makes it hard for you to feel proud of yourself? If so, have you started, today, to do something about that? Do you wish yourself better educated? Are you finding it hard to respect yourself because you habitually lie, gaslight, manipulate, blame others for your situation instead of taking responsibility for yourself? Do you let yourself be lied to or gaslit by others? It may not be your fault that your flat is decrepit, but have you made your bed and tidied your room? Have you decorated your home, thereby bringing order and beauty into your world? Have you stood up to bullies and to those who might manipulate or gaslight or take advantage of you? If you don’t know how to do these things: have you worked on learning how - i.e. how to do DIY, cultivate your taste, and stand up to such bullies? Have you tried looking others in the eye? Figured out what you can and what you can’t take responsibility for, and truly taken responsibility for the former? Do you treat yourself as someone worthy of respect, worthy of having the pleasures of a tidy home to come back to, someone who has as much of a right as anyone to the happiness that comes from a healthy body and an attractive environment? 

Jordan Peterson
Someone who's dignified can take pride in herself. This isn't pride as a vice, pride as vanity. It’s instead one of the few non-corrupt forms of self-love we have. And true love - I’d say - is an essentially anxiolytic force; knowing yourself as respect-worthy because you've done your duty to yourself: this is truly inwardly settling. Developing such dignity is a matter of two things: i) installing what person-centred counselling calls an ‘internal locus of evaluation’ into the psyche (i.e. you know and judge yourself according to your own values, so don’t keep taking to heart the value judgements of others), and ii) now actually taking such actions as make it possible for you, using this new locus of evaluation, to evaluate yourself positively. And all this already entails becoming less anxious about what others think, less anxious about how the world will affect you, and more ‘self-possessed’ or ‘sovereign’. I mentioned person-centred counselling just then, but we find this ambition too in the ‘commitment’ component in ACT (acceptance and commitment therapy): becoming clear about your values and using them to guide your action. And it’s of course there in the background, implicitly, of any decent psychoanalytic therapy. But I think there are good reasons to foreground it today, so that’s what I’m doing.

Now, I said I’d look today at what wisdom the philosophers have to offer us - so let’s briefly consider their thoughts on the value of dignity - especially of knowing you’ve acted rightly. So, the Stoics thought virtue to be the only true good, and therefore sufficient for happiness. The Socratic idea that ‘a good man cannot suffer any evil either in life or after in death’ is a hyperbolic expression in the same ballpark. The philosopher Wittgenstein too (in A Lecture on Ethics) talked of a feeling of ‘absolute safety’: a state of mind in which one is inclined to say ‘I am safe; nothing can injure me whatever happens’. What on earth can they mean?

One interpretation would have them believe superstitiously in the idea that God or the gods will protect the good man from harm. That seems facile though - so let’s let it pass. Another has it that by identifying solely with virtue, and withdrawing all attachment to worldly matters, one can’t be hurt by the depredations to which the body and our relationships are vulnerable. Yet while that might make sense to certain Stoics, I think it leaves us with a deeply impoverished life: anyone who follows a philosophy that leaves them emotionally immune to, say, the death of a friend is, I think, not really living. 

A third interpretation of the Socratic claim finesses the sense of ‘harm’ into ‘moral harm’: a good man cannot be morally harmed. The thought here is that the soul - i.e. one’s moral character - is only harmed by the commission of evil (Here I’m drawing on thoughts of the philosopher Mikel Burley). It seems to me that there’s something in this, but taken literally it seems implausible, since, in the ordinary sense of the terms, the suffering, as well as the committing, of evil - the suffering of torture for example - can lead to soul-destroying, morally harmful, consequences - the loss of the ability to hope and love for example. A final interpretation (also from Burley) has it that the ‘absolute safety’ of the good man has to do with his so loving the world as it is and will be that he has no sense of his own good amounting to anything other than: whatever actually happens. I’ll return to this in the next section but one; here I just note what an extreme ambition it is. 

