Beginning to Think about Delusions and Schizophrenia

I don't know why--my British-Canadian instincts to root for the underdog, perhaps?--but I have been haunted for a long time by stories of psychiatric patients and their abuses not just in the Soviet Gulag in the middle of the last century, but more recently, and in a supposedly "enlightened" and free country like the US--or Canada or the UK. The stories that remain with me are those of patients deemed and treated as though they are beyond reach--and this seems primarily to encompass people labeled "psychotic" or "schizophrenic." 

I have read stories of clinicians who were unwilling to simply write such people off, or consign them to subsisting in heavily drugged states in institutions, but have tried to reach, and even to heal, them, via psychotherapy. There are four such clinicians I have some familiarity with. What follows are just some initial reflections based on learnings gleaned from each of them. (I am not mounting a defense of all of them, or even each of them singly in every one of their views; nor am I conceiving of a grand theory of anything here.) 

I think the first clinician I encountered was R.D. Laing. About three years ago, reading of him somewhere and finding what I read interesting (alongside his Glaswegian heritage, which is that of my mother and maternal grandparents, who were born in and around Glasgow and lived up and down the River Clyde before emigrating to Canada), I got a copy of his semi-autobiographical Wisdom, Madness, and Folly: The Making of a Psychiatrist and read it with not just interest but real horror also, learning in there of certain techniques used less than a century ago with certain patients--e.g., insulin comas--alongside the often callous dismissal and virtual medical imprisonment of patients labeled psychotic and/or schizophrenic. 

Incidentally, numerous films and documentaries have been made about Laing, and Amazon Prime has the most recent, Mad to be Normal, which I watched with great interest. It gives no background to Laing, and only perfunctory (but damning) coverage of his shoddy treatment of his family and his many affairs and resultant children, but focuses almost entirely on the "experimental" community he founded and ran from 1965-70 in London at Kingsley Hall, a place where patients could live without judgment and enforced treatment--which was not unproblematic! 

Freud (without much experience) claimed--and everyone else seems mindlessly to have repeated--that psychosis and schizophrenia were impossible to treat with psychotherapy. Laing and a few others would show Freud to be wrong on this point. Laing was not successful with every patient, to be sure, but with enough that we must, if we are dispassionate clinicians of truly open minds weighing the findings of (loaded phrase!) an "evidence base" to consider his efforts seriously and give him credit--no matter the problems that come with some of his views, and certainly with his destructive conduct towards his children and wives. 

He writes about his clinical work in his earliest book, which I have just finished: The Divided Self: An Existential Study in Sanity and Madness. In this book, Laing writes of debts I did not know he had, including to Jock Sutherland (author of the interesting study Fairbairn's Journey into the Interior), Charles Rycroft, and the great D.W. Winnicott. 

True to his subtitle, Laing immediately dives into a claim--derived from Freud's Civilization and its Discontents--that what we call "psychosis" may be a sign of a serious split from the unbearable parts of our world, and thus have more of an external-social "cause" than an internal-biomedical one. He also notes that people locked in a psychotic state may--a theme also found, he notes, in Frieda Fromm-Reichmann (about whom see below)--be helped by the presence of a patient clinician: "since relatedness is potentially present in everyone, then he may not be wasting his time in sitting for hours with a silent catatonic who gives every evidence that he does not recognize his existence" (26). Fromm-Reichman says this, and so, as we shall see, does Christopher Bollas. 

A little later he returns to this theme, noting that the clinician must, at a minimum, make every effort to "know how the patient is experiencing himself and the world, including oneself. If one cannot understand him, one is hardly in a position to love him in any effective way" (34). 

Laing recounts an interesting claim of a patient in group therapy who felt another patient was threatening his existence and so the first patient became very argumentative precisely, he claimed, to preserve his existence. This leads Laing later in the chapter to caution (pace his earlier claim) that with some patients the therapist needs to be very careful not to extend love because it might in fact be more feared from and in the therapist than the latter's hatred. Themes of engulfment and annihilation abound here, as they will later in George Atwood, discussed below. But even more than in Atwood, Laing focuses on the necessity of a sense of autonomy in the patient, whose delusions may come about in part as a function of feeling that autonomy is under attack. 

As one comes to love a person diagnosed as schizophrenic, Laing counsels reading Kierkegaard, especially The Sickness Unto Death (which was my introduction to the Danish philosopher in high-school), saying that the clinician must first understand real despair (and Kierkegaard is an excellent guide to it) before understanding his schizophrenic patient, for the latter is nothing if not mired in despair. 

The middle section of The Divided Self is really focused on the schizoid personality, and the splitting characteristic of it. Here Laing's debts to Winnicott and Fairbairn are very clear. As we get into the final section, he deals more directly with schizophrenia, and provides in some chapters very extensive clinical material. He notes, however, something I have also found: "it is never easy to obtain an adequate account of a schizophrenic's early life. Each investigation into the life of any single schizophrenic patient is a laborious piece of original research" (179).

Laing notes something other authors have: violent fantasies and delusions, including of murder, are common in schizophrenics and reflect their sense of "having murdered their selves." He calls these delusions, but immediately says they "contain existential truth" (149).

Those in psychotic states are often known to speak what others regard as incomprehensible gibberish, but Laing notes that this is a deliberate defense mechanism: the "deliberate use of obscurity and complexity" reflects the fact that the patient is trying to scare away the doctor because the patient "is terrified of love" (163) and  wants to "avoid at all costs the possibility of being held responsible for a single coherent idea or intention" (164). 

Such are some of the gleanings from Laing which I will continue to think about. Many of them, as we will see presently, are very similar to those of George Atwood and Bollas again. 

Having finished Laing's The Divided Self, I have lined up next to read Daniel Burston's biography of Laing, The Wing of Madness: the Life and Work of R.D. Laing. (I interviewed Burston last year about his newest book.) Biographies have long been my go-to genre for bedtime reading, and I will get to this as soon as I finish another one currently underway, viz., Helen Swick Perry, Psychiatrist of America: the Life of Harry Stack Sullivan.

In addition to Laing, the other person who tried with some success to reach those often labeled as hopeless cases is Frieda Fromm-Reichmann. I have discussed her life and work here, so I will not say more about that now. She, too, remains a greatly admirable inspiration. 

Instead, let me turn to a clinician who is still alive: the retired Rutgers psychologist George Atwood, author of the recent book The Abyss of Madness. It is an enjoyable book, though the last chapter (focused entirely on 'existentialist' philosophers) seems rather tacked on and not at all integrated into the rest of the book, which mixes much good clinical sense with interesting case material. Atwood early on notes that "psychotherapy is always a dialogue between two universes, one that transforms both" (35). 

A little later in the book he comes to his titular focus, saying that "Madness is not an illness, and it is not a disorder. Madness is the abyss. It is the experience of utter annihilation" (41). Madness gains its terror, he suggests, because it raises the specter of falling into nonbeing. And madness should not be thought some rare and singular phenomenon that happens to others. Rather, Atwood suggests (and here he puts me in mind of Christopher Bollas, who has suggested that all of us cycle into and out of periods of 'madness' at some point, to greater or lesser degrees, but only a few of us get stuck there long enough to need or attract clinical attention), "the abyss is a universal possibility" (43). 

Much of the book is spent attempting to understand delusions, which at one point he regards as an attempt to restore a "lost connection to someone life-giving," a point he illustrates with an especially harrowing case study of a child devastated by paternal suicide (44). He found working with this severely delusional woman that it was necessary for him as a psychotherapist to feel and show her that he had a real "understanding of the horror" and saw his job as helping her return from the land of horrors. Doing this, he says, does not require a "diagnosis," which he sees as not just objectifying but reifying the delusion. Instead, she needed from him "validation and mirroring" (45). 

