My initial idea was to present a seemingly simple set of arguments and basic ideas for an article to illustrate the challenges of integrating psychological practises with advancing medical and biological technologies. Between this idea and the process of writing this article, I soon realised, with some trepidation, that many complexities and paradoxes exist and need to be identified and tolerated, rather than being reduced to simplistic polemical platitudes. Many aspects of the debates have a history and roots in ancient times and philosophy. Debates, concepts and questions from fields as diverse as genetics, neurology, linguistics, philosophy, sociology, and political economics are all germane.
This writer realises that many of the questions do not have a clear, unequivocal answer, and rather than present this article as a claim to having resolved the complexities of the debate, I humbly hope to render the questions more accessible, by presenting my own and colleagues’ clinical experiences that have raised relevant concerns. I will also refer to prominent arguments in both historical and current literature. The author proposes exploring aspects of the debates by referring to specific psychological and psychiatric conditions commonly encountered, often controversially raised in both the popular press and professional literature, such as addictions (Substance Use Disorders) and Attention Deficit Disorder. I shall then move on to more abstract arguments and conclude with a discussion of what in this author’s mind, seem to be the most promising approaches to the body-mind dualism problem, without assuming in any way to provide final resolution. An enormous problem in itself, is that the debates have become often inaccessibly specialised and utterly abstruse, for example, presupposing an understanding of matters as arcane as quantum mechanics.
Issues of psychiatric medication occur within often invidious debates and conceptual acrobatics involved in the processes of diagnosis. The questions of psychiatric medication often evoke extreme and vitriolic positions regarding what psychiatric practises are allowed under the guise of rationality and medical help. These accounts sometimes amount to claims of flagrant abuse of human rights, dehumanising forms of social control, and the forced administration of psychiatric drugs which Weitz (2008) describes as chemical lobotomies. In South African psychiatric hospitals, we are accustomed to seeing patients in the so-called biological or organic wards shuffling along with varying degrees of Parkinsonism, not to mention cramps, blurred vision and Tardive Dyskinesia, which is a sign of brain damage. (Weitz 2008). ‘Do these living dead represent our supposedly advanced and humane psychiatric medical care? I recall vividly that neither I nor any of my fellow psychology interns ever raised a single critical question as to the treatment, or offered possible alternatives.
It is widely accepted that the medical model is hegemonic, and this view tends to look no further than biology for explanations of psychopathology (Moreira, 2005). Szasz (1972) argues that psychological processes have been reduced to disease and mental illness, or the medicalisation of morality. He also notes the psychiatry’s colonisation of ‘mental illness’ in the huge step by which psychiatry no longer required a demonstration of structural biological anomalies, in favour of so called soft functional symptoms of illness. At the other extreme of the biologically reductive brain-disease diagnoses one finds views that dismiss all diagnoses as fictional. Regrettably, and possibly inevitably where human power is unchecked, hiding beneath a mask of rationality, under many psychiatrists, (and I would emphasise, all those who stood by without protest), the most abominable human rights violations have been perpetrated. Unlike prison, committal to a psychiatric facility can be a Kafkaesque experience at the State President’s Pleasure, there in no way of knowing when incarceration will end.
There is a body of almost febrile attacks on psychiatry as being nothing but a form of social control, which resorts to inhumane methods to achieve these ends, using methods from the now outdated insulin shock, lobotomies, to ECT and the mental straitjackets of antipsychotics and antidepressants which Weitz (2008) describes as chemical lobotomies. It cannot be denied that all medication carries risk. Equivocal though I am about a method such as ECT, discovered in slaughterhouses, I must confess to having seen two dramatic resolutions of psychotic suicidal depressions. On the other hand, they were geriatric patients, and were literally doing somersaults! When all else failed with a patient intent on suicide, I recently for the first time, was forced to recommend a trial of ECT. The patient returned amnesic and clinically not healed. What was striking, was the absurdly high cost of hospitalisation and the total lack of any other therapeutic intervention.
The less extreme position presented by Moreira, (2005) who insists that we acknowledge the realities of biological correlates of emotional distress or individual pathology, provided that the social, political and economic context of psychopathology are borne in mind and that such factors receive due acknowledgement as causal and/or maintaining the psychological and psychiatric symptoms which patients experience. She also does not simplistically suggest a reductionistic link to capitalism, although the Ideological State Apparatuses such as education, the media, and the legal system cannot be under-estimated in submerging us in an ahistorical social reality in which profit, competition and individualism are the over- idealised, supposedly natural forces governing our society. The advertising media feeds a hankering for consumerism in an insatiable search for new markets, regardless of the costs to real humans and our world.
The ideology of science is by no means neutral, but is explicitly linked to goals of prediction and control; a subject that I shall return to at the end of this paper in terms of questions of whether we have a spiritual nature that can only be optimally expressed in service and surrender. Intoxicated by the usually impressively productive and destructive forces unleashed by modern technology, while not minimising the high tech discoveries in medical equipment and drugs, however, we seem seduced by an illusion of our creative and destructive power and control over nature. In our secular society, it seems to make sense that medicine has been absurdly idealised in contrast to our muteness around the inevitable reality of our deaths. Our rapid exit from this planet; the inevitability of sickness, old age and death do not sit well with secular consumers and producers. There is a reality in our modern time that the only certainty is change, and that all change, positive or negative, is inherently stressful.
The stress of modern living is not ameliorated by any unifying meaningful philosophy or socially integrated plans for change. In fact the antidote for the social malaise created by profit seems to be even more consumption, debt, and stress.
Referring back to Moreira’s (2005) call to bear social context in mind, one finds one small concession in that tome of empirical idiocy, the Diagnostic and Statistical Manual, which finally granted an axis devoted to stress in the multi axial diagnosis of psychopathology. Although the Fourth Axis in DSM III- R was promising in this direction, it tended however, in practice to be dealt with rather superficially, not exploring psychopathology in relationship to the stressors which certainly exist in South Africa and, in different guises, the ‘First World’. Globally, social realities rank close to severe forms of dehumanisation, whether or not there is a glut of money masking this inherent ‘chronic trauma’. I do not mean to suggest that the starvation and structural unemployment that many face in Africa, as well as s Aids and violence, can be simply equated or trivialised by comparison to ‘First World’ countries. Nor can we deny the violence which naturally though maybe less visibly, props up the state in any country, in which the state is defined as having’ legitimate’ control over the use of violence for social control. The psychoanalyst Nguyhena (2007) who specialises in severe Post Traumatic Stress Disorder makes the point that there are many aspects of taken-for-granted daily reality that we live that may well be abnormally normal, and therefore many symptoms of PTSD such as absence of desire and hope, may be more ubiquitous than we would like to admit (Nguyenha, 2007). It has always been one of the important aspects of psychoanalysis that is nicely stated in the simple title of Freud’s “The Psychopathology of Everyday Life.” This is the contention that the distinction between normal and abnormal is largely a statistical normality than a qualitative one- that there is no obvious radical dichotomy between madness and sanity.
