Saturday, 25 March 2017

John Berger on loneliness and recognition

"Most unhappiness is like illness in that it too exacerbates a sense of uniqueness. All frustration magnifies its own dissimilarity and so nourishes itself. Objectively speaking this is illogical since in our society frustration is far more usual than satisfaction, unhappiness far more common than contentment. But it is not a question of objective comparison. It is a question of failing to find any confirmation of oneself in the outside world. The lack of confirmation leads to a sense of futility. And this sense of futility is the essence of loneliness: for, despite the horrors of history, the existence of other men always promises the possibility of purpose. Any example offers hope. But the conviction of being unique destroys all examples. 
An unhappy patient comes to a doctor to offer him an illness - in the hope that this part of him at least (the illness) may be recognisable. His proper self he believes to be unknowable. In the light of the world he is nobody: by his own lights the world is nothing. Clearly the task of the doctor - unless he merely accepts the illness on its face value and incidentally guarantees for himself a 'difficult' patient - is to recognise the man. If the man can begin to feel recognised - and such recognition may well include aspects of his character which he has not yet recognised himself - the hopeless nature of his unhappiness will have been changed: he may even have the chance of being happy."
The quoted section continues with a remarkable description of how the physician John 'Sassall' offers such recognition in his medical practice in the 1950s Forest of Dean. Sassall
"is acknowledged as a good doctor because he meets the deep but unformulated expectation of the sick for a sense of fraternity. He recognises them. ... 'The door opens,' he says, 'and sometimes I feel I'm in the valley of death. It's all right when once I'm working.' ... It is as though, when he talks or listens to a patient, he is also touching them with his hands so as to be less likely to misunderstand and it is as though, when he is physically examining a patient, they were also conversing."


Thursday, 23 March 2017

self-possession in talk

Last night I saw the Rheingans Sisters in concert. I admired their music. I also admired their sisterliness. I thought: how admirable to be able to love and hate each other as robustly as this! And found myself imagining their robustness to be a function of a lifetime of counter-dependent individuation. Imagining they had to fight for themselves, to continue to manage their relationship and identity and strife, in the midst of their sisterly love.

All of that may have been my fantasy. Yet it prompted a thought about self-possession, thought and conversation I'd like to share. Here's the scenario:
I have a thought. I share it. You understand my words a particular way. I don't notice that you have supplied but a reading of them, but one parsing of their intent and their implications. I start taking myself to have had just the thought you understand me to have had. The conversation that follows rather presupposes this on both sides. Perhaps somewhere along the line I start to feel baffled and lost.
I think this can happen rather a lot. The determinacy of thought does sometimes and somewhat precede its outer expression, but often gets achieved through progressive finessing along the way. And one can easily collapse into someone else's finessing, or into the dead metaphors and tropes that pervade one's culture, and thereby lose the immanent intent of one's drift.

'Immanent... drift': I have in mind the notion that whilst one hasn't thought out in advance just what one meant by what one said, what such words do mean in one's mouth are yet aptly thought of as a part function of the other things one might naturally say in the ambit of this and related discussion when one's interlocutor gives one the space to mentally breath. I'm thinking not at all about what we might wishfully like our words to mean - no overly charitable unaccountability this - but rather about what they do mean, where what they do mean is a function of what else one is disposed to say.

I felt for a moment like saying: '...disposed to say absent a controlling other and absent a hypnotic disposition'. Yet that is my question here. Are the determinacy of my thought's content and my degree of self-possession quite so obviously separate matters? To what extent is the true content of my thought to be understood as aptly indicable only by the least forceful of my interlocutors? Or might my capacity to weather the rough and tumble of conversation, my self-possession, itself be a determinant of my thought's determinacy?

My thought, in short, is that my self-possession and the determinacy of my thought are not two different things. Underlying this is a Heideggerian idea concerning Discourse: that we are thinkers to the extent that we can partake in discussion. That, sure, we can take refuge away from actual conversation and think cleanly and clearly in the privacy of our own studies; thus J S Mill called solitude 'the cradle of thought'. Yet this psychological possibility, I'm suggesting, should not be thought to give the lie to an ontological necessity which is its paradoxical condition of possibility: namely that such private conversation is still only as good as the public conversation in which it could find its realisation.

