Sunday, 18 March 2018

how to live with a personality disorder

I continue to be struck by how my 'personality-disordered' patients ruined their lives by damaging their relationships through what we could call the breaking of promises. This promise-breaking rarely happened explicitly. It happened, rather, through an erosion of human trust: by the largely unacknowledged changing of tunes over time; by the insistent and too-convenient use of excuses; by doing too much of what they momentarily felt like and too little of what was the right thing to do; by insisting, when others tried to hold them to what they said in the past, that these others were taking their past declarations too seriously - whilst getting annoyed if they weren't taken utterly seriously in their current declarations; by tacit attempts to gain others' pity; by excessive invoking of illness or disability as moral get-out-of-jail-free cards; and, at worst, by emotionally abusive, conscience-overriding, efforts to project guilt and shame and inadequacy feelings into others (i.e. trying actively to make others instead of themselves feel like the morally bad one), efforts which become a vicious cycle when what also now has to be defended against is the guilt about being emotionally abusive in this manner.

In such ways the 'personality-disordered' adult has, despite much intellectual development, remained in their heart and morals a toddler-teenager. They have not developed that self-sameness over time, in the form of being a word-keeper, which is essential if there can be something in us in which others can meaningfully be said to trust, something which allows them to then come to know and love us.

Before continuing, let's be clear: everyone has some degree of 'personality disorder'. (The concept of a morally mature adult is an 'ideal type', it is not something which many of us manage to completely realise all the time.) But the degrees vary widely!

Sometimes I met with someone who in their heart knew full well what they were doing, and so who  understood that those they called friends really either merely tolerated them or had fallen for their charms and excuses perhaps because they, the friends, tend to see the best in people or tend depressively to see the worst in themselves. But often I met with people who seemed puzzled and hurt by the chaos they created, perhaps because their projections against overwhelming unbearable moral emotions really did succeed in ridding them of a sense of their guilt and shame, i.e. ridding them of a sense of what they had done to deserve their shunning.

Here I share my thoughts as to what someone might do if they find themselves spoiling their relationships in the above ways. 

a. Bring to mind a clear sense of what the right thing for anyone to do in any situation is, and always act only according to this general understanding. In this way you can align yourself with the good rather than only with what feels comfortable or rewarding to you. You can then also reap the rewards within yourself of what we call 'adult dignity' - i.e. feeling good because what you're doing is the right thing to do - and can leave behind the childish form of satisfactions which come from getting your way or getting out of something unpleasant. Dignity is not often talked about today, but in truth it is the only valuable form of self-love. The dignified person can feel good in herself because she knows she is living according to what is right, and this provides the deepest nourishment that the self can have outside of the love of another. The ambition of living a dignified life also helps with what to do when there's not much joy to be reaped in life. It has us ask: well, what can I do, today, to use my talents well, to help somebody, to grow, to discharge my responsibilities; what meaningful options are open to me? So long as we do what we can then, even if there's not much we can do, even if nothing goes our way, we can feel good in ourselves, so long as we are organised by dignity. By living a dignified life we also reap the rewards of the genuine love and respect of others.

b. Be honest with yourself in acknowledging that whilst there are no criteria for what count as: a reasonable or an unreasonable excuse, a legitimate or illegitimate changing of one's opinion or values, respectful or disrespectful talk, etc, in no way does this mean that it is up to you to say what is and isn't reasonable in your own actions! To think in that way - to think that we have some kind of privileged position from which we can inwardly know about the reasonableness or genuineness of our excuses, and some right to insist on what is thereby true of us - is to be what clinically is called a 'narcissist' - i.e. is to adopt the moral stance of the defensive teenager. (To put it philosophically, our first-person authority is a function of the expressive transparency of our avowals to the thoughts and feelings thereby avowed; it is not a function of our being better informed than others about what we think and feel.) The discernment of what is and isn't reasonable cannot be done in a defensive state of mind; it comes along in life as one develops a mature moral sensibility.

c. Develop a moral practice in which you learn to tolerate and even cherish your guilt and shame and feelings of inadequacy. If this doesn't happen then those awful defensive spirals, in which you keep needing to bolster the lie or the denial of blame and to try to push it into others, thereby alienating them and destroying friendships, will flourish. The person with a 'personality disorder' has got stuck in a moral universe in which admitting blame feels dangerous or seems to make one vulnerable in a potentially devastating way. This is after all how it may seem if you were raised by a 'personality-disordered' parent: your guilt will not be forgiven but held against you as a weapon, and so acknowledging guilt will be felt to be foolish, leaving you open to attack. Well, you can choose to stay in such a moral universe if you want, or you can choose to cultivate a different way of moral being, a way of moral being which is compatible with having genuine friends. In a morally mature universe others respect and forgive you precisely when you make genuine apology, and it is in the genuine apology and the forgiveness that proper relationship can be restored. Moral maturity consists in learning that such vulnerability to being seen as blameworthy is an essential part of friendship. (Going to confession is an example of a moral practice of this sort.) I said 'cherish your guilt and shame'; what I mean is: come to cherish your conscience which gives you such feelings. (I'm not talking about the bogus neurotic versions of depressive guilt and shame, but the genuine articles!) Your conscience is your friend because it helps you know when you've done things wrong; it enables you to rebuild your friendships. And your vulnerability is your friend because it is the condition of possibility of you having meaningful human relationships at all.

