Monday, 9 January 2017

probity and personhood

The concept of an insincere or untrustworthy or fickle person makes sense. But only up to a point. For if one never kept one's word then what has the outward form of someone's word could no longer meaningfully be taken as such. This is the situation we meet with with serial liars. They have no integrity, and the effect of this is that their words - and their word - no longer mean anything. Such people sometimes fool themselves that their word yet means something - that they really are promising something when they utter words with a promissory form. Perhaps they 'feel an intention' inside themselves. Perhaps they imagine they can just 'know' this from within. Yet, as Wittgenstein says, 'an 'inner process' stands in need of outward criteria'. Such a person truly is just kidding himself; yet if he keeps at it eventually he won't even be a person kidding himself. He will have lost his soul.

Sunday, 8 January 2017

integrity as the lynchpin of integration

Orval Hobart Mowrer
The concept of the pathogenic secret and its significance to psychotherapy belongs, in the twentieth century, to the troubled and now largely forgotten American behaviourist Orval Hobart Mowrer. Influenced by Harry Stack Sullivan, Mowrer disagreed with Freud that neurotic guilt was at the core of much psychopathology, instead proposing real guilt as the driver, and de-repression through confession (in Integrity Groups - this was the 60s and 70s...) as the therapeutic solution. Mowrer modelled psychopathology as addiction, and it's perhaps unsurprising that it's in the field of addiction recovery that his work still has some influence.

What does it mean to model pathology as addiction? It means, Mowrer's pupil Bixenstein tells us, that the sufferer indulges in short-term pleasures whilst making herself unaware of their cost. In the kind of psychoanalytic terminology which Mowrer rather eschews, we might say that she represses, or splits off from, her awareness of the cost of her pleasures.

A defence subserving this latter unawareness, one we often encounter in the clinic, is projection. I  can't tolerate my guilt and so I project it into you - i.e. I make you out to be the bad one. Needless to say the projection may in fact - contra Mowrer - be of both real and neurotic guilt. A typical situation is one in which a patient is caught up in projecting the castigations of their superego, or so inexorably reads what the therapist says through the lens provided by the superego that (what is imagined to be a retaliatory) projection can almost feel like a moral duty.

Such projection is most effective when it is subtle, and it is subtle in ways which, I think, make clear just how the integrity group or 'pathogenic secret' concept has little chance of tackling it effectively. Just think of: a partly raised somewhat quizzical eyebrow whilst the therapist speaks; a minutely dismissive shrug just after the therapist speaks; a supposedly urgent question asked for which no answer could be satisfactory; amusement at something the therapist says or does which hovers on the in-between of laughing-at and laughing-with; requests made which exploit the inevitable ambiguities regarding what is reasonable to press for, thereby inviting slack-cutting and the latent queering of the moral pitch of the interaction; frustration at the therapist's incomprehension being expressed which would be utterly reasonable were it not for the fact that information which would have been rather helpful has been held back; conveniently construing the therapist's sincerity as tiresome earnestness so as to avoid the disturbing felt obligation to reciprocate the former; the subtle disowning-of-accountability (e.g. in a strategic use of psychiatric illness labels) in a push for not-quite-warranted-sympathy in how a story unfolds; etc; etc. Think of the sotto voce nature of many of these interactions - how they may be engaged in with a degree of plausible deniability - how the letter of what the patient says may yet be impeccable - how swept along by it one inevitably is. Think of how upsetting it is to have one's loving kindness gently trampled on and how, thank you but no, it's really not par for the course in this relationship just because it has this financial element to it.

The addictive buzz for the patient of such micro-abuse is akin to what we also find with schadenfreude - a sense of vulnerability and haplessness and culpability is relievingly located elsewhere - in the micro-agressed therapist. You are the clumsy insensitive dolt, not I, and if I perpetrate my aggressive relocation of doltishness not so much through the verbal content but, perlocutionarily, through the twisting of the tonal form of our interaction, then hopefully I can get you to suck it up into your self-conception in a way which allows you and I to let me off the hook (and you feeling shit). (A Bionian take on projective identification.) Yet such interactions nevertheless carry the typical cost and share the ongoing dynamic of addictions: they spoil the soil-structure of the relationship, making it unavailable as a collaborative loving resource to be internalised, and the sense of guilt or shame which is projected yet always lurks since it will painfully return unless the defence is maintained. In fact it increases, since the patient now suffers not only his original projected guilt or shame, but now also the additional guilt or shame at having micro-abused the therapist. Without an alternative ethic for relating, the projective besmirching spirals - this is the driver of the addiction to projective identification.