Integrating Psychotherapy with Medical Diagnosis and Treatment
Most research nowadays recommends combined psychiatric treatment and psychotherapy as ‘best practice’. An immediate concern, however, is that the recommendations seem to have Cognitive Behavioural Therapy in mind, which certainly has an important place in psychology, but in this writer’s opinion, seems to lend itself to being a decontextualized technique of adaption to societal realities, more readily than critical research and psychoanalytic approaches. Secondly in almost all cases, psychotherapy and pharmacotherapy are administered by different people. This may in itself reinforce and add to confusion in both the patient and therapists mind as to who is ultimately responsible for treatment, and unwittingly feed into a Cartesian Body-mind split. Despite our illusion of medical advancement, the FDA requirements for treatment effect size are rather dismally low, and the performance of many well known psychotropic medications is much less impressive than the widespread advertising would suggest (Shedler 2010). Detre & McDonald (1997), from a position of neuroscience, make the startling claims that psychiatry itself is an over-priced speciality, given the nowadays simple protocols and low side effects with psychotropic medicine. The same article claims that the only other treatment strategy in the psychiatrists’ arsenal is the mastery of the simplistic platitudes of cognitive behavioural therapy, which requires little specific qualification or advanced understanding or experience and can be mastered by anyone of adequate intelligence. Psychoanalytic therapy is dismissed as only reliably expensive. There is an endless repetition that there is a total lack of evidence for psychodynamic approaches, and the blame also lies with psychoanalysts who for years stood in complacent aloofness from questions of developing appropriate research methods. This is certainly now being addressed and psychodynamic therapy now boasts some reliable research, meeting the most exacting criteria of empirical research, even showing effect sizes which surpass those of medication, but where positive gains increase with time after treatment, rather than decay (Shedler 2007). At this point briefly, to pre-empt the question, my use of the term patient has been chosen precisely because of its etymological meaning, and is not associated with medicine and passive treatment. Rather, I believe that at root and as a whole, it describes the person who learns to suffer pain or intense feeling, with an attitude of forbearance or simply patience. The meaning will become even clearer I hope, in discussing Bion’s concept of human suffering versus an animal’s experience of pain.
Some patients come to us referred by a medical practitioner and are already possibly prematurely diagnosed and on medication. Others are self-referred and are all too eager to find the ‘silver bullet’ which will cure their symptoms and relieve them of their pain. There are also those who have tried a range of medications and who are not happy with the results, for example, the symptoms caused by medication which we euphemistically call ‘side-effects’ (Shedler 2010). These include a sense of ‘cotton wool’ cushioning them from a sense of connected experience, nausea, dizziness, loss of libido, weight and appetite changes. I have looked with concern at photographs of patients who have been subjected to a few months of polypharmacy, reduced to retarded overweight dull- eyed lumps of chemical inertia yet who claim to have maintained ‘functionality’. Other patients and a fair number of therapists raise their concerns as to whether their medication is simply blocking symptoms of problems of a broader psycho-social dimension. The author takes issue with the frequently heard and glib advice from some medical practitioners, that patients will need medication for the rest of their lives. Unfortunately, this is seldom acknowledged as opinion but as having the full weight of scientific evidence and authority behind it.
Wherever medication is part of the picture, we are faced with the dilemma of whether the medication, while suppressing pain, is also suppressing other complex aspects of the symptom which may be necessary to fully engage with the real person, or suppresses unknown bodily and psychological processes, which may be an integral part of their complex pathway to healing. Much of the blame seems to be related to the hedonistic, utilitarianism which pervades our society. How often do therapists hear the empty refrain from parents and patients that, “I just want (him or her) to be happy! For example, in the cases of the psychoses such as schizophrenia, we nowadays rarely encounter a patient in whom any natural course can be discerned. Instead we witness patients shuffling along in total chemical suppression, not only from the antipsychotics, but often added drugs to increase compliant sedation and those for side-effects. Those already diagnosed, and who are on medication regimens which they find acceptable, even though they may have been told by their physicians that life-long treatment is necessary, pose complex questions for the psychologist. My intuitive psychological bias usually leads me to question more precisely what the patient’s acceptance of lifelong medication will mean for them. In many cases, I have noted with concern that the medication is suppressing a painful symptom which I consider a meaningful communication or response to a life which it is doubtful that the patient should tolerate. This entails the question as to whether successful interventions involve the patient’s adaption to life circumstances, for example, abusive relationships at work or home. To rephrase the critical point, is it not the task of successful therapy to assist the patient bear their pain in such a way as to make adaptations to their lives rather than to adapt passively to pain and to remove the source of pain, or where it is part of inevitable existential nature, such as the inevitability of death and loss, to develop an attitude of mastery (not pseudo- control or denial) toward the pain, using it to enrich rather than denude life of its meaning and sink into futility and despair and depression? This is the central thrust of Bion’s (1962) exposition of our capacity to think about and feel loss, rather than simply evacuate or project and split it off. In the chronically medicated patient, despite superficial acceptance and claims of being better, closer evaluation, in this writer’s experience, almost always reveals significant problematic issues, from chronic loss of libido, to difficulties in intimacy and even, a loss of emotional range and depth.
Of course, some present with such pain or risk of self-harm, or with anxiety that is so overwhelmingly debilitating, that there is a serious ethical question raised as to whether discouraging access to medication that we know will provide fairly rapid relief of pain, is not a violation of the principle of basic mercy. The psychologist may believe that, at least temporarily, medication should be used to create a therapeutic window, allowing us to access the patient who literally cannot hold even a most basic interpretation. Even basic structured cognitive behavioural therapy techniques may not be learnable when anxiety is at a ‘thalamic’ level, preventing even most basic cognitive functions and behaviours such as learning a practising basic relaxation technique. Alternatively, a confident experienced therapist may believe that sufficient structure provided by four or five sessions a week will soon create the containment necessary for therapy to proceed. The costs initially of course may be relatively high. Research does seem to suggest though that comparatively, considering hospitalisations and endless unnecessary expensive investigations, psychotherapy, even intense therapy, may be able to show both short and long-term reductions in costs. (Eells, 1999) A patient may accept that if this is what it takes, procuring a loan or whatever is needed to pay for such treatment is justified as they would if a surgeon specified a procedure as necessary. Of course, this implies clinical integrity and competency. For the psychoanalytic purist, in an ideal world, it might be a small victory to show right from the start that it is human connection which is the ultimate healing factor. For most of us and our patients, we strive for a compromise, recommending the temporary use of pills to fill the gap in the personal therapeutic relationship
Many patients are diagnosed and on what they consider to be a comfortable confection of medications, which frequently they are told they may be expected to accept for the rest of their lives, especially with the ever so popular and to this writer’s dismay, proliferation of varieties of Bipolar disorder diagnoses now being so frequently applied. In this regard, consider bipolar type III- a patient who responds to antidepressants with symptoms of mania is lumbered with a bipolar diagnosis.