Saturday, 10 March 2018

senses of presence

In a previous post I proposed a theory of hallucination as a particular kind of anticipation or readiness - what I called a 'bodily anticipation' - of right now having a sensory experience, which anticipation is unrelinquished (when it is relinquished, the hallucination of someone coming down the stairs ceases) despite it being unfulfilled (nobody is seen to come down the stairs - since there is, let's imagine, nobody there to be seen). This power of updating or relinquishing through sensory engagement with the environment is, I think, of a piece with what we call 'reality contact'. I wrote there too that the idea of the 'inner image' is hopeless as part of the explanation of hallucination; naturally, though, I have no objection to the use of the term as merely another way to referring to an hallucination. But if to form a mental image of a cat is either to imagine looking at a cat or to imagine looking at a picture of a cat, then it could be misleading to talk of hallucinating a cat as having a mental image of a cat. To be sure, we might say of someone who hallucinates a cat that they are unwittingly imagining looking at a cat, but a risk of talking that way is that one thereby fails to distinguish hallucinating from daydreaming.

As against my understanding of hallucination, it could be said that one of the things which hallucination at least often-times shares with perception is a sense of the presence of the hallucinated or perceived object. But an anticipation by itself hardly constitutes a sense of presence. So don't we need to add something to unrelinquished anticipation to arrive at the sense of presence which hallucination shares with perception? Perhaps what we need to add is - heaven forbid - an inner image! It is, perhaps, the image which at least is 'present to the mind'. And perhaps such an image is also, in its way, the fulfilment of the anticipation.  

By way of answer I want to press the question what is really meant here by this notion of a 'sense of presence'. For there is a standard use of that term which itself implies something unshared by hallucination and perception, but instead indicates something which only obtains when we don't perceive something. So let's avoid the risk of misleading ourselves by getting that use clearly on the table first, before rushing on too quickly with the discussion.

So, we do sometimes talk about 'sensing the presence' of something or someone; we may even talk about sensing 'a presence', 'presence' now being another term for ghost or spirit. I suggest that the logic of this talk of 'presence' is best understood by comparison with our talk of déjà vu. An experience of déjà vu is properly articulated with a phrase like 'it is for me just like I had already experienced this very same thing happening.' Such uses of words defines the experience in question. However we have gazillions of experiences every day which we have had before - walking down the same corridor to our office, using the same toilet, drinking from the same coffee cup - and these precisely do not engender an experience of déjà vu. So in a sense the experience of déjà vu is precisely not like an ordinary experience of encountering something again. What this goes to show, I think, is that we are here using the phrase 'as if I had already had this experience' in what Wittgenstein called a special 'secondary sense'. We are drawn to use just this phrase; that we are so drawn is criterial for the experience in question; yet the use is not to be taken as justified by the current experience having something in common with the perfectly ordinary experience of encountering something which one had previously encountered in just the same way. (It is neither justified nor unjustified; that's just not how it works.)

What I am claiming is that the ordinary use of 'sense of presence' is, just like that of déjà vu, a secondary sense application of the term. We precisely do not mark with it something which is shared by both hallucination and perception. But perhaps, the objection goes, this is not the sense of 'sense of presence' which is relevant here. Sure, there is such a sense which applies specifically to hallucination, but what is relevant here is rather the (...alleged...) sense that (...allegedly...) applies to the case of the perception of objects. When I ordinarily see an object I ordinarily have a sense of the presence of the object ( the argument goes....). And this same sense of presence can obtain in at least some hallucinations. Thus one might use, in both hallucinatory and perceptual cases, sentences like 'It is for me just as if I were actually seeing the cat' to emphasise the same point.

As against this I want to ask just what is meant here by a 'sense of presence' in the non-hallucinatory case. For example, does the person who says that when I actually see a cat I have a sense of the presence of a cat mean more by this than that they are, er, seeing a cat? If so, what? I see a cat and in seeing this cat most often can also be said to see that there is a cat there on the mat. This however is precisely not shared with hallucination: when I hallucinate a cat I precisely do not see that there is a cat there on the mat. ('Seeing' and 'Seeing that something is there' are what we call success verbs/clauses. Hallucination is not successful or unsuccessful seeing!) Or is it that when someone sees a cat and hallucinates a cat it can seem to them that they see a cat? Is the 'sense of presence' a 'seeming' of some kind? But then, well, honestly, it is rather hard to know what is being done with the phrase 'it seems to me that I see a cat' when used by someone who straightforwardly, in a situation which wasn't anticipated by them to be one of deception (for we do use it as an expression of hesitancy when we're not sure if we should believe what we see, even when we are in fact undeceived), does see a cat. The concepts of appearance (seeming, etc.) gain their sense in virtue of the distinction they draw between the case of the seeming and the case of what is.