Much later in the book he returns to working out a definition of delusion, noting succinctly that it is "a belief, any belief, about the validity of which there can be no discussion" (p.99). Given that no discussion is possible, Atwood advises against making any comparisons between the delusion and "reality" for this will not help the patient. Instead, in an interesting turn of phrase earlier used in the book, such a comparison will awaken an "epistemological trauma" in the patient. (This phrase, and the way Atwood describes it, are very close to the great moral philosopher Alasdair MacIntyre's 1977 article on "Epistemological Crises, Dramatic Narrative, and the Philosophy of Science," which I have often used with my students over the years.) 

Given that delusions admit of no debate, Atwood advises that the clinician discuss these delusions as one would discuss dreams, about which he has an entire very interesting chapter. (He counsels the wisdom of something I learned both from my own experience as an analysand, and also from Nina Coltart: pay attention to the first reported dream at the outset of treatment for it may well concern "the deepest theme of the treatment that is to come" [89].)

The similarities between dreams and delusions are threefold: neither follows laws of logic and rationality; both engage in condensation and concretization; and both can, with time, fade and be forgotten. 

I confess I wish I had finished this part of Atwood's book even a day earlier, for it would have come in handy with someone whose delusions I mistakenly tried repeatedly to challenge, without any discernible effect--other than making this person acutely uncomfortable and distant which, in turn, gave rise to a counter-transference image in my mind of a ship with a damaged rudder being blown in circles in the South Atlantic.

Atwood reports additional case material, including of a patient whose delusions about coming from a "family of vampires" made a lot of sense once the patient's history was known. The sense was derived not from comparing the delusion to some notion of reality, but instead by asking what the internal meaning for the patient might be. Here as in most other cases reported, the "madness" this patient suffered was a "result of the failure of sustaining human relationships" and, usually, "disastrous trauma," sometimes visible but sometimes not (55).

What are reported as "delusions" in children, Atwood suggests, may well be potent vehicles for some truth hitherto hidden or denied. When they express themes of murder and violence this may indicate not necessarily literal violence earlier in their life, but nonetheless a strong sense of having had something precious killed.

When he turns to schizophrenia, Atwood notes that patients carrying this diagnosis "often do not experience themselves as existing. They live in a felt state of nonbeing" (58-59). As a result of this claim, Atwood at several points cautions the clinician to remember, and remind the patient, that we all live in a common world as experiencing beings, but that our experiences can and do differ. Saying such a thing to such patients helps may help them feel less estranged and threatened. 

Let us turn directly to Bollas now, almost all of whose books I have read in the last 3 years. His first book, The Shadow of the Object: Psychoanalysis of the Unthought Known remains, to my mind, perhaps his most original and important. But two others are relevant here: Catch Them Before They Fall: the Psychoanalysis of Breakdown; and then especially When the Sun Bursts: the Enigma of Schizophrenia. I just ordered the former and hope to read it over Christmas; but I have now read the latter, on schizophrenia, and it is a very rich and rewarding book indeed. Bollas writes in here with an easy and sometimes "seductive" elegance, which one does not expect in a book devoted to often such disconcerting cases and their suffering. 

Commendably, in When the Sun Bursts, he notes some limitations at the outset: the book is not a textbook on schizophrenia but is simply based on his extensive clinical work, in England and the US, going back decades. Even with this, however, he lays no claim to be an expert in schizophrenia or anything else. As he rightly puts it, "no human life is long enough to allow any clinician to claim that he or she has truly grasped the meaning of any of the 'disorders'" (2-3). 

By the time I reached the end of the book, I had come back again to this realization with renewed gratitude. We do not need, and should rightly question, anyone--no matter how distinguished--laying down the law about what Disorder X, Y, or Z means in definitive terms. Bollas eschews all of that, and it allows the reader freedom to think and to disagree. There were parts I questioned, and by the end realized that it is not necessary for me to have an over-arching and comprehensive theory that explains all psychotic phenomena, or all patients thought to be schizophrenic: instead, it is enough that this one book helped me very considerably with one case at the moment, and gratefully to receive its gifts while remaining open to and awaiting others (noted at the end of this essay).  

Bollas starts off with a blunt assertion, which, in my very limited experience so far, I fully share: "no one a psychoanalyst meets is more compelling than the schizophrenic" (p.2). Like Laing and Atwood and others, Bollas is horrified by the "throw away the key" approach we have seen in too many instances of schizophrenic diagnosis (p.8). His own approach is team-based, working with physicians and others to provide community-based care that, where possible, avoids heavy drug use and institutionalization.

He suggests that the schizophrenic might bear more than a passing resemblance to the child who finds his or her own mind more puzzling and incomprehensible than just about anything else. With time, and "good enough" parenting, they learn how to decipher parts of their mind, and to be able to bear it. But "when defenses against the complexities of the mind break down there can be a breakthrough of too much. Selves cave in" (p.8). 

At the end of the introduction, Bollas is quite insistent that if you can catch someone--especially an adolescent--at the outset of what seems to be a schizophrenic episode, then the "crucial factor that is vital to whether the person has a chance to survive and reverse the process" is that "there is someone for the person to talk to for long periods of time" over many days and weeks. If this is provided "there is a good chance that clinicians will see transformations back to non-psychotic functioning" (8-9). 

As we move into ch.1, we get some fascinating glimpses of autobiography, taking us back to Bollas' early training and work in California in the 1960s at a school with a lot of severely disturbed children. More of this emerges in ch. 3. One valuable lesson he learned then, which has remained with him all these years, is that "almost all psychotic behavior was comprehensible if one could discover the underlying logic of thought" (20). (This is a point made by Sofia Jeppson in her new article, "Psychosis and Intelligibility," Philosophy, Psychiatry, and Psychology 28 [2021]: 233--249.)

In the third chapter, Bollas speaks of "negative hallucinations" as those things that negate "the presence of objects that are present in the world around them [i.e., psychotic patients]" (45). This was a helpful phrase for me in trying to understand a particular case right now. 

Though he doesn't call them this, Bollas scatters throughout the book some "techniques" that he uses and seems to recommend. These include:

• finding out from the person what has been helpful, what "self-therapy techniques" they have successfully used to date, if any (47);
• try talking about "everyday reality" rather than inner disturbances in order to give the patient a sense of safety and anchoring (50);
• allying himself with Harold Searles, Hanna Segal, and Wilfred Bion (inter alia), Bollas advocates "listening to the free associations and unconscious communications" of the schizophrenic (50), a point he reiterates seveal times throughout the book;
• a comfortable use of silence throughout sessions (67-78).

It is in the seventh chapter that we get the story of the book's title. Bollas says that very often "those on the verge of schizophrenia may experience profound changes in their way of seeing, hearing, and thinking" (75). A little later he names these "apocalyptic moments in which the person's worldview is changed" (80). One young male patient named David in his early 20s went through a series of shocks and changes, and described them to Bollas as being the point in his life when the sun burst.  

What are some signs of such changes? Bollas lists several, including dehumanization and ritualization in which real acting persons are replaced with people playing roles. Real people are too untrustworthy and dangerous, so now they are forced into a narrative or a "play" in which they have fixed roles. The patient does so as a way of keeping people away from him. Fragmentation here is tolerable, but self-fulfillment and self-unity are not: "a self fulfilled is a self endangered" (81).

The second part of the book opens with a claim from a patient who insisted he knew things of his life before birth. I found this startling insofar as I once knew someone who made a very similar claim. Such a person creates what Bollas calls a "mythic personality" one of whose hallmarks is often a "metasexuality" marked by "frenzied connectedness" (91). Later in the chapter he returns to this, speaking of the experience of some patients in manifesting a "rapaciously deranged sexuality" (96). 