Kandel (1998) received the Nobel Prize years ago for his discovery with sea slugs which led to evidence for the enormously important findings linked to neuroplasticity. At one level there is incontrovertible proof that environment may affect how genes are expressed or switched on or off. Secondly, evidence exists that changing the environment, either through CBT, other therapies and pharmacotherapy, meditation etc, results in definite changes in the neurological system such as strengthening of synaptic connections and the interconnections between brain nerve cells. Kandel (1998) states that learning produces changes so that “nurture becomes represented in nature”. He posits that genes have two functions, one being the template which contains all the DNA information which may be altered by mutation but certainly not experience. Their transcriptional function is, however, responsive to environmental factors and experiences. Overall, he argues for abandonment of Cartesian dualism as inimical to the fertile development of psychiatry and psychoanalysis with biology entering into a fertile interchange.
Obviously seeing patients who have been on a heavy and protracted dosage of medication pose more challenges as to reasons for considering withdrawal of medication, as it may seem reasonable to say that since they are at least functioning on the cocktail, why meddle? However, having conducted therapy with some patients and observing how the cocktail has been evolved, I have found that less than rational practices often prevail. A patient comes to mind who presents with self mutilation urges. She recalled that prior to falling pregnant, she had felt at an optimal psychological state while taking Lithium a few years previously and requested her that her psychiatrist reinitiates a trial. After a brief week of optimism, she soon reverted to her previous level of depression. In fact, two months later, she for the first time, made actual suicide attempts. The point is that the Lithium was not withdrawn due to lack of efficacy. What of the dangers of long- term chronic use, especially when no major or even minor benefit is discernible? The concerns I have are threefold. Firstly, whether her supposedly good response to Lithium was not linked to her goal of having a baby rather than inherent properties of the drug, and secondly, the fact that she was not responding to it but that no doctor seemed to suggest withdrawing or abandoning the Lithium and to recognise it as an unsuccessful trial. Thirdly, I question whether the suppression of extreme lows does not simultaneously suppress natural cyclical ups as well. Lastly, she became sluggish with weight increase reaching the point of obesity. After admitting her to a private clinic, during which she was subjected to ECT, she returned two weeks later, worse than ever, and then being even more agitated by her loss of short term memory..She was also officially diagnosed as having Bipolar Disorder. The writer has noted a recent trend for making this diagnosis. She had being seeing psychiatrists for over eleven years prior to our therapy and none had ever suggested Bipolar Disorder. In the absence of any manic behaviour, no response to mood stabilisers, I question the diagnosis completely. I note that a diagnosis of Bipolar Type III in now made if a patient responds to antidepressant medication with manic symptoms
Obviously we need to recognise that for many, it is also appealing to receive a ‘medical’ diagnosis, with all the blame and responsibility shifted to genetics and ‘nerves or a chemical imbalance’. To what degree do we share our questions with our patients that these diagnoses are not of the same order as medical diagnoses, where a blood test or scan can unambiguously assert the presence or absence of a disease? Although the drugs work on serotonin and noradrenalin, the exact ways through which they work may involve other, perhaps still unknown or unidentified neurochemical pathways (Janet 1988, personal communication).
Our pragmatic complicity in using the diagnostic system and attempts even to pursue research using these diagnoses as key variables raises many questions. The whole question of which power relationships and ideologies dominate research is a problem unto itself. Without getting involved in over simplistic anti- capitalistic debates and rantings, a closer examination of the dangerously close relationships between the psychiatric and pharmaceutical industry does deserve close scrutiny. I will return to this theme below. There is a vast discrepancy between what I was taught of psychiatry by a leading psychiatrists and unabashed biochemical reductionists (Janet 1988, personal communication). The writer understood that he unequivocally taught, at that time, that polypharmacy reflected diagnostic imprecision, the idea being that if one really targeted the cause, there should be no need for multiple drugs. Which of us sees such a patient? So many neurotransmitters are being modified, who knows what’s doing what to what?
The manner in which diagnoses are made, remains notoriously unreliable from practitioner to practitioner, and most diagnoses still require clinical judgement, not laboratory tests or PET scans or blood tests. In using the DSM, this writer was taught that the Axis 1 diagnosis is somehow hierarchically dominant, the ‘real illness, with Axis II diagnoses being technically and practically ‘deferred’ or discounted, depending on your view, given the seemingly rational argument that a major depression or manic state would preclude any reliable capacity to assess pre-morbid personality. Of course, in many cases, anyone seeing a floridly manic or deeply depressed individual would agree, but despite the more extreme distortions of personality, my experience has shown that the basic personality structure may shed a great deal of light on an eventual overt psychiatric breakdown. Even in some cases where the Axis I symptoms seem to dominate, can we not sometimes see that some patients express their depression in a more narcissistic contact- shunning manner, compared to those who become more dependent and clinging and more overtly needy of endless re-assurance. A case study comes to mind, of a young man seen several years ago, heavily medicated and having gained weight, mentally and physically almost literally lobotomised. The patient was diagnosed Schizoaffective. A heavy duty diagnosis indeed!
After a few weeks of twice weekly therapy, an initially sinister delusion that his “face was melting” turned out to be, in context, a construction by a very overprotected young man, developed on a first overseas holiday away from his mother, believing he’d been fed cannabis. His panic and reactions in a foreign country did indeed cause people to stare. Not having mommy close by to reassure, he was quickly on high medication and bundled back to SA. My experience was rather like ‘talking through’ a person who’s having a bad and prolonged overdose of hallucinogens. He persisted in isolation because of a lingering belief that people were staring at him. I decided to take a walk down a street with him to observe his fantasy in action. Stepping out into the street, immediately I was struck, as was he, by two men staring at us very intently. All I could do was affirm they were indeed staring unusually. I was able to point out to him though that in more general way, staring at people, making intense eye contact with passersby, would evoke a more intense reaction from them, which he failed to realise was precipitating their staring. I refer to this case showing actually how very little I did. He was certainly not cognitively and emotionally ready for a deep meaningful therapy. What it did was remind me how an elaborate diagnosis can obscure such simple realities. I believe simply affirming his perception but opening his mind to the myriad possible interpretations including his obliviousness to the amount of information we transmit non-verbally, was a key in anchoring him. From an admittedly over- simplistic perspective I would suggest an acute separation anxiety reaction. Whether he actually was given cannabis remains unknown. However, given what we know from the studies of Bowlby (1952) about how frightening stimuli are to an infant when separated from the primary attachment figure, compared to the capacity to tolerate without fear the very same stimuli when the primary attachment figure is in close proximity. In my experience, underlying separation anxiety problems are increasingly relevant. In our modern society where the emphasis is on independence, where even the nuclear family is a rare ideal, and parents are forced into premature return to work, and even with the best intentions, are too depleted emotionally after work to be, in my opinion, emotionally optimally available. I shall return to this question below in discussing social and political and economic factors implications for the holding of the matrix of extended family which was the norm no less than 400 years ago.