Now, it may be that there is some use being envisaged for 'sense of presence' which has not yet been spelled out. A use which is shared by both hallucinatory and perceptual cases. I however have not had it introduced to me, nor have I yet been able to pull it out of my own noggin. So, well... I'm waiting.

What however is also interesting to me is that we do use this notion of a 'sense of presence' to describe cases of hallucination.  I think it is worth pondering why this should be. (And when we think on the 'why' here I think we should make sure that we don't automatically start to look for a justifying reason, rather than an elucidatory cause, for our talk.)

On my understanding of hallucination it involves a form of anticipation of right now perceiving something which is unrelinquished despite the fact that one also has no experience of this anticipation being confirmed. Despite, that is, one not perceiving whatever is presently anticipated. This leads us to use the word 'presence' in the spooky, secondary sense, manner. 'I sensed the presence of my dead grandma' or 'I felt her presence' is what we are spontaneously drawn say. Despite her manifestly not being present: if she were actually present then we precisely wouldn't have that experience which we call the 'experience of her presence'. So, my question is: why are we drawn to use this locution? I take it that the question is the same as that which attends the use of 'déjà vu': why do we use this phrase to describe an experience which is precisely not like the gazillions of experiences we have everyday for the second or third or millionth time? 

Well, the reason (in the sense of cause that moves us, not in the sense of that which I could give as my reason) why we use the notion of 'presence' is, I think, because we have here to do with an unrelinquished anticipation. In this way it, the hallucination, is similar to a fulfilled anticipation (i.e. to a perception) since in the hallucinatory case there is no cancelling of the anticipation despite the manifest absence of what is anticipated. And in the perceptual case it is also not cancelled since it is instead fulfilled, and now has its life immanently within the perception itself. In short, this is what both perception and hallucination have in common: the continued life of the bodily anticipation. 

Similarly with déjà vu. It is not really that I seem to remember having had this conversation or visual experience before. We've all done that, all the time, and it doesn't amount to déjà vu. We don't reach for that description because it is part of the content of the experience; we are not justified, not even seemingly, in using the 'as if I've done this before' locution. Something in the temporal structure of the experience has instead gone awry. Something like the registering of the newness of each experience through time has failed, thereby constituting a distinctive dissociation. We want to say something like 'It is as if this very stretch of experience - not simply its content, but it in its temporally individuated identity - had happened before.' But that of course is nonsense, since what it is for the experience to be this one, when we are thinking not about its content but about its temporally indexed identity, is precisely for it to not be any previous experience. And yet we want to say what we say, and that we want to say just this is criterial for the experience being what it is. It's notable that with both déjà vu and hallucination we necessarily encounter a form of dissociation or trance or loss of reality contact - not necessarily any global state of such within the individual, but within the experience itself, as an essential part of its form.

Tuesday, 20 February 2018

moral character, illness, and the mind

What is it that makes for illness? In trying to answer this question we are perennially tempted to look toward the causes of illness - diseases for example - and away from the work that the concept does for us. In what follows I pay closer attention to that work by relating the concept of illness to that of character. The discussion also considers the question of what we are to make of the concept of mental illness and how it relates to physical illness. I shall both draw on and dispute a claim of Wittgenstein's and a claim made in a paper by T S Champlin. The remark from Wittgenstein is (Culture & Value p.54) 'Madness need not be regarded as an illness. Why shouldn't it be seen as a sudden - more or less sudden - change of character?' First however I turn to Champlin's paper.

Champlin is amongst those who consider the concept of 'mental illness' to be derived from 'physical illness' or, more perspicuously, from what, before the concept of 'mental illness' was invented, was simply called 'illness'. Unlike those (like Neil Pickering) who consider 'mental illness' a conceptual metaphor, Champlin considers it formed by 'secondary sense' and offers an analogy to help us grasp this. The analogy suggests the model of a 'rhyme for the eye' which stands to a 'rhyme for the ear' in the same kind of relation as 'mental illness' stands to 'physical illness'. So just as we may call the end of two lines of poetry which look the same even if sounding differently (...he'd read quite enough / ...of The Golden Bough) a 'rhyme for the eye', so too we may talk of an 'illness of the mind' even when we don't have to do with such features as are essential to illnesses 'of the body'.

But what is it that grounds (by way not of justification but of inspiration) the extension? Champlin suggests that 'the counterpart to position at the end of the line which facilitated the extension of the word 'rhyme' to cover rhymes for the eye but not the ear was that, typically, the mentally ill have in common with the physically ill the fact that they behave in ways similar to the physically ill. They often look ill and fail to carry on with their normal lives and need to be cared for by others.' Well, I don't buy this. For those who are mentally ill often don't look ill, they may never really have had normal lives or may be carrying on with what for them is a normal life in a mentally ill way, and they may not need to be cared for by others to a greater extent than the rest of us. These consequential difficulties do not take us into what it is for the mind to itself become 'ill'. So I suggest we keep the analogical idea - mental and physical illness needn't share something in common in virtue of which they are both illnesses; instead of something in common we need to look for a counterpart - but think again about what the counterpart is.