Why does this matter? It matters to the extent that, if it is right, it shows that we do wrong to hive matters cognitive and matters dynamic off from one another. It strongly suggests that the development of my personality is not entirely separable from the development of my ideas. It ontologically elevates matters personological to a place in the philosophy of mind. It undermines the self-arrogated independence of cognitive science from matters psychoanalytic. Naturally we can think of all sorts of exceptions, real and apparent, to my thesis. We might for example bring to mind the boorishly over-confident person who is unshakeable in his drift. Yet for him we might well wonder whether his apparently determinate ideas really are quite so, since he hardly seems able to attend to the subtleties of our critique, to listen to what our questions regarding his thought mean in our mouths, and so he hardly seems able to render his own thought determinately accountable. Maybe our sense of his cogency was partly a function of our cowedness. Or we might bring to mind the fragile genius. Yet here, and this was all along my point, this genius must be able to stand up in some or other test, in correspondence at least if not in badinage.

Wednesday, 22 March 2017

organic, psychogenic, factitious

Something which makes it hard to achieve conceptual clarity regarding the psychiatric distinctions of the organic, the psychogenic and the factitious is the perennial temptation to import metaphysical distinctions between the mental and the physical into their explication. Yet this is but a way  philosophy hinders rather than aids psychiatry's reflective self-understanding.

One result of a glib importing of the metaphysical distinction into the psychiatric categories is a well-meaning psychologist's proffered: 'Oh, these distinctions between the organic and the psychogenic are so old-fashioned and dualist. These days we know we don't do well to assume that mental causes and neurological causes are two separate phenomena. The mind is not somehow some separate thing from the brain you know...'

The irony here is that it is the psychologist rather than the psychiatrist who is making the crass philosophical assumption - the assumption that in psychiatry the category of the 'organic' is to be understood in terms of that of the 'physical', the 'psychogenic' in terms of the 'mental'. The result is not that the distinction itself is shown to fail, only that the psychologist fails to achieve any rational reconstruction of it, and causes further muddle to boot.

So how are we to understand these distinctions? I propose that the fundamental category - the one we need to start with, the one an understanding of which is presupposed by the other categories - is that of the psychogenic.

A psychogenic condition, I suggest (tell me if I'm wrong!), is a breakdown due to intolerable pressure on the ego due to the thwarting of drives. Thus a breakdown due to unrequited love, to hopelessness, companionlessness, thwarted aggression, etc. Note that this definition says nothing about the degree of change in neurological structure or function. Perhaps a serious case of unrequited love involves all sorts of striking neurological alterations; I rather imagine it would! But the point of saying the category is fundamental is precisely to say that the nosology doesn't depend upon differentially diagnosing the absence of neurological alteration.

An organic condition, I propose, is one which is not psychogenically intelligible. (The concept of an organic illness in psychiatry is, I'm suggesting, not the same as the concept of an illness in general medicine, for the everyday concept of an illness is not left ontologically hanging on the absence of psychogenicity.) The alterations we find in the brain of an organically ill psychiatric patient (e.g. a late-stage syphilitic) are not due to thwarted drives (but to spirochetes!). Yet an organic illness is in one sense still defined functionally. That is to say, an organic illness is defined in terms of such impairment of an organ as causes disturbance in organismic (i.e. your) function. (If a spirochete eats away half your brain but gets so depressed with its miserable life that it gives up the ghost, and yet you suffer zero functional impairment, then in what sense are you ill? Who gives a monkeys if you've lost half your brain?) What is important, however, is that the illness is not constituted by an environmental thwarting of function. The brain changes are not caused by atrophy due to impossibility of drive satisfaction. Again, the concept of the psychogenic wears the differential trousers here.

A factitious illness is not an illness. It is someone pretending to be ill. You gotta understand it in terms of intentions to deceive.

We might add hysterical to the above list. If I had to define it I'd suggest: psychogenic with a form offering secondary gain (?is that right?). (And if anyone tells you that there is always and everywhere a clear distinction between intentional and non-intentional action, I recommend asking them where they got the license for their conceptual confidence. Our concepts so often have raggedy edges and admit intermediary cases. I for one see no grounds - other than egregious philosophical fiat - for saying that it must be the case that someone always either intends or does not intend something.)

It is natural for medics to worry that they may be mistaking psychogenic for organic illness. (The opposite of course may happen too, but is usually less fatal or less shaming for both patient and doctor - although we really shouldn't underestimate the disastrous existential and financial costs of undiagnosed or misdiagnosed psychogenic illness.) What can be said to reassure them?

On the one hand: not a lot. You just gotta do a careful examination of your patient. You can't just go around guessing that they have unfulfilled desires of such intensity as to cause functional breakdown. You look for the actual signs of this. But really this is just like the rest of medicine. Again: the concept of the psychogenic is the one wearing the trousers here; the concept of the organic is only to be invoked when the former finds inadequate purchase.