With the advantage of years of clinical experience and supervision, we may increasingly make accurate assessments, in consultation with the patient, as to optimal agreement as to when to begin a trial gradual tapering off of medication. It is always important to differentiate between the patients re-experiencing tolerable levels of feelings and anxieties, as distinct from possible relapse or extreme and severe variations of the Serotonin Withdrawal Syndrome. When we treat a symptom as multidimensional as anxiety, which surely is almost inevitable, no matter how apparently diverse the presenting problems, we should continuously be exploring effects of medication, our own and the patient’s life situation, differentiating pathological, chronic or episodic anxieties from a normal, healthy capacity to experience existential anxieties, and performance- based ones. Clearly, some anxieties serve survival and preservation of the self and relationships, compared to those that have been dislocated from meaningful links to the psychosocial integrity of the person. I suggest that Melanie Klein’s differentiation between paranoid-schizoid and depressive anxieties is a beautiful concept capturing aspects of the process of the development of our capacity to love a separate individual. It is possible to use and expand this concept, without buying into some of her more alarming ideas, or even the psychoanalytic paradigm itself. In an ideal situation, a psychologist needs to be able to access supervision in those cases where the limits of his or her own experience, make it necessary. As with all relationships, the therapist should gradually evolve trusting relationships with a referral network, including that of psychiatrists where mutual understanding and respect for each other’s roles is implicit. Mutually trustful collaboration should liberate the psychologist to focus on the subtle therapeutic complexities.
Reviewing twenty years of practice, the writer recalls in early years sending almost every patient with excess anxiety or panic attacks to a psychiatrist, whereas with increasing experience and confidence, the need to refer has become the rare exception. However, we also all probably note how our understanding of the presenting problem, or diagnostic acumen, evolves dramatically over time, and, if we learn from our experience, even our conception of the core problem evolves. Inevitably, this also involves therapists’ owning their often painful issues, and ongoing psychological development, surpassing almost any other professions of which this writer is aware. This is one factor that makes being a psychologist such a rewarding, but daunting challenge.
Aspects of Eastern psychology and philosophy may provide critical insights and tools which are applicable to many of the problems associated with evoking concepts of illness and medication. In fact, simple bad habits, crystallising over multiple repetitions, can often be identified at the root of very significant problems. Due to our ignorance and deference to so-called experts, we often overlook key consequences of our activities, such as the need to incorporate routine activities into life in order to preserve and maintain. (Prabhubpad, 1998). Only recently have words like ‘sustainability’ entered into our daily discourse. Neglecting activities of maintenance, in favour of production and destruction, we are confronted not only with the destruction of the planet’s ecology but social and individual disintegration as well. The psychoanalyst, Bion, formulated a theory of mind which, in the writer’s opinion, is compatible with insights from Eastern psychology in his modern exposition of psychoanalysis. The writer presents a brief exposition of some of Bion’s fascinating ideas, in the hope that it will provide a fertile background from which to consider substance abuse disorders (SUD) or addictions and Attention Deficit Disorder with or without hyperactivity below. (ADD or ADHD) Before doing so, however, the writer will more closely explore the economic aspects of medicine and medication.
The Materialist and Capitalist Economy
It is difficult to ignore the vast power of the global pharmaceutical companies and the doctors who prescribe their dugs and the diagnostic systems employed and the illnesses for which these companies claim to provide relief. Another concern with the medical model is that we are so bedazzled by the spectacular technologies that we neglect two simple points. The first is that these sophisticated machines are in most cases nothing but a means of extending our senses. The same imperfect senses which we use in other situations of empirical observation, are equally limited by the conditioning that our minds and senses have been subjected to, the processes through which we learn to perceive in certain inter-subjectively accepted ways. The second concern that deserves repeated emphasis is that the psychological and psychiatric research encountered, does not reveal a causal relationship between the variables of biology and mind, but correlations certainly exist.
Consciousness has been astonishingly neglected in psychology. We may consider how relatively recently Skinner was able to pontificate about the irrelevance of the ‘black box’ troublesomely intervening between stimulus and response. I propose that reasons for this neglect are not neutral but closely linked to the materialistic acquisitive ethos in which we live. Consciousness remains elusive to any attempts to patent, package and sell it as different brands.
As non-prescribers of medication, most psychologists may be of little direct relevance to the pharmaceutical industry. We are, however, inextricably parts in the entire ‘psy’ business. Every time I capitulate to the requirements of providing an ICD X diagnosis, I am aware of a certain uneasy sense of hypocrisy. We may warn our patients that this information is not subject to the ethics of confidentiality. Possibly, too we should discuss and clarify the meanings that a patient may ascribe to the use of a diagnosis, attempting to always impress upon them that this diagnosis is a pragmatic economic concession. It does not refer to a static entity, but is a crude approximation of one state in a myriad of processes. To their credit, the Johannesburg Psychoanalytic Study Group long ago registered an official complaint to the HPCSA on being forced to use this diagnostic system.
Karen Shore (2005) emphasises that the use of the term ‘provider’ represents the dominance of the impersonal industrial culture in health care, which is eradicating the humanitarian culture from which we developed. Terms such as clinician made it clear that it refers to a human, whereas the word provider blurs the distinction between people and things, eroding individuality, professional identity and integrity from the minds of patients, legislators and clinicians themselves.
The public seeking help are also encouraged to see those that provide the care as interchangeable parts. Shore (2005) stresses that words are not neutral since language influences attitude and behaviour. Her invective is directed towards managed care in the USA, but in South Africa we are all categorized as service providers by both medical aids as well as the HPCSA itself. Shore (2005) likens the use of the term provider as having a similar agenda to plantation owners who changed their slaves’ names in order to facilitate forgetting their true origins. She reminds us that this renaming reveals a demeaning destructive agenda and that we need to consider ways in which we can challenge the status quo and develop alternative visions and practises.
Despite the failure of communism, we need to learn from the errors of social engineering and perhaps, precisely the abomination created by the fanatical adherence to the concept of historical materialism. This mode of thought sought to reduce the complexities of consciousness and subjectivity to an economic base of relations of production. Despite its perversion in the official state sponsored forms of ‘communism’, the author believes that many key concepts created by the young Marx, such as alienation and commodity fetishism and species-being, have an ongoing place in a critique of the social economic matrix in which we struggle to express that most complex of all specifically human capacities, that is of choice. There is no way we can assume that the reality of global capitalism does not impinge on all aspects of our lives. A crucial reality that is discussed by (Krause, 2005) in attempting to account for the enormous increase in anti-depressant medication since 1968 is that for most people, technology has by no means decreased work, but has in fact increased it. Although Krause (2005) does not give much credence to the idea that diagnostic criteria have broadened, this author would disagree. I would also argue that he focuses rather too narrowly on extra stress involved in increased time of work (quantitative), rather than examining inherent increasing stress involved in modern work created by, for example, the information overload and multi-tasking made possible by modern technology (qualitative changes).
The ongoing attempts at a veil of objectivity, the deadly depersonalised past passive voice of science, the still rather rigid rules seem formulated to take any creative or truly original spark from research and render it lifeless in order to make variables operational and generalizable. The entire assumption that therapy or even therapeutic techniques can be standardised and manualised to meet the criteria of Western science’s goals of prediction and control is called into question by newer qualitative research methods which lend support to the not new, but very central idea that therapeutic outcomes seem to be very strongly linked not so much to the school or type of therapy used, but to more subtle influences related to the person of the therapist. Official espousal of allegiance to a particular school of therapy does not seem to be clearly related to what the therapist actually does. I would suggest that this is the therapist’s capacity for a meaningful and deep engagement with the patient, with the technical rules of therapy serving this end. In essence, this writer argues that it is the personality of the therapist, and the quality of the relationship, that ultimately count.