Leaving aside for now such metaphysical considerations, that being virtuous somehow guarantees our happiness, let’s remind ourselves of what nevertheless appears the empirical fact that having clear values and living in accord with them, and taking an ordinary healthy (non-self-satisfied...) pride in so doing, is very often a potent source of well-being. Having a clear sense of one’s duty to oneself and others, and acting in accord with this sense: this, I suggest, is one of the greatest salves there is for both existential anxiety and loneliness. I’ve recently had the privilege of seeing one of my younger ‘borderline’ patients radically transform his life through the pursuit of dignity: truth-telling, being respectful, and relinquishing manipulation. Such a pursuit of virtue, amongst other things, simply knocks on the head much of our conscious and unconscious interpersonal and existential guilt. But also, by inwardly relocating the source of judgement, it means he’s no longer so enduringly fretful about the feared or actual judgements of others.

Having now considered the concept of dignity, a concept which I take to be the backbone of wisdom-in-action, let’s now go on to examine some other relevant virtues.

2. Ego Strength (Inner Courage)

Here’s what I tell some of my more neurotic (i.e. conflict-anxiety-riddled) patients near the beginning of their therapy:

“Your conscious mind is, we might say, a ‘container’ for your thoughts, wishes, and feelings. When these conflict with one another - as when, say, you’re angered by your mother whilst also valuing her love and respect - you naturally feel anxiety. Without sufficient capacity your mind can only contain one of these states at a time. The other remains unconscious, but threatens to break through: the structure of the mind trembles. Our job is to work together to help you expand this ‘mental container’ so there’s space for all your thoughts and feelings. The work will be hard, and you’ll have to face plenty of anxiety. By facing it, though, you’ll grow as a person, become more self-possessed, ultimately become less anxious, and enjoy better relationships. Are you ready for this?”

You perhaps tell your patients something similar. In doing so we’re introducing them to the essential role of inner courage - the capacity to steel oneself - in the search for psychological health. (We’ve also set up therapy in such a way as to make clear the relation between the method and the goal, and this provides a vital marker to be appealed to whenever we encounter resistance.) Here I want to highlight three essential features of this psychological learning:

The first concerns tough love. Yes, the talking cure is a cure by love. And yes, meaningful therapy is tough and requires a willingness to confront the monsters of inner space: it requires courage. But many patients haven’t had a chance to learn how these two attitudes - of tough exhortations, of love - can be of a piece with one another. They haven’t learned that true love is in this sense necessarily tough love: love that, because it has the genuine long-term wellbeing of the other in mind, invites her to courageously face suffering for the good of developing valuable ego capacity. The particularly important part of this has, ultimately, to do not with the therapist’s (tough) love for the patient, but with what the patient can internalise (into dignity). The therapist holds the attitude: “you can face this; facing this is the way to reduce suffering; greater ego capacity makes for greater dignity”. And the patient can internalise this into dignity; can come to trust in the superability of her conflicts; can see the project of overcoming them as manifesting healthy self-love; can know this project for the way a worthy mind is built.

Jean-Paul Sartre
The second feature of inner courage I want to highlight concerns the fact that courage has to be taken. ‘OK, that all sounds good, but how do I become more inwardly courageous?’, asks the patient who actually just doesn’t yet get it. Perhaps they’re after a technique, something they should think, something they can do. But what they’ve missed is the existential truth that right now they’re being invited to step up. Courage doesn’t just passively grow like a muscle after exercise (i.e. exposure) and from nutrition (i.e. loving care). Instead: To develop courage, decisions must be made. The will must be actively put in play, not as a wish, but as a chosen moment of self-creation, as the fashioning of a new commitment. This step of will itself inaugurates a new ‘political order’ (as it were), a new ‘economy’, within the psyche. When I describe this as an ‘existential’ step, what I mean is that it’s self-creating. In the existentialist’s jargon for a moment, we ‘pour-soi’ (for-itself) beings are not fated to facticity; to think we are is to succumb to ‘mauvaise foi’ (’bad faith’). Instead we’re ‘condemned to be free’: it’s our fate to be self-creators. Leaving aside the jargon now: As soon as I grasp that I could here think and act other than I do, I’m faced by an unavoidable choice - which I can either step up to and take, or decline and now live in guilty misery. Taking the step - of growing the mind - is temporarily anxiogenic. Yet declining it, hiding under the mental duvet, is to fate oneself not only to the prolongation of anxiety, but also now to existential guilt: to knowing that one’s not now living authentically, not doing one’s duty to oneself, asking others for help which one can only give oneself, feeling sorry for oneself, and so on. So: the patient needs to step up and be willing to suffer all her feelings and thoughts and wishes. It is this decision to step up, along with the learning from experience which follows it, which constitutes that growth in her ego strength and ego capacity which makes for a readier accommodation of all her emotional life. 