This takes us into the tenth chapter which is devoted to metasexuality. Here Bollas speaks of the schizophrenic tendency toward "sexualizing everything" in order to eradicate "the specificity of erotic fantasy life and the reality of sexual engagement with a specific other" (97). Why might a person do this? 

For Bollas, one answer might be that "the mania of sexual omnipotence aims to re-situate a failing self within a position of power" (98), but such a self is situated in a "profoundly solitary position" (101). 

Chapter 11 is devoted to "Hearing Voices," and Bollas here notes that in addition to voices, some schizophrenics also have very acute and prominent experiences of colours. He counsels that we first recognize the voices come from the inner child, and that we must also treat these voices with great respect. We should neither judge them nor critically compare them to reality, but instead simply "ask what each voice is saying and to ask for further details," confident that in doing so we will be listening to voices whose main task is to disguise and protect the self. 

Bollas says that instead of frontally challenging voices (which I have done, to utterly no avail at all!), we should both (clinician and patient) puzzle over them, asking: what can they mean? The task here is not challenge or dispute, but translation. If you ask the patient to talk about the voices, Bollas says the effect is often profound. Ask the patient to try to explain to you what the voices mean. Treat them with dignity (109). (I found this very helpful in one case after having earlier failed by challenging the delusions. It occurs to me that this is a "technique" that might admit of wider application in, e.g., our infamous political problems now with conspiracy theories about vaccines, stolen elections, etc.) 

As a psychoanalyst, Bollas notes that voices cannot free-associate and if the patient can come to see this, it may change everything. It may, in fact, provoke the kind of "epistemological crisis" we noted earlier: the supposedly all-powerful voices can do little more than repeat their claims ad nauseam, never being able to elaborate upon their points in any intellectually compelling manner. They speak for the split-off parts of the personality, but do a poor job of it, and if their poverty can be seen and accepted by the patient, this may be the beginning of the dissolution of the voices' power.

In  chs. 12 and 13 (but really throughout the book) Bollas makes excellent and very enlightening use of object relations theory to help us conceptualize what is going on in a schizophrenic mind. External objects become invested with profound meaning, speaking for and representing parts of the self that must, for several reasons, be disowned and even disdained: "Mental processes may be housed in objects that perform them." In extreme form this can result in "schizophrenic emptiness" (135-36) as the patient puts the self into various objects, retaining little to nothing for and of himself. In doing so, the patient ensures that "action defeats thinking" (142) for thinking has been made too dangerous and intolerable. The clinician who attempts to "interpret" these projections into objects is on precarious terrain here for the patient may regard such actions at tantamount to theft and react with alarm or even violence. 

A little later Bollas argues that "schizophrenics are often precocious as children, frequently speaking early and developing language skills to a very high order" (163). He does not here mention, but I naturally immediately thought of Winnicott's famous essay (which I discussed here) on precocious children, "Mind and Its Relation to the Psyche-Soma." (Bollas later in the book talks about the somatization of certain schizophrenic phenomena.) Such children, he notes, may often be "highly sensitive to colour, light, and sound" and may become experts on certain physical objects (this has been confirmed in my clinical experience.) 

As the book gathers itself towards a conclusion, Bollas circles back to make something of a plaidoyer once more for several techniques he has successfully used. 

1) Got a Comprehensive History:

He stresses repeatedly the need to get a good history, saying that places like Finland this has long been understood and practiced. Involve the family. Almost all cases reveal there was some kind of "apocalyptic" moment, some kind of abrupt shift and change that led to schizophrenic symptoms beginning. If you catch this early enough you may be able to prevent the patient from falling into a full-blown disorder. 

One additional crucial task a history does is allow for the "restoration of human temporality itself" (179) in a mind increasingly slipping far into the past or future. 

2) Narrate the Quotidian:

Ask the patient to narrate in as much detail as possible the events leading up to the painful break or moment. Do so in a way that engages the self, the I, and allows the patient to see and recover a sense of agency and subjectivity. This he says is "crucial. If he has not given up, there is time to get him to shore" (171).

Additionally, part of the task here is to re-narrate that event, to restructure it in the mind, so that it is no longer destructive, persecutory, etc. 

3) Ease the Annihilatory Defenses:

Help to decrease the anxiety about the self and begin to work towards the restoration of the subjective voice. Before (or simultaneous with) this, however, you may need to engage in the next step, often for some time. 

4) Talk to the Patient About Commonplace Matters:

They may watch you to figure out how you navigate the world, how you are not overwhelmed by the experiences that they are, and how you seem to make sense of objects in ways that differ from their use of them. Tell them about the weather, or a movie you saw, etc.

5) Ask for Examples:

How does the patient structure his mind? What heuristics does he use? What assumptions about people and the world exist? What core convictions does he have? Where are there unthought knowns? Here is where a free-association type method (and the reverie and associations it evokes in the therapist) may be useful as these things may be discovered by simply listening to and watching the patient not just talk but also interact with the environment 

6) Remember the Poets:

Bollas ends this hugely insightful and helpful book by turning to W.B. Yeats and a passage from his autobiography. This leads Bollas on to claim--without, just a few pages earlier, at all disdaining the need for psychotropic medications and hospitals in some cases--that perhaps the "poets may have more to teach us about schizophrenia than psychiatry and psychopharmacology. After all, they have learned how to descend...to the sensorial, imaginary, and symbolic in such a way as to convey our unconscious knowledge. Perhaps poets come close to the mental intersections experienced by the schizophrenic. Who knows how this happens?" (197). 

I reach the end of When the Sun Bursts: the Enigma of Schizophrenia with that familiar sense one has of having been greatly enriched by a book, but a little saddened that this enjoyable and deeply edifying conversation has come to an end--though this is a book that will repay careful reading, I am sure. Its lasting gift to me has been twofold: first, to take a disorder out of the shadows and to strip it of the fear surrounding it that I have felt as I watched it seize control of two family friends over the years; and, second, to reveal to me that this is a population I would very much like to work with. 

Next up (but not until next month, when my academic semester is over!) I hope to read Harold Searles, Harry Stack Sullivan, and Silvano Arieti (this latter introduced to me on Twitter by Mark Ruffalo, whom I thank for this kindness. He also put me on to MIchael H. Stone's useful piece, "The History of Psychoanalytic Treatment of Schizophrenia," Journal of the American Academy of Psychoanalysis 27 [1999]: 583-601.). Other suggestions of still more authors I should read are welcome in the comments. 

K.R. Smith on Ethics and Psychotherapy

It was, if I recall correctly, Jason Blakely (whom I interviewed here) who put me in touch with Kevin R. Smith, author of two recent books: Therapeutic Ethics in Context and in Dialogue (Routledge, 2020, 108pp) and The Ethical Visions of Psychotherapy (Routledge, 2020), 112pp. I have read both of these books with great profit, and found them much more philosophically enriched and enriching than anything else I have to read currently in the area. I might even be bold enough to say here that clinicians who are only clinicians, that is who have never done any hard work in philosophy, have no business lecturing the rest of us on topics they scarcely understand themselves. Happily, Smith is not like that, coming at these books with a wide-ranging background that shows up in both books to great profit. 

Following my usual practice, I e-mailed him some questions for an interview about these books, and with heroic patience (such a key virtue for clinicians!) he has waited 

AD: Tell us a bit about your background:

KRS: My path is not the standard one for professional psychologists. I was not a psychology major as an undergraduate. While I had some good psychology classes at Berkeley in the early 1970’s, the program was influenced by positivist and behaviorist conceptions of psychology that missed the complexity and richness of human experience. As an alternative to a psychology major I took advantage of the option available at Berkeley to construct an interdisciplinary major that included classes in psychology, other social sciences, and the humanities. 