The most powerful underlying driving force of our economy is the quest for profit. In this process, people are reduced to mere commodities. For a useful incisive non-Marxist analysis of the extent to which profit damages us, the reader is referred to Pollan’s (2006) book, “The Omnivore’s Dilemma: A Natural History of Four Meals” in which some of the more obvious and more subtle ways in which the quest for profit in agribusiness is doubtlessly having an extremely negative effect on the nutritional value of the food that we eat, not even taking into consideration the questionable ‘food’ available at fast-food outlets, is exposed. Ignorance is fast becoming or already is a precarious and potentially life threatening form of bliss. As psychologists, we have a duty to inform ourselves as to what it means to be human. If nothing else, we can speak and write about the dehumanisation that we encounter. As exponents of the talking cure, we should consider seriously the power of speech to transform both ourselves and others. It may be seductive for us to comfortably peddle our wares from behind closed doors. However, surely every therapist is in a position to ask radical questions about the relationships between the deformation of the human psyche, and the profit- motivated, hedonistic, narcissistic and even ‘psychopathic values’ which dominate political and economic practises.
The overriding mandate of advertising is to colonise basic human needs and create associations with obsolescent products. True service, from a spiritual perspective, requires surrender, personal attunement and sacrifice. The low priority given to the maintenance of those needs that do not generate profit reveals the destructive nature of capitalism. Advertising helps create an addiction to novelty. Addicted to novelty, we are encouraged to forget the tedium and costs of preservation and care. The Bhagavad Gita (1998) reminds us that all material activity involves a balance of three modes of activity which I will simplistically translate as a) maintenance/preservation, b) creation/production and c) destruction/consumption. A unique balance of these three modes is required in each individual and society. The imperatives of creation and destruction have more appeal compared to the smallness we may feel when facing endless repetitive tasks of preservation. We confront our ephemeral nature, and our narcissistic illusions are fundamentally lost. For example, when buying a new car, there is a focus on an image or status, while the real costs of maintaining it; in terms of fuel, oil, mechanical services and endless replacement of parts that wear out, is seldom emphasized. Maintenance activity balances the whole person, preventing creativity from spinning into its opposite, profound destruction. An individual who is so focused on being creative may ignore the necessity of regular sleep and eating so that he or she begins to self- destruct. Even before Marx, Hegel made the astute observation that human needs are simultaneously the most concrete and abstract foundations of society. In other words, human needs and their satisfaction form the foundation of all societies. Needs are also highly plastic and susceptible to modification by ideological agencies such as advertising. An ordinary need for recognition may become associated with the consumption or possession of a specific product or service as the means to attain it. States of constant hankering, frustration and anger seem to be associated with this economic ethos. Equally devastating, is the spectre of unemployment, as a result of the convulsions of an over-extended economy, or the need to keep a reserve army of labour, or as a tragic structural reality of modern capitalism. Whatever its cause or function, the stress it brings take people beyond malaise to The stresses here reach points beyond malaise, to severe alcoholism, violence and family murders.
The MaterialisticModern Economy, Psychopathology, Medicine and the Pharmaceutical Industry
Krause (2005) provides a powerful exposition of the rather astonishing statistic that the prevalence that all types of depression were estimated at less than one in a thousand in 1968, compared to the 2005 estimate of between five to ten cases in one hundred. The DSM has, as it evolved over time, to the current DSM V, with each manual included an increasing number of diagnostic categories and specificity. The categories of exogenous or reactive depressions (precipitated by death, losses, illnesses etc.) are nowadays largely replaced by the diagnosis of Major Depressive Disorder.
Krause (2005) notes that changes in technology have not resulted in less time spent at work by Americans and also that one third of Americans rated job stress as their greatest stressor. A host of stress related medical conditions can also be considered in terms of work related stress such as gastro-intestinal problems, high blood pressure problems, cardio vascular diseases an even smoking and alcohol abuse.
Krause (2005) using a Foucauldian point of reference, states that scientific claims to neuro-biological knowledge replace socio-cultural and psychodynamic analyses, with the result that those professionals and organisations operating within the neuro-biological discourse will be empowered, and those external to this paradigm become marginalised. Over time, there has been a loss of the distinction between exogenous and endogenous conceptions of depression, and with the advent of the SSRI’s, it is widely held that there is an obvious causal link between serotonin levels and depression. The biological reductive approach as previously noted by this author, neglects the probability that in most cases, life stresses have contributed to the depression. It is assumed that all depressions have neuro-biological underpinnings but that not all endogenous depressions have contributing life correlates.
Krause (2005) suggests that if most cases of depression stem from neurobiology, there should be no increase in depressive incidents unless one makes the unlikely claim that human bodies themselves have changed. Although I agree with Krause (2005) to a point, I would not dismiss the hypothesis that, because of widespread social stress and the lack of availability of both parents to provide for an enriched experience of dependency, subtle changes in neurochemistry are indeed taking place. The effects of stress in a society based on rapid change amongst many others, includes enormous anxiety expressed by many parents who, simply as a result of relativism, come for consultations, simply because they do not know what is to be done or not, for their child. Work stress and consequences of single parenting may permeate even the mother-infant’s earliest experiences, and may result in widespread pervasive changes in the way genes are activated or not. The impingement of noxious social concerns into the very mother-child unit (where a working father alone or the mother’s barely sufficient maternity leave) may result in parents not having the time to enter the states of reverie necessary to contain the infant, and transform beta elements into alpha ones.
Medical journals increasingly ignore the effects of external contributing causes, and now actually focus on causal effects on external factors, specifically how the depressions affects productivity in the workplace and how the workplace suffers! Krause’s (2005) article, notes how studies funded by the pharmaceutical industry focus on the costs to the corporate, implying that it is the corporate that are the victims, rather than the worker with depression. The costs of treatment itself are always a significant consideration in terms of time and absenteeism required to continue the delivery of treatment.
Krause (2005) invokes Foucault’s concept of the ‘implantation of perversities’ to exemplify the concept of bio-power. There is a concerted effort by governments and public health groups to insert the category of depression into the discourse of the lay public. McDowell (2005) cites detailed examples based on the United States’ supposedly neutral, consumer protection organisations, providing a rather powerful argument that their main agenda is to define medicine as a commodity. There is an inherent conflict of interest between industrial profit and national health care. McDowell (2005) warns against a simplistic blame of the corporations, but points to everyone involved in the mental health industry.
McDowell’s (2005) analysis reveals that through interlocking directorships, major banks, insurers and corporations as diverse as General Motors and IBM are effectively represented in the National Council for Quality Assurance (NCQA). The United States Coalition for Service Industries (USCI) takes a negative stance towards national health care in England, Canada and elsewhere, viewing them as opportunities for United States business to expand. The USCI views all social services as potential gold mines; this includes the entire spectrum of health and social care, hospitals, clinics, and nursing homes including the informal infrastructure such as self-help groups.