Wittgenstein asks - in what was presumably intended as a rhetorical question, although I shall treat it otherwise - why we don't talk not of mental illnesses but of sudden changes in character. The remark does the helpful work it does by virtue of shaking us out of the idea that we could, with our concept of 'mental illness', meaningfully be said to here have hit upon 'the right concept'. (We play the language game, and that's enough.) It also helpfully brings the concept of 'illness' into relation with that of 'character'. But what I want to suggest is that the whole point of the concept of 'illness' is that, precisely, we don't sanction an inference to the idea of a change of moral character, and that the whole point of 'mental illness' is that we may continue to draw on such exculpatory benefits in cases where the attribution of a character change is even more tempting.

Here's my main claim: Illness essentially involves changes in personal disposition which would, unless we reference that defeating condition which is the illness ascription itself, be seen as constituting a decline in moral character. Thus when we are ill we are disinclined to work, to take care of our responsibilities to others, to exercise our talents, to enjoy our appetites for life, to cultivate and spread hope. We are instead inclined to withdrawal, sloth, pessimism, self-preoccupation. Were such changes to happen to someone in the absence of disease we should say of that person that they had developed a poorer character. Such habits essentially find a negative moral evaluation, but thankfully we may be excused by being ill! The concept of 'illness' allows us to keep our virtues intact, if you like. In this way the concept of 'illness' does important work in regulating our social and occupational interactions. We cut the ill person some moral slack, discharge them of responsibilities, give them a sick note, do not hold them accountable for incompetencies to the same extent, etc. That the concept should be open to abuse by the pity-seeker or the work-shy is an important part of it. But another important part of it is that the mentally competent adult who is ill is able to acknowledge that he is ill. That he can do this is also an important part of our not ascribing character change to him. He himself offers illness as a legitimate excuse.

Now what about mental illness? What I suggest is that the excusing function of the concept of 'illness' is also central to the identity of 'mental illness'. And the person we call 'mentally ill' also starts to do things which would, were it not for the leeway we afford her, be judged as showing failure of moral character. She becomes preoccupied with herself, she stops respecting the shared norms that constitute conversational sense, she shows failures in courage and resolve, she shows less solicitude with others and does not make genuine heartfelt emotional contact with them. In short she demonstrates what looks to be a deficiency of humanity. Were it not for our saying of her that she is mentally ill then we should say of her that she was not being her better self, and if the difficulties were enduring then we should say that she had a change of character for the worse. However, the person who is the paradigm of the mentally ill has 'lost touch with reality'. Unlike the physically ill adult, she does not say of herself that she is ill. She may have moments of insight and during those say that she is unwell at the moment. Or she may look back at her past thoughts and deeds and say 'I was really ill during that time'. But in the moment of mental illness itself she does not say of herself 'this is illness'.

It is this, I am suggesting, which discriminates the mentally from the physically ill. In both cases the positive functioning of the concept is to defeat a moral judgement to do with bad character. In the physical case it works through citing bodily ailment: the person, we now allow, has the same good character, it is just that his character enactment is currently blocked by his bodily infirmity. In the mental case we also find the same helpful defeating function, and here we also say that the person is 'not herself' rather than that she has succumbed to vice. And we do this even though she in her adult self is not willing to say 'I am ill'. She 'lacks insight' and this lack is constitutive of her illness being a mental illness; she suffers a detachment from reality i.e. a foundational disturbance in her reason (notice I do not write: 'in her reasoning').


Addendum: The above discussion aims to discern some underlooked necessary, although not of course sufficient, conditions for talk of illness. I thought just append here what seems essential to me in illness generally and mental illness in particular. Whilst we may have what today we call a disease without feeling dis-easy, we become ill when we are, for example, overwhelmed by a disease. When you get the flu, for example, your body is overwhelmed. For a while you might have been 'fighting off' the virus. But then it gets to a point when your usual homeostatic mechanisms that maintain ordinary energy and balance collapse. You get a temperature, can't muster energy, feel hot and cold and achey all at the same time. Your health has broken down.

In mental illness you also suffer a 'break down'. The breakdown here is of the normal processes which keep you from being overwhelmed by painful emotional experience. Normally we find ways to deal with shame, grief, guilt, envy, fear, anxiety, and anger. We symbolise them in words and encase them in narratives, we take appropriate assertive action, we take time out to grieve i.e. to accommodate to loss. When this doesn't work we sublimate or repress. But when even these defences break down we become overwhelmed. This, I believe, is the basis of the use of illness talk when it comes to the mind. What we analogise between is the overwhelm of the normal self-regulating mechanisms in the case of bodily illness and in the case of emotional experience. The person who breaks down is no longer able to cope with reality. In the case of mental illness it is because what we call 'symbolisation' breaks down (i.e. the ability to put as yet inchoate affect into thinkable form is overwhelmed). In the case of physical illness it is because the regulation of appetite and energy provision and temperature breaks down. The analogy is so natural that it is surprising that the concept of mental illness didn't become more widespread earlier than it did.