After a master’s degree in religious studies at the University of California at Santa Barbara, I entered the doctoral program in clinical psychology at Duquesne University. I had been exposed to the work of Ricoeur and Heidegger at Berkeley and Santa Barbara, and was excited to be studying psychology from the perspective of existential phenomenology. This program deepened my appreciation for the implicit philosophical assumptions often present in psychological theories that purport to be based upon objective data alone. 

But finding work where this alternative perspective on psychology was even known, let alone valued, was not easy. I worked in various settings (community mental health, a rehabilitation hospital, and a large psychiatric institution, and research center) where I gained further experience and training before starting my own practice. In retrospect, I’m glad I have had experience in these work settings, where mainstream ways of understanding and practicing therapy and conceptualizing psychopathology were dominant. 

But the sense was always there that something was amiss with the standard approaches. I have been struggling ever since to articulate what seemed wrong, and what the alternative might be. I have had help along the way from fellow therapists who wanted to understand people and their psychological difficulties in depth. Pittsburgh provided me a continued connection to the human science approach to psychology at Duquesne, experience with psychotherapy research at Western Psychiatric Institute and Clinic, and a series of seminars organized by Bill Cornell that exposed me to a variety of perspectives on psychodynamic therapy.

AD: You had me hooked on the first page of The Ethical Visions of Psychotherapy when you wrote this: "Therapy is also a social practice that enacts some perspective on what constitutes a good life, human well-being, or flourishing." And yet you note later on (ch.5) that "therapists rarely allow themselves to use the language of ethics in a full sense. They are often more comfortable with the language of repair." Why does it seem that virtually every school of psychotherapy wants to run from this question of the good, of flourishing--even as it smuggles in such assumptions through the backdoor?

KRS: There are a number of reasons why therapists avoid explicitly acknowledging that they are promoting ideas about the good. One category of reasons has to do with the nature of the goods that therapy promotes. These are often some variant of personal freedom or authenticity that is frequently understood to have its source in the individual. Whether this is viewed as a personal choice of how to live one’s life, or as fidelity to some core, authentic self, it often leads therapists to assume that they ought not to interfere with the patient’s free choice, or that their task is simply to free up an authentic self that has been buried, blocked, or distorted by social constraints and internal defenses. These ideals can often be valuable guides for practice, but therapists are mistaken when they think that there is no vision of a good life on offer here. Autonomous self-direction and authenticity are ethical ideals.

Another category of reasons for reticence about the promotion of some picture of human flourishing in therapy is the history of therapeutic efforts to challenge or undo the damage done by the excesses of conscience. Many people seek out therapy because they feel they are failing at life in some important respect. For some of these people, there is a recognition in therapy that they have been suffering from excessive demands to meet standards for a good life. 

Psychoanalytic ideas about relieving the relentless character of superego demands and rational-emotive therapy’s challenge to the oppressive “oughts” and “musts” under which people labor are both examples of the way that therapy seeks to undo the damage done by alienating expectations of doing well or being good. As a consequence, many therapists are wary about proposing another set of obligations for patients to live up to. Nevertheless, an ethical ideal is still present here, one that emphasizes the need for people to find their own way to live rather than take on what family, church, society, or their therapist have said their aims should be (even as the therapist is here promoting an ideal).

Both these reasons to steer away from open discussion of human flourishing receive support from yet another quarter. This has to do with the effort to give therapy scientific credentials. Often this effort is built upon a conception of science as only giving us information about what is the case, not about how things should be (the “fact-value dichotomy”). To the extent that therapists think of themselves as intervening in disorders or patterns of behavior based upon a scientific understanding of their causes, they can claim that they are simply agents who help to change circumscribed problems, not proponents of a particular set of ideas for how to live well. 

This view of therapy as technical intervention can hide from view the ways that therapy also functions as a social practice that instantiates various ideas about living well. Consider the different ways that psychological disorders are defined. If one compares the Diagnostic and Statistical Manual of Mental Disorders with the Psychodynamic Diagnostic Manual, for example, it is clear that there are different conceptions of the difficulties in living that people bring to therapy, conceptions that imply different ideas about what is important for human well-being. The DSM model implies that disorders are impediments to people getting on with their lives as they have decided to live them--the ideal is some form of autonomous self-direction. The PDM proposes a thicker set of ideals regarding a complex set of capacities for self-reflection, affective attunement, and interpersonal engagement, with autonomous self-direction as only one of many valued characteristics of psychological health. 

AD: You write early on that "the central thread that runs through this book is the philosophy of Charles Taylor." I've been reading Taylor for years, and drew on him in my recent book about the Catholic sex abuse crisis. Tell him why he's important for your work, and what ideas of his you find especially useful.

KRS: Taylor’s philosophical anthropology makes a great deal of sense to me, and helps to highlight many of the dead ends of current conceptions of therapy. A central theme of Taylor’s work on human science is his critique of claims to naturalistic objectivity and ethical neutrality. Insofar as persons are “self-interpreting animals” in Taylor’s sense, it is not possible to understand their actions as the result of objective influences alone. 

People do much of what they do because of how they understand themselves and the dilemmas and difficulties that arise in the effort to live a form of life they aspire to. To aspire to a form of life is to assess what one does and how one lives against a set of standards that one feels called to answer to, it is to be what Taylor calls a “strong evaluator.” 

An enormous range of questions can arise in this context that go far beyond removing obstacles to pursuing a life one has chosen. One can question whether the way one has been living one’s life is basically misguided. Do I hold myself to an impossible standard of perfection? Have I misunderstood what I am aiming for? Why do others keep responding to me as though I were someone different from whom I understand myself to be? Is the life I’ve been trying to live possible for me, truly my own, or an alienating imposition from family or culture? Questions like these are often an essential context for understanding particular psychological problems like panic disorder or depression. The level of discourse in which such questions are framed and addressed cannot be derived from a set of findings about which technical interventions bring about changes in particular symptoms.

Further, it is not just the difficulties that patients struggle with that point to deeply held evaluative assumptions. In the effort to assist people with their difficulties each therapy also promotes a particular take on what is essential to a life well-lived. The role of ethics in therapy is not always acknowledged. Sometimes the failure to acknowledge an implicit ethic is based upon therapists’ assumptions that their ideas about well-being are so basic or universal that there is no need to justify or reflect upon them. 

It is here that Taylor’s work on the modern identity in Sources of the Self, The Ethics of Authenticity, and A Secular Age is enormously helpful. In identifying the particular socio-cultural context for many of the modern ideas about human flourishing that are evident in the psychotherapies Taylor provides a platform from which to begin see that ideals like authenticity, interpersonal intimacy, rational self-mastery, or liberation from social constraints are not universally desired components of a good life.

AD: You note the importance of examining "ethics" in the eyes of psychology and psychotherapy and all the assumptions therein--as well as what is missing. You note that every form of therapy has some implicit ethical or moral notions: CBT people implicitly value what they call rationality (to which I'm always wanting to retort with MacIntyre's famous question: Whose Justice? Which Rationality?); psychoanalysts place great store on freedom; and of course everybody, including mainstream medicine, stresses "patient autonomy." Why is it important to call these out and examine them? What happens, in other words, if we continue to leave these notions of rationality and freedom unexamined?

KRS: To see that various assumptions about living well only make sense in socio-cultural context makes it possible to begin to question those assumptions. This is important, even if at the end of this questioning a decision is made to re-affirm those views, now not as unquestioned assumptions but as having some situated rationale. For example, it is not difficult to locate different therapies in relation to Taylor’s exploration of two distinct versions of the modern “inward turn.” 

There are traces in contemporary therapy of both the stance of rational, disengaged reflection descending from Descartes and Locke and the more immersive self-exploration running from Montaigne through Rousseau and the Romantics. As Taylor spells out the history of these two forms of modern inwardness he also points to the ethical rationales that have been given in support of them. In Taylor’s view, neither of these has definitively won the day nor proven the other to be simply mistaken. The differences between them are not such that there is likely to be a resounding defeat of one by the other, even if mutual critique is illuminating.