McDowell (2005) suggests that the history of science over the past forty years is an account of political orthodoxy masquerading as scientific truth. Using the theory of cognitive dissonance, he suggests that researchers are unconsciously biased in terms of who pays them. McDowell (2005), citing a 1998 New England Journal of Medicine (NEJM) review of 70 studies of calcium channel antagonist drugs, notes that researchers rated drugs favourably 96% of the time when they had a financial relationships with the drug manufacturer, compared to only 37% of the time when there was no financial connection. Research is also manipulated by lawsuits against individual researchers and their employers. Medical journals such as The Lancet or Journal of the American Medical Association (JAMA) receive demands to withdraw research publications under threat of lawsuits or ask the authors to tone down their conclusions and insist on a negative editorial slant. Before financing research contracts, drug companies institutionalise the pharmaceutical company’s rights to delete information from the work.
Outreach programmes and support groups themselves often become the unwitting agents of the pharmacological industries’ interest. An example is of how the Panic Disorder Support Group, founded by a sufferer of panic attacks, Zane Wilson, became the recipient of the services of a consultant psychiatrist with biological leanings, who in turn soon organised the support of a major pharmaceutical company. Today, as The South African Depression and Anxiety Group (SADAG), it is able to make much more significant social inroads, since it is better financed and able to pay for staff, telephone lines and to provide literature explaining the ‘disorders’. There is, however, the inevitable emblazoning of the pharmaceutical companies logos and adverts on their literature. An explanation of depression as an illness responsive to appropriate medication is certainly raised both visibly and invisibility.
Another extremely significant change has been the increase in direct to consumer advertising. Krause (2005) reports an increase of 212% of such spending estimated between 1996 and 2000. An effect is that people now identify their lived experiences in terms of a diagnosis of depression. Doctors report that as a result of this marketing strategy, patients increasingly ask for specific medication. For example, withdrawal, a sign of being overwhelmed, given the impingement of physical space and time by the employer is suppressed by the use of an antidepressant. The antidepressant increases tolerance of such overload, rather than changing the environment, such as aspects of the job itself or looking for alternate work.
The ultimate point is that the economy is not actually a thing but the productive activity of human agents who have been negated as conscious persons through a depersonalising combination of materialism, power and greed. And neither Marxism, nor South African communism has the will or capacity to bring into question the entire notion of ownership itself.
Mohroff (2008, pp121-26) articulates a point regarding our need to explore alternative epistemological approaches, particularly those from the East. Unfortunately the writer has found much total nonsense in the guise of New Age ideology, plagiarising in most cases some great truth, stolen from its contextual matrix, and generating often large financial returns for expedient charlatans. There is profound ignorance by supposed scholars, which present distorted views of Eastern philosophy. In most cases what is taught is Buddhist theory which is monistic, claiming that all is illusion suggesting that only spirit is real and the material universe is not (Maya). Actually there are several forms of qualified dualism, the one which this writer proposes as most intriguing is the Vaishnava concept translated as ‘simultaneously one with and different from’. The material world is not unreal, simply impermanent.
The indispensible yogic precondition is disentanglement of the true witness self (atman) from the endless activities of the mind with its beliefs, needs, opinions etc to attain pure subjective knowledge of the world. The typical Western response, that subjective knowledge is inaccessible to another is not true. In many instances we operate from a position assuming we can. Firstly, that the so-called privacy of consciousness is an insurmountable problem is wrong, since what matters is that another person, using the same methods will access similar results. Secondly, the sensitivities we are capable of feeling to the experiences of loved ones, are daily cases of such sharing of subjective experience. Bion’s modification of projective identification, which is based on the capacity of the mother/analyst to enter a state of reverie to receive the projections of her child/patient, has developed into use as probably the primary tool in decoding counter-transference. Therapists may often note that breath and heart rate may change within minutes with a particular patient, stomach turning or sinking in apparent absence of explicit verbal or even non- verbal cues. Of course much research is still required to illuminate this fascinating area, where it seems that fields of consciousness interact. In many instances, the non- verbal cues to which our brains respond maybe subliminal rather than absent. Mirror neurons are the latest offering from neurology, it being suggested that we pick up the non-verbal cues from the other, which result in a rapid experience of a corresponding mirror modification in our own nervous system, relevant organs and musculature relevant to the emotion being experienced.
Bion: An Alimentary Theory of Mind.
The implications of a theory in which consciousness is considered primary which is in contrast to the primacy of the material- economic, sexual, neurochemical is profound. The prevailing ethos certainly seems to relegate consciousness to an epiphenomenon of neurobiology. By no means being a final answer, the writer believes that introducing a few aspects of his psychoanalytic contribution is extremely useful, since it holds the promise of strong compatibility with Eastern mystical tradition or at least, my limited understanding of the philosophy and psychology espoused in the Veda.
In his autobiography, it is clear that his experiences emotionally as a child in India left very powerful impressions on his mind. Obviously for a psychoanalyst, we would not find it difficult to accept the importance of these experiences, but this writer is not aware that Bion explicitly acknowledges Eastern thought on his own psychoanalytic development, although he is careful to give full acknowledgement to the contributions of Freud and Melanie Klein. At the most abstract meta-psychological level, Bion proposes a dialectical dynamic between truth and lies, as the central human dualism, superseding Freud’s Eros and Thanatos and Klein’s love and hate or paranoid schizoid anxieties versus depressive concerns. This approximates very closely, in this author’s mind, the dialectic between ignorance and sattwa, which form two poles of the Vedic theory of material activity. Bion (1970) speaks of links consisting of L, H and K or Love, Hate and Knowledge which may bear a resemblance to the three modes.
Bion (1973) reinvented the Freudian concept of analytic neutrality, expressed explicitly as “evenly suspended attention”, into a recommendation that a state “beyond memory and desire” is essential to the psychoanalytic attitude. The parallel to the ideal of a meditative state is clear more generally in the Bhagavad Gita (1984), it is recommended that one works in a state of duty and surrender, without attachment to results, be they negative or positive. Obviously during the course of psychotherapy, the therapist may well find him or herself wishing, needing or feeling in certain ways toward the patient. However, in the absence of memory and desire, the therapist will note these feelings and impulses and use them as a basis for interpretation, rather than acting on them. It should be noted that this state also includes a therapist’s wish to cure a patient, which several psychoanalysts (Hinshelwood 2002, Safouan 1997) consider to be a dangerous reaction formation to the therapists own anger or need to control.
Through listening to the patient in the way recommended by Bion, the therapist is approximating the state of reverie which Bion considers necessarily provided by the earliest care giver. In this state of reverie, the parent/analyst opens their minds to the child’s projections and holds these often toxic feelings until they are understood or digested. The process of receiving and detoxifying feelings that the child/patient had considered intolerable and only fit for evacuation is called alpha-function. In other words, intolerable beta-elements are transformed into tolerable and ultimately thinkable states. Through experiencing alpha-function in the context of a containing and holding relationship with the parent or analyst, the child or patient learns to introject this capacity, and apply it to his or her own mind.