Monday, 19 February 2018

real hallucinations

Here are some merits of Matthew Ratcliffe's new book: 
  • He listens to what patients say and so develops a discussion which (like Merleau-Ponty's)
    turns away from philosophers' idealised hallucinations to look at the symptoms of actual hallucinators.
  • He attends to disturbances to the modal structure of intentionality itself. He considers that psychotic experience, in particular, may involve breakdowns in the individuating polarities of different modes of experience (imagination, perception, etc.). So we don't have a business-as-usual set of psychological categories (faculties) in which to place hallucination.
  • He draws on the promising phenomenological idea of a form of anticipation which is constitutive in different ways of different kinds of experience. Different types of experience, he says, incorporate their own characteristic patterns of anticipation and fulfilment. 
  • He inscribes sociality at the heart of selfhood, rather than preserving some notion of a 'minimal self' which precedes or underpins such self-experience as is constituted by or in relationship.
  • He draws on this relational conception of selfhood to make really important links between form of social engagement, phenomenological matters of form, and emotional and psychodynamic matters of content. This, as I see it, really is the oft-unacknowledged holy grail of psychopathology: to grasp the relationship between the emotionally salient meanings of a person's life and the form taken by their psychopathology.
Here are what I take to be the central elements of his theory:
  • Hallucinations obtain on continua - for example they are experienced as arising both within (as more thought-like - in which case they are also on a continuum with thought insertion) and without (more sensory).
  • Those experienced as arising without are due in part to misperception. Shame - a pervasive social emotion in those who suffer psychosis - may prevent using other's minds to reality test the experiences (p. 98).
  • Hallucinatory voices may constitute what R. E. Hoffman calls the 'repopulating' of a 'barren interpersonal world' - one might say that they are not just hallucinations of voices but of otherwise absent relationships (p. 99).  
  • Those experienced as arising within are due in part to (p. 82) anxiously anticipating an increasingly determinate thought content.
  • Just as (p.85) 'fear of something that is taken to be past could disrupt the sense of that event as firmly anchored in the past', so might 'anxious anticipation induces verbal hallucinations... by shaping the sense of which intentional state one is in. ... Anxious anticipation of p ... contributes to the experience of relating to it in a perceptual or perception-like way. Anxiety is not ordinarily associated with our own thought contents and, when it is associated with them, they are experienced as the contents of a perception-like intentional state that also retains some of the features of thought.'
  • Against the objection that we often anxiously anticipate what we are thinking about - without thereby hallucinating it (for example we might anxiously anticipate an intruder hiding in the cupboard) Matthew replies that he is not talking about our anticipation of what we are thinking about (the robber) but about the thinking itself (we are anxiously anticipating our thoughts about the robber).
  • Consider abusive voices (p.89): 'in the case of an abusive "voice", there is an unpleasant emotional content p, which provokes anxious anticipation of a more determinate linguistic content q, one that is elicited by p and also consistent with p. Anxiety is intrinsically alienating and so its object, the thought that q, is experienced as alien, as something unpleasant that one faces and is unable to avoid. Whatever forms of anticipation our thinking more usually involves, anxious anticipation of thought content is not one of them. That style of anticipation is more typical of certain affectively charged perceptual experiences. So an unfamiliar, perception-like experience of thought content arises.'
  • Such hallucinations are experienced as not being self-caused, even if experienced within, because (92) 'the sense of being immersed in a shared world is already altered and diminished. None of the person's perceptions and thoughts are embedded in a public world in the way they once were, and so the ordinarily taken-for-granted distinction between a consensus reality and his own experience of it is eroded.'
  • Verbal hallucinatory 'contents ...are crystallisations of negative, self-directed emotions that reflect ... estrangement from the social world.'
  • Why are hallucinated voices are attributed by 'voice hearers' to particular subjects? Matthew suggests (95) that the thematic consistency of what the voice 'says', the 'voice-hearer's' imaginative elaborations, and confusions between imagining and perceiving all feed into what he calls the 'personification' of the hallucinated voice.
Here are some issue-takings:
  • Matthew accepts the notion that to perceive, think, remember etc is to be in an intentional state. I take no issue with the philosophical idea of intentionality; it's the relevance of the category of state I object to here. We (and other things) are in states and do not have them; states progress from one form to another; we are not in more than one at a time (if we are in a state of confusion and tiredness, we are in one not two states); states have no composition or location (Roger Squires 1970). Perhaps this seems phenomenologically fussy of me; well, perhaps I am fussy. But I think this kind of talk has risks - that it encourages a tacitly objectified conception of the exercise of perceptual and intellectual powers which illegitimately turns such exercises themselves into possible objects of transitive consciousness - objects of a transitive consciousness which may then go wrong (resulting in psychopathology as conceived by the philosophical psychopathologist). That it does encourage a reified conception of intentionality is, I think born out by the rest of my concerns which now follow.   
  • Matthew's approach seems to me to reify or psychologise the notions of 'thought' or 'content'. As I see it, thought qua content, rather than qua thinking, is a purely formal, logical notion. What it is for my hearing and seeing and thinking and imagining a cat to share the same content (a cat) is that I would use the same words to express what they were of ('a cat'). This content is not any kind of thought in the mind and is not something to which we can turn our attention (er unless by 'turn our attention to a content' we simply mean 'answer the question as to what we think or hear or...'). (I will revise this if I've got it wrong!)
  • Matthew appears to accept the notion, popular amongst certain phenomenologists who sit close to the philosophy of mind (e.g. Dan Zahavi), that our exercises of our perceptual and agential and rational powers come along with a a form of automatic 'self-consciousness'. Where by 'self-consciousness' here is not meant the ordinary idea of awkwardly feeling under inspection but rather a form of awareness of our own exercise of such powers which awareness is of both the type of the power (seeing, remembering, etc.) and the content of the intentional act (that cat again). He tells us that 'if I look at something and have a visual experience of it, I appreciate that I am perceiving it (and, more specifically, perceiving it visually), rather than imagining or remembering it. ... Put crudely, it is like something to remember, which differs from what it is like to perceive.' I think this approach is wrongheaded (i.e. not right or wrong) and will now try to say why (see also Peter Hacker 2006 and Joseph Schear 2009).
    • So, yes, I'm not going to claim instead that there isn't anything it is like to remember or perceive or... My claim instead is that talk of there being something it is like to remember or perceive is misconceived, as is talk of appreciating that we are exercising this or that mental power (hearing, remembering, etc); the idea that seeing and remembering strike us similarly or differently itself strikes me as peculiar. 
    • What is it that motivates the idea that there is something it is like to see a black cat? I suspect that one motivation is the notion that knowledge requires reasons. So let's accept (which I don't really) that it definitely makes good sense to say (in whatever context - that of us looking at a cat, say) that you know that you see a cat - both that it's a cat and that you see it. Then we might think to ask 'How do you know that you are experiencing it visually?' And then we might think we need an answer like 'Seeing strikes me a particular way', or 'Part of my visual experience is a pre-reflective auto-affection in which the modality is 'given' to me in self-consciousness. It is because of the deliverances of this inner sense that I know what sensory modality I'm in.' But, ok then, what is it like to see as opposed to smell a cat? Please tell me! It's no use waving around vague words like 'something', 'it', etc. - for, surely, if someone asks what it was like to go on the big bouncy castle then there being something that could form the content of an answer itself supplies the question with a purpose and a sense. 