The situation is similar with regard to the therapeutic orientations that derive from them. Failing to consider the fundamental ethical differences between different therapies leads to the mistaken idea that one type of therapy can be vindicated by simple empirical evidence regarding a narrowly defined efficacy at symptom reduction. But it also leads to avoidance of the richer ethical language necessary to grapple with what is at stake between the therapies. Moreover, any particular view of what it means to live well can have an enormous range of variations, even within one therapeutic orientation (consider the variations between the different schools of psychoanalysis). Autonomy, authenticity, liberation, and rationality can all come in many forms that deserve careful examination.

AD: You note at one point something that has long bugged me: The very idea of finding more "efficient" means of therapy contains within it a conception of the good life. And then Ch.5 opens with: "If one type of therapy works better than another, why should we care about its underlying view of flourishing?" Tell us a bit more about your thinking here about issues of efficiency and efficacy, and why it is important to analyze such seemingly unobjectionable ideas while also taking account of human flourishing?

KRS: The emphasis upon efficacy and efficiency in many discussions of therapy can introduce one notion of living well that deserves consideration, but it cannot simply be assumed to be definitive. There are nested domains in which this language appears. The most common one is the call for efficient and effective therapy, that is, for therapy whose value is measured in terms of how well, how quickly, or sometimes, how lastingly, it reduces concrete measures of disorder, like symptoms, self-report measures of distress, or associated measures of functioning, life satisfaction, etc. At a “meta-level” are arguments to develop methods to effectively disseminate these effective therapies, that is, to effectively and efficiently train therapists to do these therapies. 

Fundamental to all of this is a sort of utilitarian ethic that attempts to develop a sort of calculus of suffering and scientifically founded methods to reduce that suffering. There clearly can be value in this project. It has motivated the development of therapies that have benefited many people. Reducing the fear about and frequency of panic attacks or decreasing suicidal ideation are not trivial improvements in people’s lives. 

But to think about the benefits of therapy only in these terms is to ignore other ways of thinking about how therapy helps people to live well. It is simply not a forgone conclusion that therapy is the removal of impediments to living whatever life people want to live. For many, their psychological problems point to something amiss in their reigning assumptions about a good life, assumptions that are now open for re-examination. One risk of a focus on effective removal of symptoms is that it can imply: “Get rid of your symptoms, then exercise your free agency to choose whatever form of life you like. After all, there can be no real answer as to what makes for a good life. It’s simply a matter of personal preference.” What is suggested here is that what really matters is an unencumbered freedom to choose. That is the ultimate good. But that leaves no reason for one’s choice, for there is no good outside of my preferences that I answer to, or that can give some confidence or grounding to my choice. 

AD: If I was cheering earlier, I was on my feet for a standing ovation when you recognized that "the evidence to warrant the designation 'empirically supported therapy' is far weaker than is routinely claimed, especially for the short-term manualized therapies." Apart from Jonathan Shedler's invaluable work, yours is one of the only other voices I've come across recently calling out the dangers of excessive deference to that talismanic phrase "evidence-based," which tendentiously smuggles in all sorts of ideological assumptions hidden under philosophical naiveté. Tell us a bit more about the problems and assumptions built into claims to be "evidence-based."

KRS: It is certainly reasonable to ask if a therapy does any good. But the usual criteria for a treatment to be considered evidence-based are a truncated form of this question. The appeal of this way of assessing therapy is that it lends itself to empirical evaluation. The results are not always impressive. Shedler and other researchers have noted that the measurable symptomatic improvements of the short term therapies are often small and temporary. 

Further, different types of therapy can achieve similar results according to standard measures of symptom reduction. The question then arises as to whether different therapies might offer different benefits beyond symptom change. One danger of the evidence-based practice movement is that it implies the irrelevance of questions about the relative value of a broad range of goods or benefits that may be on offer in therapy. 

To use a simple example, if both Dialectical Behavior Therapy and mentalization-based psychodynamic treatment have some success in measurable outcomes in the treatment of borderline personality disorder, how do we assess the relative value of the dialectic of self-acceptance and change that is part of DBT against gains in mentalization?  There is something internal to these distinct therapies, something that is part of their particular views about what matters most for living well that deserves consideration on its own merits, not just in terms of symptomatic improvement. As an analogy, suppose one were to decide whether to be a Presbyterian, an Episcopalian, a secular humanist, or a Marxist based upon research showing that the members of one of these groups had statistically higher measures of  self-reported happiness, or higher levels of functioning.  To choose one form of life over another upon such bases is to ignore the distinct views of the good internal to each. 

Therapies designed and tested against the criteria to be evidence-based may well provide significant benefits. But the talisman of “evidence-based” can obscure a number of other important considerations about the value of therapy.

AD: At one point after comparing DBT and psychodynamic approaches to treating borderline personality disorder, you note that "common factors are operative across technique and problem. They do not subsume and dissolve all specifics into one common therapy for all disorders." This leads me to a worry I have about those calling for psychotherapy integration, not unlike appeals for "Americans to come together" after the election: what notions--potentially problematic and objectionable notions--of the good life are being smuggled in behind these appeals to unity and integration?

KRS: Efforts to bridge the differences between the therapies by integrating different components of practice or theory are not necessarily misguided. It can be part of a laudable effort to develop therapy in new directions, and can lower the temperature of debates between competing schools. 

But there are dangers. Under the guise of integration, one perspective can be subsumed within another, with the loss of what is distinctive about what has been subsumed. The aim should not be to move the many schools and sub-schools of therapy to a unified theory and practice, but to engage in a more vigorous debate about the competing aims of the therapies. There is value in respectful engagement with the diversity of approaches. Dialogue here includes debate and critique—agreement may not be the outcome. But at least with regard to the debates between different schools of therapy there should be some protection of the right for all to be part of the debate. This is far more valuable than unity.

AD: At the end of ch. 5 I felt very much called to account when you write that "adherence to favored therapeutic orientations is influenced by the appeal of the particular picture of flourishing, of how to live life well and fully." This very much undergirds my continuing allegiance (but not uncritical, or unappreciative of other approaches) to psychoanalysis and its picture of flourishing as freedom which disrupts various forms of repression--individual and social alike (as we see in a recent book A People’s History of Psychoanalysis: From Freud to Liberation Psychology by Daniel José Gaztambide, whom I interviewed here). Is part of your argument that therapists need to be more open about their adherence, and more willing to subject it to searching examination to analyze underlying moral claims?

KRS: Absolutely! Adherence to a particular approach to therapy often has complicated sources: experience with being a patient or therapist in a particular therapy, or the way that a particular therapy matches one’s intellectual or cultural assumptions and style. And there’s nothing wrong with therapists finding a home in one school rather than another, even if that means they are limited in what they have to offer patients. None of us can be all things to all people. But it is problematic to let the justifications for a favored approach lead to definitive conclusions or institutionally enforced policies regarding which therapies are legitimate. Therapists’ reflection upon and debate with others about their underlying moral claims can not only protect against hubris--it may also help them to amend or even fortify their ethical assumptions. 

AD: If that's the case, then I'm wondering whether training programs do not need a whole lot more serious philosophy courses built into them, so that "ethics" is no longer a single course telling prospective therapists what their professional association's code forbids and requires, but instead gives them a level of facility and insight so that philosophical debates about human flourishing can be much richer than they are now?

KRS: I would love to see greater discussion of these issues within training programs. Unfortunately, ethics is often presented in training programs simply in terms of how not to avoid missteps in one’s professional duties. As valuable as those considerations are, they overlook important questions. For example, the American Psychological Association’s code of ethics promotes fundamental principles of beneficence and nonmaleficence, principles which enjoin therapists to offer something of benefit and to avoid doing harm. But if the benefits are understood only in terms of standard ideas about effective treatment a wide range of fundamental ethical questions are overlooked, or worse, they are assumed to already be definitively answered.