Bion’s work refers to the digesting of facts. Undigested facts or beta-elements are stored in form of bodily sensory traces- the raw elements of sensuous and affective impressions. They are prior to psychic material and are physical and distinguished by being dealt with by only evacuation by means of projective identification. Beta-elements are unavailable for thoughts and consciousness until they are transformed by alpha-function. Alpha-function involves the interpretation of the selected fact by recycling them as memories which can be re-transcribed, forgotten or recalled.
Learning from an emotional experience is a re-transcription. The mind develops bit by bit by digesting experiences. Undigested facts (facts not metabolised) remain in unrememorable and unforgettable, what cannot be remembered, cannot be forgotten.
Higher order consciousness, in contrast to primary consciousness, involves the developments of new neuronal maps and then mapping of the maps, which are mutually interactive. It also involves the emergence of consciousness of self from non-self. Brain mapping of its own processes involves consciousness of being conscious, comparable to the feat of thinking about thinking.
Higher Consciousness involves consciousness of being conscious. Memory or the brain repertoire in the frontal cortex capable of being stimulated i.e. experiences affective rewards by delay of gratification, and so the mind is capable of modifying past and future. The critical capacity to modify frustration, rather than only evade it, may then develop (Bion, 1962).
With the alimentary system as metaphor for mind, its task is the digestion or metabolisation of emotional experiences, capable of differentiation of sustenance through truth versus the toxic quality of lies. Bion’s (1962) theory of mind has been termed ‘alimentary’. One notes the numerous references to digestion, incorporation, detoxification etc. This notion is closely compatible with the Vedic theory of mind, which suggests that mind is the subtle material representation of the body. The Veda suggests that all sense and motor organs are represented in subtle mental form. A biological reality, that intriguingly links to the prioritisation of language and speech as our tools as therapists, is that the tongue, of all sensory-motor organs, occupies relatively the most cortical representation on the brain compared to other motor organs such as legs , arms and hands. The use of mantric meditation to control the tongue and body-mind is an obviously interesting associated issue. In Vedic terms, the ‘belly and genitals’ follow closely.
Da Silva (1989) argues that there is evidence that the ‘alimentary’ model of mind is more than metaphorical. Embryological research has revealed that the two most primitive layers of cells forming the embryonic plate detach into ectoblasts and endoblasts, becoming the neural tube and brain and alimentary canal. Peptides not limited to gastrointestinal tract but are also found in the central nervous system. The locus coeruleus has afferent and efferent connections to the gut. Da Silva (1999) goes so far as to refer to an enteric nervous system, a third division of the autonomic nervous system, structurally more similar to the central nervous system than the peripheral nervous system.
The attitude of the analyst, certainly as espoused by Bion, also distinguishes itself from the medical and Western scientific model’s emphasis on control, knowing and results. The Veda attributes the perception of ourselves as the knower, doer and possessor as illusions generated by the false ego. In addition, Bion himself (1970) specifically distances psychoanalysis from medicine, pointing out that the material of analysis is intuition, rather than sense impressions used by medicine.
The application of a diagnosis carries the danger of disempowering the patient. It reifies in the sense that the diagnosis implies a state rather than ongoing part of a dynamic developmental process. Regarding addictions especially, Peele (2010) and the Baldwin’s (2009) report that now that the 12 Step models have become almost standard, unquestioned parts of almost all rehabilitation strategies. The medicalisation of addiction as a lifelong disease has been incorporated into the official discourse which may, partially at least, explain the rather dismal 5% success rate for alcoholics using AA as their primary therapeutic intervention. There does seem to be an obvious danger in reciting daily, weekly, monthly and yearly repeating “I am X and I am an addict/alcoholic”. Does this not assume the impossibility of any development or healing, which would suggest that the person is developing a sense of self beyond that of primary identification as an addict? It also flies in the face of what we nowadays seem fairly certain is the existence of a natural ‘maturing out’ process Dos Santos (2010). Does it not fail to allow for members to make significant spiritual progress, and/or simultaneously heal the deficit, so that continuing to identify oneself as an addict becomes problematic? In terms of diagnosis, problems associated with self- fulfilling prophecy, cannot be underestimated. This may apply even more specifically to heroin addicts who are surrounded by the beliefs that the prognosis is extremely poor, with about a one to two percent recovery rate. Compounding their belief in a bleak outcome, social stigmatisation itself may create symptoms consistent with profound stigmatisation and isolation.
O’Brien (2008) asserts that at a clinical level, addiction may be considered similar to an infectious disease such as tuberculosis, depending on an interaction of host, agent and environment. These could be manifested as genetic predisposition, high drug availability or affordability, and regarding environment, whether the availability of alternative recreational facilities exists. Since experimental evidence shows high limbic activation (emotional arousal) associated with any drug cues, drugs which dampen limbic system activation are proposed as one element in a multiple target treatment program. O’Brien (2008) concludes, somewhat abruptly confidently that findings such as these (limbic system activation), support a biological basis for addiction.
The masking of the patient’s real issues may significantly get in the way of the therapists access to the true needs and emotional defensive structures. A therapy conducted entirely in conjunction with medication cannot convincingly claim that the risk of relapse is minimal should the patient discontinue either the medication or therapy. Panic attacks, so responsive to SSRI’s are a good example. I mention them at this point because in the course of withdrawal from a substance, panic attacks which often existed prior to the substance dependence, or emerge only after detoxification, are frequently encountered in my practice. Although we may arm the patient with the best range of CBT strategies, it is this writer’s belief that a key triad, anger, fear of loss of control and fears of separation, need to be resolved, to prevent relapse once medication is terminated. A side remark, the Serotonin Withdrawal Syndrome can be very difficult for a minority of patients to negotiate. I have had a few who required hospitalisation and tapering for over a year to finally cease the SSRI. In terms of my understanding, panic attacks are just more evidence of crucial significance of problems in attachment and inability to tolerate loss and separation in almost all the clinical problems we encounter.
Lifschitz (1989) places an inability to tolerate loss as the most central dynamic in addictions. Life involves a capacity to tolerate loss as we develop and let go of earlier ideal of self and other. In all choices, we sacrifice other potential opportunities. Living fully requires a capacity to tolerate loss and separation as we give up the narcissistic fantasies of perfection, idealised love. In order to do so we must be capable of tolerating and thinking loss.
Since so much of the debate involves the medical model, I shall briefly enumerate its principle characteristics as distinct from a life process model of substance abuse disorder/addiction These points are adapted from Peele’s’ (1994) listing of the differences as applied to the disease model of chemical addiction. The medical view suggests that addiction is inbred and biological, rather than a way of coping with the self and the world. Medical solutions and expertise are required, instead of an emphasis on the development of self awareness, new skills, changes in environment and relationships. From a medical point of view, addiction is an all- or- nothing concept, rather than existing on a continuum. The condition is seen as a permanent illness, not a symptom of processes that may be outgrown. The medical model places diagnosis of the substance abuse as the primary disease, whereas the life-process model suggests that the diagnosis stems from other life problems. Lastly, there is a tendency to view a failure to accept having a disease as part of denial, and recovery is seen as contingent on submission to dogmatic traditional methods of detoxification including full acceptance of the twelve steps programme.