    • So too I may sensibly ask my neighbour how she knows that her cat - this cat here, wrapping itself around our legs, of visually indeterminate sex (the cat not the legs) - is a boy and not a girl. There is something about the cat (the just about locatable genitals) or the shared testimony (the certificate from the cat breeder) which justifies her claim to knowledge. But I may not sensibly ask her, in that same vein, how she knows that the colour sample in front of her which she is looking at, in normal daylight and with no perceptual barriers or other peculiarities in play, is pink rather than blue. An answer would be possible - for example she could tell me that she learned the names of the colours at school. But note the difference between the two situations: in the one we justify empirical knowledge, in the other we acknowledge the ancestry of conceptual know-how. I suggest that we know that we are seeing rather than hearing only in the same kind of sense that we know that the sample in front of us is blue not pink, or e.g. know what our name is. There is nothing about pink that tells us that it is pink, and there is nothing about seeing that tells us that we are seeing. We don't need telling when it comes to know-how! There isn't something about seeing which tells us that we are seeing. It's not as if we're in the predicament of needing to sort out whether our knowledge is visual or auditory. Similarly with remembering: remembering is not a nothing or a something and there isn't something it is like or unlike to do it. What it is to remember - to exercise this capacity - is to retain knowledge. (Perhaps we could say: what it is like to remember is to not be forgetful!)
    • Finally, there are clear uses of the 'what's it like to...?' question. We use it to compare one thing to another. And we also use it to describe an experience where by 'experience' we don't now mean a perceptual act but rather a multifaceted event like going on a bouncy castle or taking a long walk in the rain. Talk of 'what's it like' and talk of 'appreciating' has its place here. But Matthew is not envisaging such a use for 'what's it like', and so I want to ask 'what use did you have in mind?' (I think there isn't one - i.e. that phenomenologists are here suffering from what Rupert Read calls a 'delusion of sense'. However it occurs to me I may be wrong - and that perhaps the idea of different senses being constituted by differently articulable anticipations gives us the content we need. I will revise this if it turns out I've been confused.)
    • To take it back to hallucination: Matthew theorises hallucination as content apprehended in a modality which modality is appreciated as other than the one it is. I am claiming that content (being merely formal) is not apprehended and that modalities are not appreciated.
  • Matthew's theory (along with various approaches taken by other philosophical psychopathologists) seems to me to sublime the logic of the notion of inner speech. (This is somewhat akin to the psychologising of thought qua content.) What I have in mind is that such theories of hallucination tend to imagine that it is both straightforwardly coherent and informative to say of a hallucinator that they are talking to themselves without realising it - that they have inner speech but mistake it for something more like hearing (or something which in some respects is between thinking and hearing). The idea is coherent yet uninformative if taken as simply definitional of hearing voices. But if it is supposed to do some explanatory work then we will need a criterion for talking to oneself other than one's sincere say-so. But none is forthcoming. Well, I don't think one is... Is there?
  • Finally, on 'personification'. Matthew asks why it is that someone experiences hallucinated voices as coming from particular people. The question is made room for, within the theory, by the fact that it is what I call a 'psychological' theory: namely, it attempts something of a psychological reduction of voice hearing - seeing it as an experience which is made sense of in certain ways. (Unlike certain psychological theorists, Matthew at least allows the sense-making to go on within the experiencing itself. And that surely takes us closer to the phenomenological facts.) I suggest that this gets the phenomenology wrong: hallucinations of voices present themselves ab initio in a range of distinct voices, voices which have tones (high female, low male, etc) utterly different from the speaker's.
Here are some alternative suggestions:
  • Sensori-motor anticipation is an important notion to draw on in a theory of hallucination, and, yes, this anticipation is not to be hived off from the hallucinatory experience itself. However what is anticipated is not that a particular thought qua content will have a particular form. Rather what is anticipated is, after all, the experience of something happening (not 'in the mind' but) in the world (that one will hear someone being mean to you by saying 'you stink', for example). 
  • Such anticipations are forms of readiness or preparedness essential for negotiating social reality.
  • Normally the subject who is in contact with reality 'cancels' or 'relinquishes' such sensori-motor anticipations when they are unfulfilled. This happens automatically. The cancelling of sensori-motor anticipations enables the experience of changelessness.
  • The psychotic subject is not well connected with reality. Some of his or her sensori-motor anticipations are therefore not cancelled despite the absence of the anticipated stimuli.
  • A sensori-motor anticipation which is both unfulfilled and uncancelled simply is an hallucination. A hallucination stands to a perception like a photographic negative stands to a positive (the photo): it is an anti-experience if you like.
  • We can grasp this most easily by thinking on the experience of getting on a broken escalator. We can see that it's broken, and so in one sense do not anticipate that it will move. However in another sense our body still readies itself for getting onto a moving staircase. This is the sense in which we do still anticipate that it will move. But then, of course, the broken escalator does not move. What we then tend to experience, unless we've really gotten used to it, is a lurch. This may seem daft because, after all, you can see that the thing is not moving. However that lurch, which is a feeling as of the escalator moving backwards, is itself the form taken by an unrelinquished anticipation of forward movement in a situation in which no actual movement is detected. It is, if you like, a haptic hallucination; it is a kind of shadow thrown by the sensori-motor anticipation.
  • Other aspects of Matthew's theory I should very much want to maintain. I'm thinking here, in particular, of the focus on loneliness, terror, and especially shame and social anxiety - not just as the psychological context which happens to inspire (be the efficient cause of) the hallucination but as the existential matrix which in-forms or de-forms the modal structure of intentionality. Anxiety doesn't relate to what for some silly reason we call reality-testing ('maximal grip' gets it better, but really we're talking about the ability to instantiate a distinction between perceiving and imagining, not some merely epistemic capacity to tell the two apart - i.e. the problem is that there aren't two modes here any more!) by way of one thing (anxiety) making something else (reality testing) hard to do. Anxiety is the shaking apart of reality-contact itself. When we are badly anxious we find it hard both i) to imagine anything much and ii) to achieve a good experiential understanding of our situation. Finally I should like to retain the idea of crystallisation (pp. 88, 94). Here we have the idea that hallucination involves the condensation of quasi-sensory solid out of an initially diffuse existential atmosphere. I would relate this to the human disposition to 'symbolism' (Langer) more generally - i.e. to what psychoanalysts also call 'dreaming' or 'thinking' - the giving distinct shape to as-yet-unthinkable-because-too-diffuse experiences. However if I read him right I think that Matthew might be thinking that the crystallisations into hallucinations involves the quasi-realisation of what is anticipated, whereas I think they are a function of a failure of the relinquishing of anxiolytically crystallised anticipations despite the absence of their manifest non-realisation. 