Consider the amalgam of neurotic and real guilt and shame one often finds in such interactions. Here is what in good (if idealising) humanistic spirit one might want to describe as the fundamental situation: at root the patient struggles to tolerate her vulnerability in love and connection. She so readily imagines shame being the apt emotion for so many of her ordinary reactions. She imagines - where by 'imagine' I mean simply the dispositional phenomenon of being inclined to expect - that she in her actual feelings - of upset, disappointment, anger - will be met with a lack of sympathy and understanding. She imagines that she will be met with self-negating criticism, with a 'pull your socks up', or a 'well what did you expect?', or a 'that's typical of you!', or a 'isn't this all rather self-indulgent?' or a 'I hope this teaches you a lesson', or a 'so you shouldn't have got your hopes up should you?', or a 'well clearly you were getting too big for your boots', or a 'stop being a cry baby', or a 'stop attention-seeking', etc. This is neurotic shame that stems from the superego, and is the kind of shame which the therapeutic relationship is designed to deactivate. Yet so powerfully does the superego force its damning message into the fabric of perception itself, thereby generating the negative transference, that the patient experiences such shaming for feeling coming from - or more often lurking unexpressed within - the therapist. And in response to this the patient goes on the manipulative attack. This manipulative attack must be subtle, since otherwise the superego-imbued-'inner'-therapist will add further scorn. Yet it is real and, to the extent that the patient stays in touch with an awareness of the possibility of a different therapist, of one who cares, one genuinely wronged by such put downs and performative beratings, her painful experience of guilt and shame increases.

Before turning to therapeutic solutions let's put one more consideration on the table - concerning how such a superego prevents integration. The goal of therapy, as I understand it, is to allow the patient to suffer/enjoy the full range of her feelings. It is in and through our feelings that we grasp the significance of our significant situations: I grasp what it means when you show me kindness or love, I grasp the significance of the fact that you no longer love me, or that you didn't love me as I had hoped, or that you have been spending more time with someone else, or that nature/fate/God has truly smiled on me with the health and opportunities I enjoy, or that I've been unkind, or that you've traduced my good will, or that I just won't be getting the promotion I longed for, or that you really have died and won't be coming back. We can't meaningfully grasp these things 'with our head' since what that would mean would simply be that we can make the apt reflective inferences when pushed; instead we must grasp them 'in our heart' which means that our reactive dispositions must change. We must experience the vulnerable joys and pains of opening up to another or of knowing that they have closed the door on us. The feeling is the adjusting to the ever-changing realities that befall us, and the task of therapy is the expansion of ego capacity - i.e. the increase in our welcome tolerance of all our feelings (which tolerance is not the same as condoning all the impulses such feelings may engender!). Yet it can be hard to adjust thus, to let the feeling course through the meaningful lived body; it so readily gets shunted off into the merely physiological body, or displaced, repressed, sublimated, projected. But what it most powerfully gets suppressed thus by is an inner critic - the voice which says that the feelings in question are shameful. This is the superego's potent contribution to the failure of integration - i.e. the failure to have ego capacity to suffer all, rather than merely that part condoned by the superego, of one's emotions.

In response to all of this the therapeutic task ought to be clear: it is the replacement of one ethic with another. Replacement of a competitive antagonistic point-scoring ethic with one of loving care, acceptance and cooperation. Replacement of this both within the therapeutic relationship and within the mind of the patient - in how he treats himself. The therapist smiles uncondescendingly, welcomingly, sympathetically, honestly, on the patient's feelings; the patient can now begin to internalise this acceptance, to make space within her soul for more of her pain and delight. Shame and guilt become welcome as opportunities for learning and growth; sadness welcomed as an opportunity for adjustment to loss and for valuing what one had; anger welcomed as a signal that one may have been wronged and a helpful prompt to assertively potent thoughtful reaction and self-rescue; envy welcomed as a clue as to one's forgotten or unrealised ambitions. Emotional feelings, in such an ethic, are calls to us to be, and reminders of the being of, our true selves.