AD: Sum up your hopes for the books and who especially would benefit from reading them.

KRS: I hope that these questions get a wider hearing, and certainly there are others who are raising them, like Philip Cushman, Frank Richardson, Blaine Fowers, Brent Slife, Donnel Stern, Donna Orange, Robert Stolorow and others. 

But the culture of therapy, which is shaped by the larger culture of modernity, has certain built-in impediments to recognizing the salience of these questions, so I think the effort to gain recognition for them will be an uphill battle for some time to come.

My hope is that the books would have a readership beyond those who are already interested in philosophical questions about therapy. I think any therapist, regardless of theoretical orientation or stage of career, can have questions from time to time about more fundamental issues about therapy, about what it is, what its fundamental aims are, what good it might do, what therapeutic aims are most worth pursuing, and why. I hope that these books provide some specificity to and justification for asking such questions. I have tried to be respectful to therapeutic orientations other than my own because I do respect them, but also because I want to encourage therapists across the spectrum of different schools to consider these more fundamental questions.

AD: Having finished both books, what projects are you at work on now?

KRS: I’m currently working on a paper for a special issue of International Journal of Philosophical Studies dedicated to Taylor’s legacy and possible future impact. I am also working with a group of analytically oriented psychotherapists in Pittsburgh to develop a new program for education in psychoanalytic psychotherapy, the Western Pennsylvania Community for Psychoanalytic Studies.

The Ethical Visions of Psychotherapy

I have just finished a short but fascinating book by K.R. Smith, The Ethics Visions of Psychotherapy (Routledge, 2020), 112pp. Imagine, if you will, Charles Taylor teamed up with Alasdair MacIntyre and Smith to write this book. It explores crucial philosophical issues that Taylor and MacIntyre have been rightly celebrated for over the last several decades, but which mainstream psychology and psychotherapy have all but totally ignored. Smith unpacks those issues, and the costs of their neglect, and the promises and prospects of exploring them in the years ahead by and for psychotherapists. To do all this in short, accessible, polemic-free book is a masterful achievement. It is the sort of book that belongs on the bibliography of every introductory psychology and psychotherapy course. 

Here is the publisher's blurb:

The standard view of psychotherapy as a treatment for mental disorders can obscure how therapy functions as a social practice that promotes conceptions of human well-being. Building on the philosophy of Charles Taylor, Smith examines the link between therapy and ethics, and the roots of therapeutic aims in modern Western ideas about living well.

This is one of two complementary volumes (the other being Therapeutic Ethics in Context and in Dialogue). This volume explores the links between therapeutic aims and conceptions of well-being. It examines several cognitive-behavioral and psychoanalytic therapies to illustrate how they can be distinguished by their divergent ethics. Smith argues that because research utilizing standard measures of efficacy shows little difference between the therapies, the assessment of their relative merits must include evaluation of their distinct ethical visions.

A key text for upper level undergraduates, postgraduate students, and professionals in the fields of psychotherapy, psychoanalysis, theoretical psychology, and philosophy of mind.

I will have more to say about the book in due course, when I also hope to have heard back from Smith with some questions I sent to him for an interview on here. Stay tuned!

Constructing the Self and Reality: An Interview with Jason Blakely

I've earlier noted the advent of this fascinating and important new book, which I read with great interest. The author, Jason Blakely, kindly agreed to an interview about it. Here are his thoughts:

AD: Tell us about your background

JB: I am a political philosopher by training. While studying for my PhD in political science at UC Berkeley I became fascinated by basic questions of how to think about human agency and the explanation of behavior. I currently teach at Pepperdine University in Malibu

AD: What led to your writing We Built Reality: How Social Science Infiltrated Culture, Politics, and Power?

We Built Reality attempts to turn the tables on mainstream social science by reading psychology, sociology, political science, and economics as forms of meaning-making or hermeneutic creation. This reveals many surprising things about these disciplines—perhaps the most arresting being that they are forms of world-making and intimately tied to the story of our time.

On a more personal level, the earliest seeds of this book go back almost fifteen years to when I was a graduate student at Berkeley. At that time the human sciences were an urgent and controversial topic on campus with many rival schools of thought participating in the debate. 

For one thing there was still a strong living institutional memory of Michel Foucault having spent time at Berkeley. Foucault’s research agenda and style of thought inspired many philosophers on campus, including Judith Butler and Wendy Brown who were both formidable presences. 

In addition, philosophers coming out of the analytic tradition of linguistic analysis—like my advisor Mark Bevir and committee member John Searle—were thinking intensely about philosophy of action and social ontology. They were joined by phenomenologists including Alva Noë and the legendary Heideggerian philosopher Hubert Dreyfus. There were also world-class interpretive social scientists like Robert Bellah and Paul Rabinow. In the midst of these very different thinkers I found myself trying to gain my bearings. This book is still the fruit of coming to terms with the debates over the human sciences at Berkeley, specifically from within the hermeneutic tradition.

AD: Your introduction seems to be building a case that what Alasdair MacIntyre almost 40 years ago memorably called the “systematic misinterpretation” of the social sciences has only become more widespread. Is that a fair view of where we are now? And if so, what has led us to this moment where what MacIntyre almost gleefully mocked in his inimitable way has actually gotten worse?

JB: Yes, we are certainly awash in naturalistic approaches to both the study and governance of human beings. At the same time very few working social scientists openly avow philosophical naturalism. This appears to be a bit of a paradox. But it is partly resolved when one recognizes that social science operates in our societies as a form of authority with attendant social practices—it is a kind of power.

MacIntyre was enormously insightful in this respect. I have written elsewhere about how MacIntyre in the 1960s participated in the British New Left, which included figures like Charles Taylor, Stuart Hall, and E. P Thompson. This group was far ahead of its time and saw deeply into the technocratic tendencies of our culture and politics.

One reason for the persistent dominance of these naturalist and often pseudo-scientific schools of thought is precisely that they are embedded in practices and institutions. They are not foremost or even chiefly disembodied or ideational. Indeed, actual research agendas—like behaviorism, sociobiology, geno-politics, cognitive psychology, neoclassical economics—tend over the long term to implode under their own contradictions. But both the ethical attraction of naturalism and the practices of arranging institutions by claiming a top-down science of management persists. So there is a deeper strata of meaning that orients people to this scientistic way of thinking even as specific theories come and go.

AD: Your introduction speaks of how “social science can undergo a strange metamorphosis in our societies and become its opposite, ideology and superstition” (xiv). This is a wonderfully bracing claim that I think it exactly right, but I also think it might raise a few eyebrows, so perhaps you might unpack it a bit for us.

JB: One of the insights of hermeneutics is that human agency is marked by the ability to take on and embody theories. We have the potential in certain respects to become more like our theories. This is in stark contrast to the natural sciences. A sunflower exists in some isolation from the theories of botanists. Not so with human beings. Our social scientific theories can build new worlds and practices of selfhood.

In the book I call these “double-H effects.” A clear example of this that is at least passingly familiar to most people is the case of Marxist theory and its relationship to the social and political reality of the Soviet bloc. But what we fail to recognize is this is true of many of our social, psychological and political theories. Modern societies have many ways of inhabiting social scientific theories. They can become blueprints for institutions, inspiration for types of self, beliefs guiding practices, and so on.

AD: You also go on in the introduction—and indeed throughout the book—to document how “social science rarely simply neutrally describes the world, but rather plays a role in constructing and shaping it” (p.xv). Give us a couple brief examples of this if you would.

JB: One example I cover at length in the book is what I call “homo machina” versions of selfhood in psychology. I think there are various streams of popularized or vulgarized psychological theory that are embodied through the self-help genre. 