Sunday, 18 February 2018

explanation and treatment

In a previous post I urged the importance of distinguishing matters of causal explanation from matters of causal constitution. What I have in mind is that the answer to 'why is he angry?' is not typically to be answered by reference to what happens in his brain, but rather by reference to what happens in his life. Such reference essentially refers to what the angry person says when he gives his reasons for feeling angry. The exceptions however are important. Thus when there is no answer (or no decent answer) to be had from him as to his reasons, then matters to do with changes in bodily constitution, injury, overwhelm, diet etc. are now 'released' to play the role of reasons. What they are 'released' from is their mereological subordination to reasonable reaction (since here, in such exceptional cases, we don't have to do with reasonable reaction). It isn't of course that constitutional matters - bodily mechanisms and bodily changes - suddenly spring onto the scene when reason goes down, but that they can now play a role in that discourse which has to do with reason provision i.e. which has to do with answering 'why?' questions about actions and reactions. What I claimed in that post too was that reasons which appeal to our psychology (dynamic motivational reasons that is - one's which cite the motivated deployment of defences, the motivated avoidance of anxiety and pain, etc.) become available (are 'released') when the provision of ordinary personal reasons (my reasons for acting, the one's I avow) give out. And I suggested too that subpersonal reasons (hormonal, neurophysiological and neurotransmitter anomalies etc) only become available as explanations when both the personal and the psychological reasons fail.