But how can the therapist achieve this if they are the target of projective attack? Isn't that the dilemma we often face? I don't mean so much when one is struggling to not respond in kind, but rather when one's notwithstanding kindness itself will be abused or experienced as shaming or received with scepticism - rather than internalised as the herald of a healthier ethic. (Well, but... don't we already know something of this from the parenting situation? When the toddler is angrily, 'selfishly', unyieldingly carrying on, the parent's job is to be firm and clear and boundary-maintaining and non-retaliatory, to judge when the time is right for waiting this out and when right for thinking about it together.) The therapeutic task, it seems to me, is here several: i) to understand the psychodynamics of the projection, ii) to clearly acknowledge within herself the quality of feeling that patient is projecting, iii) to hold onto the thought of a different ethic, a different way of relating as a real possibility for the patient and between patient and therapist, iv) to firmly yet without retaliation describe what the patient is doing in the interaction, along with a description of the significance of the projected feeling to the patient, and a comprehending-distance-providing description of where this habit of reaction might be coming from in the patient's history, v) a reminder of the cost of adopting this competitive antagonistic ethic to the patient, and vi) a reminder of the possibility of another way of relating, vii) an invitation to the patient to make a step - to take a leap of faith that there exists another way of relating and that there exists, beyond what the negative transference makes available (and this really will be a leap of faith, so all-pervasive is the transference), a different kinder more understanding therapist to be related to.

The therapeutic task, one could say, is to agitate, firmly, kindly, honestly, for a change of heart. Which means the patient withdrawing their projections and apologising. The therapist must be able to hear this apology and take it - and not dismiss it casually with a 'oh that's all right' or a 'don't worry it's all in a day's work'. No, the therapist must be able to hear the confession in a way which acknowledges its deservedness, for without this they will not be able to offer forgiveness: they will not be able to let the patient know that he is no longer resented, that the apology has been accepted, that good relations are restored.

I've met morally deprived patients for whom the above procedure - the restoration of love, and not just the calling of a truce or a conveniently repressive forgetting, after a time of projective distemper - was a revelation. So entrenched had their families of origin been in a tit-for-tat point-scoring blame culture that the very idea of real forgiveness was more bewildering than anything else. Yet what could be more valuable? Not only is the patient then able to cultivate greater ego capacity and a kinder self-relation, not only are they able to have a trial relationship conducted according to a different ethic, one which they will hopefully be able to go on and generalise elsewhere, but furthermore the patient will now be able to swap their depression-engendering guilt for a valuable pride. Not the sinful pride of having an inordinate opinion of oneself, but the valuable anti-depressive pride of knowing that one has done the right thing, that one is making the best of a bad job, or making a good ethical fist of matters, suffering well, taking on the chin what is there to be taken, living with dignity.

Monday, 26 December 2016

psychotherapy as ethics: the case of depression

In a month or so I’m to give a talk on‘psychotherapy as ethics’. The phenomena I wish to cover include making confession, calling someone out, calling someone to courage, therapeutic love, withdrawing projections of blame, and offering recognition. My guiding thought is that effective psychotherapy is therapy conducted precisely as what I call ‘an ethical relationship’. By this I don’t at all mean psychotherapy conducted in accordance with ethical practice guidelines. I also don’t mean psychotherapy conducted through moralizing – something against which, when met with in both self-directed and other-directed forms, psychotherapy has provided considerable bulwark. What I mean is psychotherapy which draws more from the understandings of what it is to be a human being living a human life we find in ethics than from what we find in psychology. What matters, I suggest, are the demands of love, the significance of accountability and responsibility, the value of truthfulness and sincerity, the meaningfulness of repentance and forgiveness.

In this post I want to explore a small part of the above - namely an important symbiosis of model and therapeutic practice (I hesitate to talk of technique) in the theory of depression, and how this alters significantly – including ethically - depending on the therapeutic approach. (I hesitate because, as I see it, such talk belongs more naturally to an instrumental conception of therapeutic action, and I should like here to take a stand against the impersonality of instrumentalism. However ‘technique’ may perhaps mean something different, and hence rather more valuable, within the context of ethical relationship.)

As the cognitive theory has it, depression is maintained by depressive beliefs, thinking habits, and passivity in life. I may for example think of others as untrustworthy, and so not engage with them, and thereby become isolated and lonely. Or I may imagine that whatever I do, nothing good will come of it. Perhaps this stems from aversive early experience. When I meet with others perhaps I habitually, maybe only semi-consciously, rehearse to myself what I imagine they really think of me, how they would like to treat me, etc. I am radically biased toward the negative in my views of self, situation and future (Beck’s cognitive triad). Furthermore, because I become inactive I no longer generate meaning, sense of efficacy, hope. As a consequence life becomes meaningless and depression becomes entrenched.