Where I think the added pressure comes from is the supposed march of progress of neuroscience. ... 'We are finding out more and more about the brain, and as a result will find out that more and more which was previously understood to be psychogenic will be organic.' ... Yet regards that: how many disorders have actually been newly understood since neuroimaging came on the scene? We have learned something more about organic conditions like neurosyphillis, dementia, parkinsons, and epilepsy. Have we really learned any more about the causes of other mental illnesses from neuroscientific investigation? Most often we just learn something more about the typical neurological alterations in this or that psychiatric condition. Yet, once again, neurological changes in no way index organicity. To suppose they do is to collapse back into the metaphysical canard with which we started. Nothing in neurology shakes the conceptual primacy of the psychogenic in psychiatry.

Friday, 17 March 2017

a different existence

The psychiatric patient is alone. He has few relationships or perhaps no relationships at all. He lives in isolation. He feels lonely. He may dread an interview with another person. At times, a conversation with him is impossible. He is somewhat strange; sometimes he is enigmatic and he may, on rare occasions, be even unfathomable. The variations are endless, but the essence is always the same. The psychiatric patient stands apart from the rest of the world. This is why he has a world of his own: in his world, houses can sway forward, flowers can look dull and colorless. This is why he also has a special sort of body: his heart aches, his legs are weak and powerless. His past, too, is different. His rearing has failed, and this in turn causes his difficulties with other people - difficulties that summarize, as it were, all his other complaints. He is alone. He is a lonely man. Loneliness is the central core of his illness, no matter what his illness may be. Thus, loneliness is the nucleus of psychiatry. If loneliness did not exist, we could reasonably assume that psychiatric illnesses could not occur either, with the exception of the few disturbances caused by anatomical or physiological disorders of the brain. We have no knowledge of animals ever having "genuine" mental disorders.

The clearest articulation of the thought that loneliness is the dying heart of psychopathology. J H van den Berg; A Different Existence pp. 105-6.

Tuesday, 14 March 2017

hope beyond hope

I'm thinking about the difference between the presence or absence of fundamental ('ontological') states of (human) being - of states which constitute us in our humanity as such - and the ('ontical') presence or absence of such feelings as are only possible when the fundamental states already obtain.

love

To feel love for, or be annoyed with, someone presupposes an ability to be in relationship with them. To be in relationship with them involves being open to being touched by them. It means offering them a place in your life. We meet all the time with love (and anger), but this love presupposes a deeper love - a love beyond love - which is the condition of possibility of love (and anger). From the point of view of this deeper love, anger could be said to be one of its forms. Ontological open-heartedness is a condition of possibility of ontical love and anger. Ontological closed-heartedness is a condition of impossibility of both love and anger.

hope

Sometimes I am delighted or disappointed - when my hopes are met or dashed. Yet there is a kind of hope in which I take out a mortgage on the happening of what I hope for, and when my hopes are not met then I am not disappointed but crushed. When I am delighted or disappointed I am able to reside in hopeful relations to the world. I am open to love and opportunity. Yet when I am crushed I become depressed; I am hopeless and have no future. 'Hope beyond hope' is ontological hope. It is an attitude of accepting openness to whatever will be. It does not hold the world to account but aims to take whatever is offered in good faith. Job saw that his complaints were, despite his terrible sufferings, vapid. We can be happy, yet vulnerable, when we awaken to hope beyond hope.

loneliness

Ordinary loneliness is an ache. In this state one knows that love and friendship are possible - this much is shown in the way in which one misses them: one is aware of what one is missing. Their love, the living meaning of their companionship, can still be felt in its absence. Yet loneliness beyond loneliness - ontological loneliness - is something else. This state of unmooring and hollowed-out bereftness makes it impossible to stay in touch with what one is missing. One is now no longer being in the mode of a companion.

therapy

Psychotherapy aims at the restoration of the capacity to feel ontically lonely, disappointed and angry. The capacity to feel thus is constituted by our ability to hope beyond hope, to love beyond love, to have companionship beyond companionship. Psychotherapists talk about their patients 'internalising' their therapists' care for them. This means staying in a mode of open-hearted relatedness to others, imagining oneself as the object of their care, and keeping them in mind too, even when alone. This is the whole task of therapy. It won't do to describe it in terms of 'affect regulation' or 'mindfulness'; what we are aiming at is rather an ontological transformation.