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


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.