To combat depression the CBT therapist, in line with the cognitive theory, helps his depressed patient become better at spotting and defusing from or challenging their depressive assumptions, and to take action to generate meaning rather than passively wait for meaning to first appear before taking acting. (The ethic guiding this approach is, I believe, when all things go well, that of unpretentious accuracy and of collaboration in the therapeutic task. And so far so good – I hope we (therapists) all sometimes engage in such tacks and embody such an ethic.) But a difficulty is that depression often tends to relapse, and constantly challenging one’s own thoughts is itself tiring and demoralizing. And the depressive thoughts just seem so natural to the patient – they seem to flow effortlessly from the personality itself, and so questioning them seems to go against the grain, feels as if it itself manifests a lack of self-acceptance, courting further depression.

The psychodynamic theorist has a partly different model of depression. According to her there is within the personality a deeper psychological wellspring of depressive cognition than either core beliefs or the learning experiences from which, it is alleged, they sprung. And according to her this wellspring is motivational in character and hence characterological in instantiation: whilst the patient is (one imagines) honest about his suffering, and sincere in his conscious opinions and in his wish to not be depressed, there is yet within him something like an unconscious wish to be depressed. Not, normally, anything like a wish to suffer (contra the absurd-when-over-extended depressive masochism hypothesis), but rather a wish to avoid the challenges which not being depressed would present. I’m talking of the life-challenges of: allowing oneself to be constructively angry with someone who has wronged one, taking a strong and courageous stand for oneself; admitting one’s guilt and taking reparative action; facing the fear relating to uncertainty and living with existential courage; allowing oneself to truly mourn one’s losses and actually take one’s leave from people and ambitions who have taken their leave of you. Depression, as the psychodynamic theorist has it, is a narcissistic phenomenon: rather than face the unknowns and possible painful disappointments of Beck’s triad - the unknowns of whether one will be accepted by others, the unknowns of how the future will go, the unknowns of the opportunities or disappointments immanent within one’s situation – the depressive individual pre-empts fate and gets in there first. They trust in their own dismal appraisal far more than remain open to a world and a fate and an other beyond the safe horizon of their own mind. They choose to dwell in their own self-ratifying delusion-like ideas and thereby justify their withdrawal from the world. (Contrast the manic patient who more profoundly refuses to stay open to reality in its unknownness, instead choosing to refashion it according to his desire.)

There is a way to present the psychodynamic model which keeps it resolutely psychological rather than ethical in character. On such an approach what is avoided by the depressed patient are his feelings and their anxieties. On such a reading – which is what is met with in ‘affect phobia’-type reformulations – the avoided reality is intrapsychic. But such an approach falsifies the phenomenology. For what we encounter in depression is first and foremost someone turning away from the world, from others, from their responsibilities to themselves and to others, from the task of building something and continuing to build it in the future. This in particular is what involves us in an ethical, and not ‘merely’ a psychological, task.

If the psychodynamic theorist is right, then the reason why the depressed person often relapses after CBT treatment is because their changing their mind was not rooted in a change of heart. Challenge your thoughts and your beliefs all you like – but unless you challenge your motivationally-driven narcissistic disposition to form such beliefs in the first place, you’ll be left disposed to relapse. Unless, that is, you challenge yourself. (Challenging your self is ethical in a way that challenging one's beliefs is not.) Come to accept that, despite what you’d understood – i.e. that you were simply a victim of your depression – you are actually its perpetrator, latently motivated to espouse your depressed beliefs – and you have an opportunity for a genuinely existential choice. A choice to live differently. A choice to do better by oneself and others. A decision to make -  to live with more openness, with better grace, with less self-ratification. To take courage. To sow seeds not knowing if the rains will be good. To live according to an ethic of gratitude and risk rather than cautious self-reference.