So what I am specifically writing against here is that form of thought which is so keen to demonstrate its all-encompassing scientifically and philosophically unprejudiced prowess that it fails to do adequate justice to the 'helpful prejudice' that is already embedded within our explanatory practices - to the 'prejudice' which says we've gotta start at the top (with my reasons) and only work down (to neural anomalies) when those forms of explanation at the top fail. I am writing against the throw-it-all-into-the-mix bio-psycho-socio-spirituo explanatory models of mental illness, for example. I am claiming that our being constituted by matters chemical, biological, psychological, social, spiritual, etc., and the dependency of our healthy minds on bodies that politely function to support them, do not mean that observations at lower levels of description (how a certain hormone affects amygdala functioning for example) could play a role in explaining why someone acts as they do unless the levels of personal and of psychological reasons fail us. If someone says 'but why can't we have both?' they are still, I think, in the grip of an unhelpful picture, a picture which without warrant transposes stories from a context of inquiry into matters constitutional (about the processes and structures which constitute or subtend our psychological functioning) into the context of inquiry into matters of reason ('why did he wave his arm?' is not helpfully answered by mentioning the tightening of his muscles).

What I want to add here is that this all has implications for rational treatment of psychological disturbance. If I am crazy because my neurotransmitters are de trop then it will not make sense to treat me psychologically. But the reason for this is that what it is for neurotransmitter levels to be de trop is something which has to determined relative to the (un)availability of reason-giving or dynamic motivational explanations for an emotional reaction. For it is perfectly conceivable (even if not actual) that the same level of neurotransmitter activation may obtain in the context of a healthy grief reaction as in the context of an endogenous depression. But in the former case there is no meaning to be had for 'de trop'. This, by the way, gives the lie to those evolutionary accounts of 'neuropsychiatric disorders' (a stupid term which begins ('neuro') where it often shouldn't even end) which want to define what counts as excessive or as misfiring or what-have-you in relation to proper function, where 'proper function' is given in evolutionary terms: is it performing the task it evolved to perform? Such accounts start in the wrong place - from the bottom up - whereas we ought to start from the top down - from the availability or otherwise of personal-level reasons for action. Sure, 'excessive activation' buggers up our psychological functioning, but what makes such activation count as excessive is that what it is doing is not playing its part in the mechanics of what on quite independent grounds we find to be rationally intelligible reactions, but is rather causing reactions which, again on quite independent grounds, we find to be rationally unintelligible. And that, I imagine, should come to all but the excitable theory mongerer as something of a relief - for it might have felt like an exciting intellectual project, but it was surely always rather a desperate long shot, to try and milk normativity out of evolution, and to milk the concept of something like a natural kind so hard that it would explain how our unscientific concept of mental illness, used with normative aplomb by many a scientifically illiterate person, could contain such hidden intricacies.

Back to treatment. The point I want to make is that whilst, with an eye on matters merely constitutional, it might seem to make a breezily unprejudiced kind of sense to say 'well, we could treat the problem with a talking cure, with exercise, or with a pill; all that's happening here is that we're intervening on different levels', in fact this really is far too breezy for its own (and the patient's) good. For a rational treatment, surely, is one which tries to address the reasons why someone is distressed. And if they are distressed because they are grieving their father, or alternatively if they are differently, anxiously/depressively, distressed because their repressed anger at the father leads to aborted grieving, then even if any of this distress or instead this anxious depression is partly (what-shall-we-call-it) 'realised' in a statistically-abnormal-for-them level of dopamine (or whatever), then 'treating' the abnormal dopamine levels will not be treating the cause of the problem. (Where what 'the cause' is is coextensive with the reason, and not with the constitutional mechanics.) ('Treating' goes in inverted commas because it can't really be called treatment if what is 'treated' isn't itself a problem.) In fact, far from being helpfully unprejudiced, such an approach tramples all over the humanity of the patient. For being given extra, or being caused to have reduced, neurotransmitters may reduce the healthily-grieving person's sadness but, since their sadness is their grief, and since what they need to do is to get used to the fact that their father is dead, and since 'grieving' is the name of that process of getting used to his being dead, then to reduce sadness is to interfere with their reality contact itself. Which, er, is not normally what we take for the goal of psychiatric treatment. Or, if we imagine that we have to do with the patient whose depression obstructs healthy grief, then having agitation removed will remove the clue that here we have to do with conflicted feelings (anger and loss) and will leave them in emotional limbo (welcome to zombie land). Only if we had a situation, as yet here un-described, in which the reason why the patient was struggling to grieve was not because of grief's intrinsic hardness nor because of their neurotic ambivalence, but because they have too much dopamine (or whatever), would it make any rational sense to treat them using drugs.

NB the different responses to Prozac: 'I feel numb now' vs 'now I feel far more myself'. Even if they had, pre- and post-treatment, the same level of (say) serotonin as each other, only the second patient had, we might rationally infer, been suffering a serotonin imbalance, and only patient's who had a serotonin imbalance could meaningfully be said to be being treated with Prozac, regardless of the efficacy of the treatment.