Self-help in our society is not just some eccentric or distasteful literature that intellectuals should consider unworthy of attention. Self-help is central to the cultural life of many people in our society. In some cases, it encourages its readers to build a kind of ethical self that treats private emotional life and relationships with others as a kind of mechanics. In other instances, it reinforces managerialism in the workplace and government.

A second example that receives extended treatment in the book is “homo economicus” or a form of selfhood that vulgarizes and inhabits a kind of ethical identity derived from the idealized models of neoclassical economics. This is the whole phenomenon of a neoliberal self but viewed as a popular or folk tradition as evidenced in cultural artifacts like Freakonomics or Fredrich Hayek’s more popular writings. I think there is a highly complex and interesting relationship between the mathematized abstraction of economic modeling and these supposedly lower, vulgar forms. My book suggests that a hermeneutic or interpretive approach helps us see the complex philosophical, social, psychological, and political linkage points.

AD: You introduce an interesting phrase and concept, “double-H effects” as when you speak of how “Double-H effects make social science profoundly unlike the natural sciences” (p.xxviii). Tell us a bit more about what you mean by these effects.

A double-H effect happens when our interpretation of reality penetrates our identity or social practices. Our attempt to interpret reality then has the potential to radically alter or change that reality. Often times this can have inadvertent and unexpected consequences. Or at least that’s one of the cluster of theses advanced by the book. 

The double-H effect is one route into understanding the radically different ontology that is characteristic of political reality. If you can see that double-H effects can happen among self-interpreting, linguistic creatures like ourselves but not other beings then you are a long way down the road to grasping what differentiates the social sciences from the natural sciences.

AD: Perhaps it’s only because I’ve been immersed in Fromm and Adorno the past six months, but I hear regular echoes of them in your introduction and again in chapter 6 when you speak of the abuses of authority and power that lurk behind certain claims of social science. Is it part of your argument in the book that scientism is in significant ways authoritarianism in disguise?

Perhaps there is some repressed influence there. Certainly Adorno was mandatory reading with a number of the critical theorists who taught me at Berkeley. Nonetheless, I tend to think of myself as working instead within the humanism of Gadamer, Charles Taylor, and others. My problem with Adorno and the Frankfurt School more generally is what I perceive as a tendency to slide into overly structuralist conceptions of politics that neglect human agency and local cultures.

In terms of the relevant form of political power I prefer the term technocracy as denoting rule by experts. I prefer this term because I think technocracy can and does combine with any number of ideological traditions—authoritarian, socialist, liberal, communist, feminist, ecological, fascist, etcetera. 

Hermeneutic philosophy of social science can do damage to any political tradition that relies very heavily on technocracy. It can do so through the backdoor so to speak—unmasking the way it has an inadequate philosophical anthropology. Hermeneutics does critical, eliminative work while also allowing for a certain amount of political pluralism. Technocracy is off the table philosophically speaking but then the question is what is the strongest remaining humanism?

AD: You reference the psychologist Phillip Cushman on the empty self that shows up in consulting rooms, and this puts me very much in mind of the Anglo-American literary scholar and psychoanalyst Christopher Bollas who in the late 1980s started writing of what he calls “normotic illness,” the chief symptom of which is the “blank self” which denies having any sort of unconscious or inner life at all and tries desperately to conform to an external construction of compliant citizen and cheerful consumer. I’m wondering if the origin of such selves is not also a deliberate creation, much as you say “the very discovery of economic man was part of the creation of economic man. Perhaps it would be best to say that free-market economists did not unearth the world but helped to contrive it” (p.43)? It seems to me that the wild popularity of pop psychology and the self-help books you discuss plays a huge role here in creating these vacuous selves of exceedingly shallow inner life?

Yes, that is an excellent observation. I am interested in what you are saying and delving deeper into it. In the book I do suggest that self-help has a long historical genealogy extending to Thomas Hobbes and machinist notions of selfhood developed in the early modern period. This is not to say Hobbes was a self-help writer which would, of course, be insanely anachronistic.

But I do suggest in the book that there is a cultural history that serves as an important background to individuals thinking about themselves along these flattened and shallow tendencies we see in self-help. An entire set of anthropologies is assumed by the self-help genre—a certain stance towards relationships, depression, happiness, efficaciousness in careers, charisma in social groups. It flattens the potential poetic depths of human inner life. Edgar Allan Poe is replaced by a kind of car manual for driving the road of life. This is, in fact, the replacement of one poetics for another. It is not actually the discovery of the “real” mechanics of being human.

AD: There’s a very interesting article in a recent New York Review of Books on the uses and abuses of the “scientific method” by late-19th and early-20th century Anglo-American industrialists to maximize efficiency and productivity at their factories. You note several times that such a “method” is itself a creation, and not a singular one: “Although philosophers generally reject the idea of a single, unified scientific method, the notion has gained a grip on the popular imagination” (p.73). Why does such a singular conception have such a popular appeal?

This is an important question that probably evades a single or reductive sociological answer. Different people have different reasons for falling into the thrall of method and ethnographies would need to be conducted to capture the relevant tales. At a general level Charles Taylor’s work on sources of the self is probably about the best answer we have at the moment in terms of the broad philosophical and historical outlines. One might also consider how an obsession with controlling reality through the fixed steps of a method shares some family resemblances with prescientific cultures and their use of magic. Granted the actual semantic content of the modern cult of method is very different from magic as it is part of a set of meanings only made possible by the scientific revolution. I suggest all that in the book. One antidote to this bewitchment by method lies in Aristotle’s conception of arete or skilled human action. This is one of the many things I learned from the Heideggerianism of Dreyfus and his students on Berkeley’s campus—the relevance of Aristotle via phenomenology to contemporary philosophy of action. The notion that you can ever become truly excellent at a practice by simply carrying out a fixed set of steps or a method is a myth.

AD: Loathe though I am to give any aid or comfort to people today protesting efforts to contain a pandemic, I do nonetheless wonder if the reason some of the less densely stupid among them are so objectionable (refusing masks, demanding the “right” to go to bars, beaches, etc) is because they recognize in some inchoate and clumsy way, as you put it, that “many people who believe they are doing science are in fact doing ideology” (p.84). What prevents scientists from seeing this and guarding against it?

I am also distressed by the lack of thoughtful attention paid to scientists in our society on questions ranging from epidemiology to climate. Nonetheless, many people in our society do intuit however haphazardly and self-destructively that scientific authority is too often overstepping its bounds. We are not very good at discerning the limits of scientific authority. I believe that in addition to poor education in science this is tied to the crisis of the humanities and the liberal arts. 

Not enough citizens—be they laypeople or scientists—appreciate the centrality of interpretation and stories to our shared political life. They do not see that while the natural sciences should be respected in terms of our understanding of the physical world, this remains philosophically distinct from the stories and narratives that structure our lives. All public policy incorporates some story that includes a highest set of goals or aims. There can be no expert science of these stories. They remain accessible to laypeople and scientists alike and so are rightly subject to democratic deliberation and contestation.

Unfortunately, there is a tendency to replace genuine democracy and open discussion over our stories with technocratic management. Often specialist languages and jargon are used to block out ordinary people from the political process. An example of this covered in the book is the response to bailing out the banks as “too big to fail” after the 2008 economic recession. When this happens genuine, deliberative democracy is replaced by a form of managerial society that claims the name “democracy” but in fact represents something very different. The resultant backlash can create a situation where rightful scientific authority and technocracy are confused with one another. We are currently living through the steep costs of the chaos born of that confusion.

AD: You open your chapter 5 (pp.89-90) by reminding us of the deadly effects of scientism on Eric Garner. In 2020, we would add to his name that of George Floyd and others. Your point here is that “scientism had revamped the dominant mode of American policing,” leading to “racialized, authoritarian, and militarized dimensions of this massive shift in policing culture” (p.99). Can you unpack all this a bit for us?