The third feature of the growth of inner courage I’d like to note is that we need it before we can hope.Here I don’t mean ‘hope' qua ‘being optimistic’. I mean your willingness to populate the future with potential meaning despite the fact that you won’t be able to cash all the cheques you’re now writing. A willingness to not crawl into your shell, to allow yourself to anticipate more than what’s under your control. A willingness to be open to life. A willingness to mourn our losses. (‘Hope deferred maketh the heart sick: but when the desire cometh, it is a tree of life.’ Proverbs 13: 12) By shirking the task of developing inner courage we deprive ourselves of that anti-depressive hope which functions as that tree of life.

Now, having considered 1) dignity and 2) inner courage, I’ll move on to consider some more distinctly ‘philosophical’ virtues.

3. Amor Fati (minimally, an acquiescing to fate)

Reinhold Niebuhr
I’ve just been talking about the significance, for overcoming conflict anxiety, of stepping up and making changes. But there are many situations in life where, beset instead by existential anxiety, we experience a clash between how we wish things to be and how they inevitably are. Perhaps I’ve washed my hands plenty, worn a mask, and so on, but even so: I might well contract this new coronavirus. My preventative actions may help a little - but probably not that much. This brings us to the fundamental Stoic choice that makes for wisdom. Epictetus put it like this: “The chief task in life is simply this: to identify and separate matters so that I can say clearly to myself which are externals not under my control, and which have to do with the choices I actually control.” This is also the message of Reinhold Niebuhr’s well-known serenity prayer: "Father, give us courage to change what must be altered, serenity to accept what cannot be helped, and the insight [wisdom] to know the one from the other.”

Now there’s plenty of silliness purveyed in (the name of) Stoic philosophy. Here’s a bit from the dailystoic.com website: “It [the stoic serenity prayer] is a reminder not to get angry and upset by things which we cannot influence such as other people and external events and to only focus on ourselves, our own behaviour. This makes things a bit easier, doesn’t it?”, it blithely states. And here’s something that’s face-value daft in Epictetus: “Some things are in our control and others not. Things in our control are opinion, pursuit, desire, aversion, and, in a word, whatever are our own actions. Things not in our control are body, property, reputation, command, and, in a word, whatever are not our own actions.” But, let’s face it, our own desires, opinions, aversions, etc. are often not ‘in our control’. And ‘reminders’ to ‘not get upset about things’ are famously both fatuous and ineffective (which is just as well or us lot would be out of a job…). And, come to think of it, the actions of others are precisely what we sometimes should get angry about, since a well-controlled anger, expressed in assertive thoughtful action, is precisely what can help us control the actions of vexatious others, as well as inform our own sense of whether we do well to engage with them. None of this, however, touches the essential point: that it’s essential for our wellbeing to both get clear about when our wishes conflict with what’s inexorable, and then to work to relinquish such wishes. Adjustment, acceptance, mourning, accommodating ourselves to the facts: this is discomforting, and so we automatically avoid it and cling onto such wishes as have hitherto defined us. Self-consciously acquiescing to fate enables us to overcome this hurdle. This, I note, has nothing to do with generically ‘lowering our expectations’, with ‘not getting our hopes up’ (… hope is important!…), with ‘relinquishing all desire’ so one can’t get hurt (…as a hack nihilistic version of Buddhism might have it). Instead it’s got everything to do with living a life which, because it’s in contact with actual reality, stands a chance of being nourished by it.