What does this model inspire by way of therapeutic practice? Well for one thing, therapy now becomes a forum of ethical challenge from the therapist. The therapist’s job is to be collaborative, sure, but also gently, appropriately, respectfully, to challenge. The challenges will be ethical: do better by yourself! Do better with this life you’ve been given! Be courageous! Stop shirking! Don’t be such a scaredy cat! Be kinder to yourself! Be kinder to others! Be more open! Such challenges are a call to conscience. And so the patient has now to make choices, to make decisions. Therapy is no longer practiced in a collaborative fact-finding mode. It becomes an ethically fraught domain. Whilst the patient was unconscious of the motivationally driven character of his depression he had an excuse to not do better by himself and others. But now the therapist has pointed it out, he has no more excuse!

There will also be challenges regarding how the patient is treating the therapist. It’s here that the most potent work can happen. Imagine a psychoanalytic therapist who hid behind her expertise and simply offered descriptive transference interpretations regarding how the patient was treating her. Such a therapy would be a poor, bizarre and alienating thing. No doubt it’s respectful and potentiating to be maximally unintrusive on the patient’s agency – i.e. to ‘allow’ him to make up his own mind, take his own decisions, and thereby achieve a genuine self-possession, rather than having him bow before the expertise of the therapist and passively relinquish his moral authority. (For a patient to act thus would probably mean that he’d got sucked up in a positive idealizing transference – itself perhaps just a way to keep at bay, keep unconscious, a more troublesome negative transference.) But whilst accepting the value of this kind of therapeutic neutrality, imagine the disastrousness of a therapy which performatively took away what descriptively it proffered: i.e. which sapped any degree of emotional and ethical tenor out of the therapeutic relationship at just the same moment that it descriptively drew attention to precisely such dynamics. Which involved a therapist failing to offer any authentic degree of ethical engagement at just the same time she invites the patient to do better by her.

Here is the long and short of it. Patient: A patient has to decide to relinquish the negative transference and their other depressive tacit commitments. They have to make a choice – to step out of a world of dismal interpersonal expectation, and start to live as if love and meaning were real possibilities. The patient who first wants reasons to live thus is missing the ethical point. Therapist: A therapist who hides behind a merely collaborative relationship, or who retreats into making de haut en bas interpretative pronouncements, is failing to offer an ethically alive relationship. Failing to meet the patient where he is. A therapy which doesn’t have the patient sometimes being angry and sometimes apologizing is probably no therapy at all. For any genuine challenge to a patient will involve an accusation: that he is actually not, despite what he is inclined to think, doing his best by himself/partner/therapist. And the therapist too will not always do well by her patient, becoming chummy or expert, becoming didactic or passively listening, and so does well to apologise as and when required and to constantly reorient herself to the good.

Friday, 23 December 2016


The best antidepressants are compounds; take the ingredients separately and the results are less powerful. The two I'm thinking of are:

i. Courage: What are you afraid of? Discover it and face it. Remember that courage is existential in the sense that it can be taken. You don't have to passively wait for it to grown inside you; you don't need to first not feel anxious. Courage is about stepping up.

ii. Self-Acceptance: What are you feeling? Accept your feelings without judging yourself for having them. Whether you're sad or angry or envious or excited: smile on this. If you're sad then, well, that's what you're feeling.

Sometimes we're encouraged to challenge negativistic or ruminatory thought. But perhaps it accurately reflects your underlying feelings. 

What may need challenging is not your thoughts but you yourself. Take courage in your life! Go on! Accept your feelings graciously; act on your world courageously!

where did bleuler's autism go?

When Eugen Bleuler coined 'autism' for us he propounded it as the central explicatory feature of 'schizophrenia' (another of his coinages). (Thirty years later Kanner and Asperger famously took it up as the name for a developmental condition - but the difference between infantile and schizophrenic autism was that the former involved a failure to enter the affectively-constituted, meaning-stabilising, intersubjective world, the latter involved a dropping away from it into private fantasy and unaccountable trains of thought.) Bleuler's concept of autism was multi-faceted. The schizophrenic psychoses, he declared, are

characterised by a very peculiar alteration of the relation between the patient’s inner life and the external world. The inner life assumes pathological predominance (autism). The most severe schizophrenics, who have no more contact with the outside world, live in a world of their own. They have encased themselves with their desire and wishes (which they consider fulfilled) or occupy themselves with the trials and tribulations of their persecutory ideas; they have cut themselves off as much as possible from the any contact with the external world. … This detachment from reality, together with the relative and absolute predominance of the inner life, we term autism.