Thank you for this question. For personal reasons I felt the deaths of George Floyd and Eric Garner very profoundly. While studying technocracy I noticed that violence is exercised in a very strange way in our societies. We have a highly theorized, rationalist form of justifying the exercise of force. There is a certain discourse and culture of dispassionate science that informs everything from our use of drones in the Middle East to our deployment of militarized SWAT teams in poor and brown neighborhoods.

In the chapter on policing, I trace the way that a set of social scientific theories spearheaded by political scientists like James Q. Wilson and Charles Murray helped rationalize and justify the militarized police tactics of the law and order movement. Policing practices like zero-tolerance, stop-and-frisk, and racial profiling all received elaborate theoretical articulations several decades ago. These theories often developed seemingly colorblind concepts like “disorder” and the statistical analysis of criminality that when enacted within the American political context had highly discrepant racial outcomes. 

The new racial caste is far subtler than Jim Crow. The theories and practices normally do not explicitly state racial distinctions. Instead, there is an elaborate set of theoretical and practical developments that are de facto racialized. They appear to be mere colorblind “sciences” on the page, but in practice they are tied to the mass incarcerations outlined so vividly by scholars like Michelle Alexander and Elizabeth Hinton. My contribution here is to focus on the discursive role of the social sciences and the double-H effects involved in building a world which has seen a great increase in authoritarian and militarized police tactics. Such tactics once in place, as we are now discovering, can later be deployed on people regardless of color or social class—journalists, protestors, political opponents—are all now coming under the shadow of a form of authoritarian policing first waged on poor racial minorities in American cities.

AD: Cognitive psychology comes in for scrutiny at several points in your book (and not a moment too soon in my view!) as do psychiatry, psychopharmacology, and the ideologies undergirding them all. Though you didn’t address this directly, I want to press on you an example I am especially leery of thanks in part to the outstanding and hugely important work of people like Jonathan Shedler: the predominance of “evidence-based” claims in psychotherapy—especially the dominance of cognitive-behavioral manualized treatments today so that therapy patients can be rushed through a treatment in a dozen or fewer sessions. That phrase “evidence-based,” it seems to me, is too often an example of everything you describe in this book—scientism in action and an ideological masquerade. Am I wrong?

No—I am highly sympathetic to your point. I think you are right and there is a lot to learn and explore further in these domains that my book leaves untouched. Furthermore, we are only scratching the surface when it comes to the possibilities of a new hermeneutic psychology. At the philosophical level, a frequent problem with manualized therapeutics is the repression of the interpretive features of human agency. Yes, we can still learn much from the different techniques developed by therapists as well as from psychologists who have taken a more medical approach to mental health. But we need to be very careful to not eliminate or hide the hermeneutic features of human life. The particular meanings, beliefs, and cultures that inform an individual life are also essential to mental health.

Unfortunately, my sense is that many of the dominant modes in psychology are reductive in just this way. They operate on the basis of an inadequate anthropology. We need to recover the way that human emotional life is always constituted or completed through the medium of meaning and culture. We are meaning-making creatures and any adequate psychology or therapy needs to have this fact about us firmly in view. This is something that I think psychotherapy—for all its flaws and tendencies to sometimes veer into naturalism—retains more deeply than many other paradigms of psychology. Yes, sometimes the meanings themselves are ahistoricized or crammed into silly just-so stories from, say, the Greek mythological past. But nonetheless psychotherapy is one school that houses the potential to address the complexity of human meaning making—its memories, identity formation, repressions, and stories. I will not say it is the only school of psychology that holds this potential. But it has retained interest for me for this reason.

AD: I was glad to read that “Gary Greenberg argued that uniformly treating depression and anxiety as diseases contributed to an ideological agenda in which a sense of malaise or discontent with a reigning social-political order was stigmatized” (p58). I think this stigmatization is exactly right, and is certainly born out by the very strong criticisms advanced in a powerful recent book, Marxism and Psychoanalysis: In or against Psychology by the Mexican clinician and scholar David Pavón-Cuéllar who seems to despair entirely of American ego psychology in this regard. I’m wondering about one possible reason for this, which you seem to hint at: research funding, much of which comes from governments and pharmaceutical corporations, both with vested interests in buttressing the “reigning social-political order.” Is that an assessment you would share?

Again, I am sympathetic to your suggested line of thought. Although I also think it is important to see the bottom-up features of psychological culture. Part of the point of the chapters covering psychology in the book is to suggest that there are folk naturalisms, so to speak. These folk naturalisms are cultures of scientism that emerge out of particular identities. The wild popularity of the self-help genre that we have been discussing is a vivid example of how the problem is not simply imposed top-down by a particular class onto another class. Without negating it, the hermeneutic picture is more complicated than power exercised by one group on another one. In other words, many people are not simply coerced or bamboozled into this kind of psychological practice. They find it ethically attractive. So the depth of the problem lies deeper in the culture.

AD: If so, one possible way beyond this—and almost everything else your book describes, if I am reading it rightly—comes only at the very end of your book when you ask “Where are the new humanists?” Well, where are they?! Do you see any examples on the horizon we should be paying attention to? How do you (or do you?) see a revival of humanists and the humanities today in playing a part in rightly recovering the role of hermeneutics that you discuss several times in the book?

Humanistic culture still exists in beleaguered pockets in our society. I was taught by heroic humanists beginning in public school in Colorado. I had teachers of literature who conveyed to me that an irreplaceable form of human knowing was opened up by literature and poetry. They spent a great deal of time impressing on us the importance of Shakespeare, Zora Neale Hurston, Gabriel García Márquez, Jorge Luis Borges, James Joyce, and others. Later as an undergraduate at Vassar College I was the beneficiary of tremendous humanistic learning in the ancient Greeks, the history of philosophy, various world literatures. The liberal arts are also frequently safe havens of humanistic understanding.

As many people are beginning to recognize, one major problem is that humanistic study is not only being largely defunded but characterized as useless and a waste of time by a society sick with economistic modes of being. We have lost a sense of the profound value of interpretation for democratic and political life. I do not view it as coincidental that our current crisis of democracy and failure to read political reality in America—everything from “fake news” which is also a problem of political literacy to the inability to properly identify authoritarian politics—coincides with the crisis of the liberal arts. We Americans are unable to read our own political situation very well. We do not know what we are living because we are effectively bad readers and interpreters of culture and politics. This is a problem of education. We need to pursue more radically than ever before the right of all citizens to a humanistic education—to the arts worthy of free persons. How different would our society look if its poorest members also received the lavish gift of the liberal arts and a humanistic education?

AD: Sum up the book for us and your hopes for it. Who especially should read it?

I hope in the course of this interview, and through your excellent questions, the general outlines of my project have become a little clearer. As for my hopes for the book, I think that books are strange things. Once you write them they have their own destiny. This is because books only retain relevance through readers. They leave the author behind, so to speak. I hope this book is helpful not merely to intellectuals but also to tenacious citizens interested in how we arrived at our current predicament. I feel a particular affinity for all those amateur lovers of history, politics, philosophy, and literature. The liberal arts are not some bizarre, inaccessible hobby reserved for the rich like yachting or polo. The art of interpretation is central to how well we weather the coming storms. The book was written for other humanists and particularly those who are still willing to learn something new. I have had a number of young people contact me since the book was published and say they found it exciting. This is very gratifying. If an egalitarian humanism linked to American democracy is ever going to happen it will have to be attractive to up and coming generations. They will need to desire and pursue it. That desire must be awakened.

AD: Having finished We Built Reality, what projects are you at work on now?

I have been slowly working for several years on a genealogy of naturalism and a historical-philosophical recovery of humanist sources.

Thank you for such an intelligent and thoughtful interview.