Now let’s consider the various further twists to this Stoic idea that one finds in the wisdom literatures, ones that both aim at installing more deeply into the psyche the disposition to not tilt at fate, and also ones which transcend it in developing an alternative positive attitude:

Think first of the Arabic saying “Insha’Allah”: “if God wills it” (God willing). The Koran would have us add this as a postscript to any statement about the future. In this way we help dismantle those omnipotent defences against existential anxiety - our knowingness, our taking-for-granted-ness - which end up causing more trouble than they’re worth. (Used corruptly, of course, ‘Insha’Allah’ merely ‘justifies’ not making an effort, or provides a recipe for fatalism!) Think next on these lines from the Christians’ ‘Our Father’: ‘Thy kingdom come, Thy will be done…’. Or how Jesus, knowing his end was near, prayed “Father, if Thou be willing, remove this cup from me: nevertheless not my will, but Thine, be done.” Here we find not merely an acceptance, but a positive attitude, toward the happening of that which is not under our control. Non-believers often reduce all prayer to its petitionary form and in turn see such petitionary prayer as effectively but a magical attempt to influence fate (or ‘God’s will’). But what we see here, in these more truly religious (rather than superstitious) statements, is prayer as precisely the opposite of this: as the difficult cultivation of an attitude of acceptance of matters beyond one’s will.

I will come back to these considerations later when we consider the notion of grace. For now I want to note that it was Nietzsche, no friend of either stoicism or Christianity, who took this attitude to an admirable extreme: “My formula for greatness in a human being”, he says, “is amor fati: that one wants nothing to be different, not forward, not backward, not in all eternity. Not merely bear what is necessary, still less conceal it … but love it.” Elsewhere he offers us this: “I want to learn more and more to see as beautiful what is necessary in things… Amor fati: let that be my love henceforth! I do not want to wage war against what is ugly [we may also add: painful]… Looking away shall be my only negation. And all in all and on the whole: some day I wish to be only a Yes-sayer.”

Nietzsche offers us the thought experiment of the ‘eternal recurrence’ as a way to try to make vivid this attitude’s cultivation: Imagine that you were fated to live this very life of yours an infinite number of times over, so that what happens to you and what is done by you today will in a future iteration of this life happen again, and again, and again… With that in mind, can you still find your way to saying ‘yes’ to this day and to all the days preceding it? Can you, in this way, by cultivating a courageous attitude in which you love fate, transcend your anxieties about external threat?

(Before moving on I also want to note the importance of learning to give lovingly - instead of anxiously focusing on whether the world will give you what you need. This involves cultivating an outward, self-to-other, form of attention; what Victor Frankl called ‘dereflection’: What can I give you today? rather than the fearful one of: How do you see me? By focusing on being loving we answer our own question about whether we are lovable, but we also dismantle it.)

4. Will to Power

So far we’ve considered the second half of the Stoic decision tree: work to accept that which is anyways out of your control. The first half, however - which has to do with taking action where action can be taken - still awaits our consideration. Again, I take the lead from Nietzsche - and his idea of the ‘will to power’, an idea which later found its way into psychotherapy through Adler.

Let’s start with an anecdote. A fatherless undergraduate who was due to take his final exams sought consultation with me. He was bright and diligent, but overwhelmed by anxiety, and fearful of not being able to sit the exams on this account. He’d gone to counselling and to a mindfulness class to try to learn how to calm down and develop some inner distance from his overwhelming thoughts and feelings. Unfortunately the counselling and the class had no effect. So I told him that what he needed was not to calm down, but instead to power up. What he needed was to actively embrace, rather than shun or inwardly watch, all that valuable energy and strife and bind it together using his will so that it come be directed at its proper end, namely: vanquishing the examiners’ questions. The advice somehow made a marked change to his psychology, and he went on to get a 1st. What my patient had done was to embrace his Will to Power.