Bleuler explains that his term is nearly coterminous with Freud’s autoerotism but that he chose a new term because Freud’s greatly expanded sense of eros/libido can be misleading. He also explains that unlike what he saw as Janet’s quite general concept of ‘loss of the sense of reality’ (diminished ‘fonction du réel’) , he considers autism to characterise the patient’s reality relation only in the ambit of her complexes. Autism for Bleuler means a circumscribed withdrawal from reality - into what today we might call a ‘psychic retreat’ (Steiner) or ‘autistic enclave’ (Tustin) - which withdrawal provides the condition of possibility for the flourishing of delusional experience and thought.

A key aspect of Bleuler's autism is its psychodynamic intention. There are three central aspects of this. First, the autism Bleuler describes involves a world of private fantasy in which wishes and fears are considered realised. This indicates a form of mentality which Freud described as no longer subject to the so-called reality principle but instead governed by the so-called pleasure principle. Second, Bleuler's autism involved a motivated retreat to this world - i.e. away from an interpersonal world that was overwhelming, and towards a private substitutive domain. Third, central to Bleuler's autism, and a key reason why he was not happy to go along with Janet's conception of a generally diminished fonction du réel is that he saw autism as only affecting the patient in the ambit of her complexes. Someone may be perfectly in touch with reality when this reality is not challenging to her sense of self-worth, when it doesn't remind her of her failures or unmet desires or shame. But trigger such complexes in someone with a schizotaxic disposition and autism supervenes; it is not that the patient retreats to their own delusional and idiosyncratic solipsistic domain. 

This essentially dynamic conception of autism is lost in the contemporary formulations of Sass, Parnas, Stanghellini et al. Marvellous and hugely illuminating as their descriptions of autism are, they typically deny that psychodynamic matters enter into the heart of the autistic condition itself. At best they are conceived of as secondary withdrawal reactions to a primary disturbance in general pre-reflective attunement. But were autism really a deficit merely in vital contact with reality then Bleuler would never have coined the term - instead he'd have made do after all with what Janet's take on diminished reality contact (l'abaissement du niveau mental - due to loss of psychological tension and lost vital contact with reality. 

I just used the phrase 'vital contact with reality' which belongs to Eugene Minkowski. Today's phenomenologists view Minkowski's work on schizophrenia (in La Schizophrénie (1927) and other works) as the profoundest exploration of that topic yet. Sadly my French is terrible and his book hasn't been translated, but from what I've read of the other works it seems clear that the general assessment of Minkowski's phenomenology is right. Here we meet with no crass psychologising of schizophrenic psychopathology, but a deep exploration of the disturbances in intersubjectivity and temporality and spatiality which we meet with in the existential foundations - rather than the psychological upper storeys - of the schizophrenic mind. But what strikes me about such of Minkowski's work as I have read is its peculiarly delibidinised quality. Matters of sexuality are given a secondary place in the structure and function of the human psyche. They are not - by contrast, say, with the phenomenologist Maurice Merleau-Ponty (or others today, such as Jonathan Lear) - seen as ontologically central in the being of the human. Instead they are seen, as it were, as 'merely' psychological. The matter of our conflicted struggling with bodying-forth in our bio-motivational drives is relegated to a kind of disturbance of mental content rather than to a disturbance in the unfolding of mental form. I'm not going to try to make the case for all of that here, but instead turn to an example from an essay by Minkowski on the 'interrogative attitude'. The case he cites is that of Paul C, a socially withdrawn 17 year old schoolboy. Here I borrow the abstract provided by Louis Sass:
Paul C. had long been overly logical and precise in his style of thinking. An acute disturbance began with mental fatigue along with apparent obsessive symptoms (e.g., extreme monitoring of his own actions) to the point that simple, everyday actions became very time-consuming; he also developed a tendency to ask endless questions even about trivial phenomena. However, unlike those of the true obsessive, Paul's monitoring, doubting, and querying seemed to lack any emotional or personal element; he was not anxious but, rather, apathetic. Also, Paul lacked real curiosity: To him, everything had the same level of importance, and his attention was not directed by any precise or personal goal.
This paper argues that Paul's interrogative attitude was actually a form of autistic-schizophrenic thinking characterized by "pragmatic weakening" and a loss of vital contact with reality, which are consequences of a weakening of the "élan vital" with its "vital propulsion toward the future." Such patients retain their intellectual powers but do not use these powers in accord with the requirements of reality. The interrogative attitude can be seen as a compensation mechanism—a way to maintain some minimal contact with the world. The paper ends with psychotherapeutic recommendations.
The paper provides a brilliant description of Paul's diminished élan vital - a Bergsonian concept (although nb Bergson developed various of his concepts out of his reading of Pierre Janet's book on neurasthenia - Bergson's 'attention to life' being somewhat synonymous with Janet's 'reality function' - (cf Pete Gunter's interesting essay on Bergson and Jung)) - but provides scant information about his inner emotional life. Early on we are told that the beginning of this seventeen year old boy's condition 'goes back approximately nine months. Paul started complaining about a lack of energy and mental fatigue. Some time before this, he seems to have been preoccupied with questions of a sexual nature; he would question his father and ask him for explanations, revealing a complete ignorance of the subject.' This is the last we hear of any explicit mention of sexual preoccupations; later Minkowski opines that  The sexual curiosity that appears at the outset of the illness, which could be considered for that reason a point of departure, can only be a precursory sign of the interrogative attitude that takes a firm hold afterwards. In any case, it is this attitude that must be rectified before attending to anything else.’  But, well: why on earth can it only be considered that?! How odd that the central preoccupation of a (of any!) seventeen year old boy should just be lost from view in this way!