What I want to highlight here is the value of the very ideas of courageous determination, incisive action, firm and tough resolve, and a fighting spirit carefully honed by a clarity of ideals. My patient had, I believe, been trapped in an ideological space we might cautiously stigmatise as a form of ‘toxic femininity’: one where assertiveness and striving for personal success had somehow become bad things; where soothing and inwardly-focused self-care were promoted as obviously the apt salve for all anxiety; where ‘being understanding' and ‘showing understanding’ were proffered as superordinate values; and where a kind of covertly masochistic self-dismantling had prevailed, one that encouraged his becoming a mere inner onlooker onto what actually were his ownmost thoughts and feelings. Trapped in that psychological milieu my patient’s dynamism of energetic, world-vanquishing, self-becoming was utterly deactivated, and with no telos (no directive) to be attached to, his unharnessed drive energies were simply shaking him apart.

As with the other values I’m treating of today, what I want to sell to you is not simply the importance of the value itself, but the importance of having a live idea of the value, an idea that can, now it’s live, function as a regulatory ideal for the living of a good life. Our patients need a clear sense or template of this - the kind provided, for example, by a potent exemplar, of the value in question. They need to be reminded of it - and I say ‘reminded’ rather than ‘taught’ because everyone has already experienced the occasional benefit of wisdom, has had humbling moments when they realise they’ve lacked it, when it becomes apparent in recollection what was wanted of them, after they’re become restored to themselves - for today the value of the Will to Power as an essential driver of responsible self-becoming so readily gets swamped by corrupt ethics and corrupt psychologies, leaving our patients vulnerable to helplessness and self-pity. (Hence the value of Robert Bly’s Iron John, say, or Joseph Campbell’s Hero’s Journey; hence the value of the martial arts.) But with a live sense of it, it can start to function as a regulatory ideal in one’s own life, thereby bringing relief from existential anxiety. And it’s through enacting this value, developing a confident assertive thrust, that one can also come to feel that healthy sense of pride and dignity I’ve been talking about today.

5. Receptivity to Grace

I want now to come back to the other side of Epictetus’s decision tree which has to do with our relation to that which is not under our control. In his acceptance speech for an honorary doctorate at the University of Western Australia, Tim Minchin the musical comedian urges us to: “Remember, it’s all luck. You are lucky to be here. You are incalculably lucky to be born. Understanding that you can’t truly take credit for your successes, nor truly blame others for their failures, will humble you and make you more compassionate.” Yes, you may say, but does that make you any less existentially anxious? Well, that will be my claim: that a receptivity to grace is intrinsically anxiolytic, where by ‘receptivity to grace’ I mean the willingness to see one’s life and the boons within it under the aspect of an undeserved gift freely given.

The concept of grace is easy to grasp in a theological context where we know to whom the thanks is due. Today, though, I’ll assume a non-religious audience, and ask if we can make sense of the idea of existential gratitude - a gratitude for life itself - without believing in a giver to whom thanks is properly owed. In a paper on this topic a philosopher friend of mine my friend Michael Lacewing offers the examples of a young mother being “grateful for a moment’s quiet after looking after the kids all morning” and of a man out walking “thankful to find a stream on a hot day”. These are forms of gratitude that “don’t raise the question of to whom one is grateful. Instead, they emphasise the welcoming receipt of that which is good from a source outside oneself”. The question now is: might these attitudes be cultivated more generally, so that one lives in a constant awareness of how dependent one is on good fortune, on other people, on nature and its provision of food and air and light, on one’s parents and ancestors?

G K Chesterton
Well, let’s say we do that. For the religious person it may be easier - one can say prayers such as ‘saying grace’ before meals, for example. (Or, if you’re G K Chesterton, also “say grace before the concert and the opera, and grace before the play and pantomime, and grace before I open a book, and grace before sketching, painting, swimming, fencing, boxing, walking, playing, dancing and grace before I dip the pen in the ink.”) Even so it’s surely also within the wit and power of the existentially alive atheist to cultivate that sense of existential gratitude and humble acknowledgement of dependency. (Dawkins professes this, for example.) But the question remains: why should anyone think such a grateful acknowledgement of luck and dependency would decrease, rather than increase, existential anxiety? For don’t our defences (at least) against such anxiety typically involve our indulging fantasies of enjoying more rather than less control?

Well, one source of calm, here, comes from that sense of orderedness that comes from acknowledging our place in a wider set of relations that support us. We become attentive, for example, to the beauteous bounties of ‘mother’ nature, attentive to how deeply we’re supported by her. Our hearts usually beat, our stomachs typically digest, our cells inexorably metabolise, all as they should, all outside our ken and control. Again, religious sources provide the clearest articulations of the sentiment, but we may be forgiven for thinking that, rather than the sentiment depending for its sense on a theistic outlook, it’s rather our independent grasp of its meaning which gives content to the idea of a ‘theistic outlook’. Thus: ‘Consider the lilies of the field, how they grow; they toil not, neither do they spin’ (Matthew 6 / Luke 12). ‘Behold the fowls of the air: for they sow not, neither do they reap, nor gather into barns; yet your heavenly Father feedeth them.’ Or, to borrow from Julian of Norwich, as T S Eliot did (Little Gidding): ‘And all shall be well, and All manner of thing shall be well’.

Looked at one way - in a blankly face-value way - that last saying is preposterous! Much in life is not well … and then you die! (The fowls of the air also sometimes starve to death!) But rather than consign it to the category of a ‘futuristic eschatology’ - that is, rather than see it as an expression of a promised future salvation that somehow retrospectively makes everything right… which to a psychoanalyst surely looks like flagrant wish-fulfilment - we might first try to grasp more closely the present-moment sentiment, the ‘realised eschatology’, resonant within it. The believer who feels herself held in God’s arms, the atheist who says ‘Yes!’ to life, the pagan who celebrates the seasons of life and death: they’re all configuring their grace-filled grate-full relation with reality in such a way as to reduce the illusory sense that they need to be in charge. The anxious grasping power-hungry disaster-predicting ego is invited to take a break, to recognise the incoherence, even, of its own ambition. (They all spurn the exhausting and hubristic ‘Pelagian heresy’ - that salvation is earned through works.) The present moment, at least, so often doesn’t need redeeming: ‘Right now I’m fine, I’m breathing’ … as the Oprah-style mantra has it - and why shouldn’t the near future be a continuation of such ‘right now’s?

Another way to express this thought might be with an ‘I’m ok; you’re ok’. Now that’s a message that that’s easy to despise and misuse! (Jordan Peterson, for example, talks of the unhelpful mushy self-esteem messages that tell everyone to basically no avail that ‘Hey, you’re ok just as you are’ when people ‘know damn well that they’re not ok’, that 'their lives are a mess’ and that they truly need to change a lot about themselves!) As with all such sayings, though, its meaningfulness depends on its context. And one context in which it makes sense is that in which one hasn’t yet developed the wisdom to check in with oneself and ask ‘Leaving future-oriented worries aside, how am I in myself right now? Am I ok?’ (For example, I find a helpful mood hack can be to ask myself ‘How am I actually feeling right now?’ Asked at times of ruminatory dejectedness, the question already jolts me out of my miserabilistic daydream and prompts me to notice that, actually, underneath all that, right now, I’m doing just fine.)

Whilst I find these 'I'm ok', 'I'm breathing', thoughts helpful, I think they don't at all give us the whole picture. Julian of Norwich's thought was, to recall, 'All manner of things shall be well', and I think this is really an expression of an ethic which aims to cultivate an attitude of acceptance of, of saying 'Yes' to, of 'blessing', whatever happens. The trials of life - can we be grateful for these too without becoming Pollyannaish? One way to achieve that is, I think, to think of them as fuel for the fire of your own self-becoming. ‘Out of life’s school of war — What does not kill me makes me stronger.’ as Nietzsche also put it (Thus Spake Zarathustra). Which is, note, not offered as an empirical fact, but as an existentialist dictum: given that life is full of hardship, how can you positively relate to it? Well, as spurs to your own individuation, as material to overcome and assimilate. This provides one opportunity to love everything. Yet might we even be able to love 'all manner of things' without thinking of what good we can make of them? In a moment of self-renunciation? That's a question I'm going to leave open for now.

6. Seeing Life “Sub Specie Aeternitatis”

I want finally to expand that theme of receptivity to grace, a theme I spelled out in terms of the anxious ego relinquishing its backfiring efforts at control, into what’s often called: seeing life ‘sub specie aeternitatis’ (the term is Spinoza’s). What is this, this seeing life ‘under the aspect of eternity’?