There are however some clues as to the possibly psychosexual significance of Paul C's symptomatology. Thus of two significant symptoms we find that one involves taking more than an hour to put the handkerchief under the bolster before going to sleep (don't ask me why these dudes were putting handkerchiefs under their bolsters in the first place). When asked for explanation Paul said that 'he wants to make sure that the handkerchief does not hang out anywhere beyond the bolster under which it is placed.' (Freud would have a field day!) Another symptom is spending hours in the bathroom. When asked for explanation all we get is the description of what Minkowski calls his 'morbid rationalism' - i.e. perseverative non-instinctual unstructured hyper-reflective devitalised thought and action. Why all this should happen particularly in the bathroom and bedroom, and what drives it all in the first place, is missing. When it comes to cure, Minkowski provides Paul with work on copying and translation. The occupational cure gets him somewhat engaged with reality again, but we can hardly imagine a less nocturnal (i.e. delibidinised) activity. We are left in the dark as to whether he has managed to integrate his instinctual life, we are left in the dark too as to why his soul is dirempting itself in the manner described. The meaning of Paul's initial attempts to put his struggles into words (his questions to his father about sex) are simply ignored. (Witness the fate of many a schizophrenic mind?)

Bovet & Parnas tell us that they think Bleuler's autism got lost because of his unhelpful psychodynamicism - and that if we just stuck to a Minkowski/Blankeburg line in our phenomenology we can develop a psychopathology that maps more neatly onto the biogenetic neurological drivers of the condition. I don't disagree with the significance of the neurological and the genetic to the development of schizophrenic pathology, but why our conception of the  biological should be thought to exclude the motivational and dynamic in this way is beyond me. Surely one can't get more neurobiological than instinctual matters such as the libidinal drive. Poor Paul C, it occurs to me, may well not seem to have managed its integration at all. (Let's face it, it's hard enough for the saner amongst us.) A properly psychoanalytic account is an account of the vicissitudes of the drives - that is, of such structures as are of their nature at once motivational and biological. For whatever largely constitutional, or perhaps sometimes also environmental-developmental, reasons, an inability to integrate the interests of the drive within the developing personality leads - so the theory goes - to massive defence formations, the creation of autistic retreats and delusional worlds, etc. ... 

Far from the psychodynamics being unhelpful, it seems to me to be key in understanding why it is that schizophrenia tends to develop in late adolescence - with the psycho-socio-sexual challenges of that time. But what it also does is allow us to understand a key further part of Bleuler's concept of autism - that it precisely doesn't stand either for some quite general abaissement du niveau mental or for a quite general loss of vitality, but instead refers to a state of mind only sometimes in the ascendant. Bleuler's idea is that it is just in the ambit of their complexes that the schizophrenia sufferer partakes of a way of being which pulls the inner and the outer worlds apart so destructively. A basal deficit theory, by contrast, not only provides less hope by way of treatment, but also less by way of understanding of the ebbs and flows of autism in the inner life of the patient. I would like to put it back to Bovet & Parnas: might it not in fact be the loss of the motivated-retreat-from-consensual-reality aspect of Bleuler's autism, and the development of quite general accounts of self-world undoing which treat not at all of matters of personal meaning and motivation, that set the concept of autism back so?