So think first of that feeling of smallness that comes from walking on the tops of mountains, or from looking out to a vast ocean, or looking out at the night sky. (‘Does not wisdom … standeth in the top of high places…?’ Proverbs 8:1-2) This, I take it, is a species of that 18th century aesthetic concept, coined by Burke and taken up by Kant, called ‘the sublime’: a concept intending to capture something of our awe-filled response to the vasts of nature. A strange thing about this feeling is that, far from humiliating us with a sense of our puniness, we often find it deeply reassuring. Our own lives may be puny, but the ocean waves endlessly tumbling on the shores, and the stars twinkling in the night skies, need no help from us as they endlessly course on with their own momentum. We are, I also take it, here within the ambit of what the Hebrew Bible’s wisdom literature describes as that ‘fear of the Lord’ which is said to be (Psalm 111 and Proverbs 9) both ‘the beginning of wisdom’ and (Proverbs 14) ‘a fountain of life’.

One way to understand what it means to live this ‘life eternal’ is as a matter of: bringing life under the purview of certain values. Experiences of the sublime throw us out of ourselves, and help us evaluate our lives not from the perspective of this or that quotidian, self-centred, concern, but instead from the perspective of ‘the bigger picture’. We start to see our lives as a whole and to see their place ‘within eternity’. This eternity has all of the past, present and future within it, as equally valuable moments. From this perspective, our death is no longer oblivion, but an essential temporal limit that gives shape and meaning to our life. To live this “life eternal”, then, means to participate in life according to whether we are able to honour, help create, and live out of, those values which make for the ‘good life’: truth, beauty, honesty, care, etc., and to leave behind irrelevant matters of personal wealth, fame, prestige, etc. Here the thought is that it’s precisely by putting the 'fat relentless ego’ (Iris Murdoch) on an existential diet that we gain the solace that comes from transcending its nervy preoccupations. (Hence another helpful mood hack, I find, is asking myself ‘But what do I really care about?’)

Conclusion: On Wisdom

We have a word for the attitude of the person who’s able to ‘be philosophical about it’. It’s ‘wisdom’ - the ultimate philosophical virtue. When we think on philosophy as a way of life, and certainly when we think on much Stoic philosophy, we might think of a rather coolly intellectual headset, one that treats passions with suspicion, where one is always reflecting, superciliously poised, or pathologically self-possessed (so can’t ‘let herself go’, be playful, erupt with laughter, etc.). But what we're really talking about, when we’re talking about wisdom, is not someone thinking a lot or feeling a little, not someone who is full of thoughts, but instead someone who’s thoughtful. This person is able to spontaneously make judgements apt to their particular contexts. And the only reason why I’ve stressed the value of here making explicit the values of dignity, inner courage, amor fati, the will to power, existential gratitude, and the life eternal, is not to propose a life spent in contemplation about these things, but to revive and clarify such values as otherwise lie misunderstood, ineffective, and unable to function (spontaneously or reflectively) as regulative ideals for the living of a life. Nowhere have I suggested that all psychotherapy should become what sometimes gets called ‘philosophical counselling’. (By which I have in mind either a rational approach aiming to expose alleged faulty premises or faulty inferences in arguments which make misery for people, or an existential approach looking at issues of mortality, isolation, freedom, and meaninglessness.) Nowhere have I suggested that psychotherapists should become philosophers, nor that we should become self-styled Jungian sages or alchemists of the internal world. Instead I’ve been offering something more like a straightforward homily: an attempt to remind you, and myself, of values and attitudes we may well already hold, some of which condition our very concept of a human life. My thought is that there is enough wisdom contained within the language of the virtues - gathered up there over hundreds of generations - to set us on a good course, so long as it’s properly and clearly understood. And my fundamental suggestion has been that existential anxiety can be perpetuated by a lack of clarity about (what we could call) ordinary dignity, ordinary courage, and ordinary humility, such that these and related virtues no longer function well as what I’ve been calling ‘regulative ideals’ for the living of a good life.