In a recent article on detoxification, O’Brien (2007) refers to studies showing limbic activation and frontal lobe disinhibition when addicts are exposed to drug related cues. I have briefly referred to his inferences above. I would agree with O’Brien’s (2008) statement that brain biology is clearly involved in addictions. However, there is no elaboration of the meaning of this statement. It implies, simplistically that brain biology causes addictions. I would argue that the concept of neuroplasticity is robust enough to explain both functional and structural changes in the brain and of course, other parts of the body through which emotion may be mediated. It would be naive to not expect that regular self- dosing with powerful drugs could be expected to create a new ‘drive’ or a neurological pathway for the drug, as a result of addiction over an extended period. The writer remain hopeful that should a former substance abuser discover practices of meditation, payer or yoga that provide alternative ‘spiritual’ highs to a former drug-based high, I could imagine that the processes could be much shorter. This follows the simple Vedic principle of substituting a higher taste for a lower one. However, psychotherapy must teach the addict to tolerate pain and loss, finding meaning rather than a desperate rush to get high.
O’Brien (2008) describes the vast array of aids to make it possible even for the opiate dependent/addict to detoxify, without experiencing the utterly disabling effects of withdrawal, allowing even for outpatient psychotherapy. Despite the impressive armamentarium of drugs to cushion the horrors of detoxification, and his confident assertion of the involvement of brain biology in the problem, his paper concludes with the bewildered lament that despite the advances in detoxification, the relapse rate remains extremely high. The author singles out O’Brien’s (2008) paper merely to draw attention to assertions which with researchers make sweeping claims as to the brain biological bases of a vast number of problems, only to peter out when it comes to finer analyses, or look for evidence of cure or even longer- term maintenance. It should be no surprise that sudden dramatic changes are relatively easy to pull off, but it is the long- term maintenance of change that is the real acid test, when the novelty of being ‘clean’ wears thin and daily confrontations with boredom, frustration and the loss of the drug to cushion normal daily disappointments and both normal and sometimes intense sadness and anxieties need to be tolerated. I have witnessed the effects of such detoxification aids. I also wonder whether a more benign experience of withdrawal does a disservice to the patient, by so masking the agony of withdrawal that he or she is deprived of feeling a full sense of victory, mastery and power through having tolerated the pain.
Jung’s explicit “contra spiritum spiritus”(loosely translated; use the spiritual to overcome the addiction to alcoholic spirits) quotation in his letter to William Wilson, one the founders of Alcoholics Anonymous, (Jung, C., 1961 in Taub, S. 2011, p18 ) and currently, but by no means exclusively, Twerski (1998), (n.d.) is the idea that we as humans may be wired to experience the spiritually transcendent. Almost all cultures and religions of the world possess a body of mystical teachings and techniques, which share certain similar overt requirements, such as rhythmic subroutines which induce trance-like states. They share the aim of transcending material limitations in order to access their conception of the supernatural realm. Many Western religions themselves became so bland in their attempts to ingratiate themselves with the modern scientific rational ethos that they failed to offer the irrational and numinous, transcendent realm of human experience. This writer still contends that one of the most central aspects of addiction is the result of failure to integrate dependency needs and associated inevitabilities of separation and loss. The scriptures of all cultures teach that humans are conditioned and dependent, and that our ultimate destiny or ‘dharma” lies in service, clearly both to other living conscious beings and the Divine). Along with all the social changes damaging the modern human’s experience of dependency, it is tempting to question to what degree the rise of secularity and relativism opened a bottomless pit of neediness and desire, which no amount of consumption is capable of satisfying. In the writer’s experience, many addicts oscillate between drugs and drink oblivion to the merger with co-dependent partners, unable to tolerate loss or the ‘gap’. The logic may be that we are using material or human objects to slake a spiritual thirst. For years, the simple statement by a heroin dependent patient still resonates- “Heroin brought me to my knees”.
Of course psychologists have typically and I think legitimately, sought purely psycho-social explanations for the now wide- spread, consistent and well known research finding that parental religious active involvement seems to offer a buffer for their offspring against addiction or substance abuse. Typically, psychologists would be seeking explanations in terms of the parent’s social integration into a community, or their authority being buttressed by their own submission to a higher authority, or the modelling of submission or service. The writer also suggests that such parents may well be finding a place for their longing for wholeness, rather than expecting their children to fill the void. Whatever the explanations, they probably have little bearing on questions of the ultimate realities of a spiritual dimension.
It may be irrational to the atheist, yet we are missing the reality that many people are not looking for reason, but need opportunities in which letting go can be expressed in socially sanctioned ways-sinisterly, it is still only through war that the aggressive impulses are accepted, despite some advances in the media, back in the school and home, sex still retains many taboos. The violence of our animal nature has many more opportunities for expression such as in hunting, boxing, wrestling, than do the libidinal. The pervasion of positivism and rationality may not be what we need-the interlinked goals of prediction and control may thwart just as powerful a need for the numinous, for ecstasy or bliss beyond the mind’s limitations. Unfortunately attempts to transcend limits without respecting the body and mind’s limits results in paradoxically even deeper entrapment. The simplest mantra, meditation using a focus on breathing, or prayer, channels the mind’s incessant movement into a regulated vibration frequency, with practise providing a means for be freed of the ‘normal’ disturbed unfocussed thoughts that adults, unlike children, have in most cases simply learned to hide or disguise. The reasons for the experience of bliss may be related to the neurotransmitters such as the Anandines, or our endorphins and/or others still unidentified. The Eastern explanation is that the different yogas allow experience of the natural quality of soul itself, (bliss, eternity and knowledge) normally obscured by our pre occupation with the contents of consciousness. Our educational system devotes years of learning to the memory of facts and skills yet consciousness itself is barely acknowledged. Again, this leads me to welcome the idea of connection without memory or desire. Possibly, many of the philosophical complexities and contradictions we find in trying to explain consciousness, may be due to fact that we are using our minds and reason, only a subtle materially based function, to interrogate the non-material nature of spirit or soul?
Possibly it is worth while taking inspiration from ancient scientists of consciousness in expanding our understanding, not through empirical or rational means, but service and meditation. The title of a fairly simple exposition of the epistemological nature of service can be easily inferred from the title, “Service as a Way of Knowing.” It should be evident, upon a little reflection, that the way in which we are taught to use our consciousness, especially the ways in which our activities which will become habits and character, affect that consciousness. I gather that it is the cumulative effect of everyday activities that have profound consequences on personality as a whole. Sleep architecture requires regulation and protection to function effectively. There are profound differences on personality and life experiences for a person who stays up late and wakes up late into the day, versus the early riser in terms of time management, the types of people more likely met and , in turn, other rhythms, like eating and sleep and dreaming, The food which we intimately interact, from prior to its preparation in the farms and all the questions raised there, in terms of our naive trust in safety in a system answerable to profit, to the attitude with which it is prepared, for whom and with whom the consumption take place, all have subtle effects on our consciousness, which attract gravity with repetition.
The types of food eaten, interestingly classified in the Veda in personal terms as chewing, sucking, licking food, within the great framework of the three modes (gunas) of material nature. Simplistically, blood or flesh-corpses I’m afraid to say, precisely to be provocative, in defiance of our euphemistic use of pork for pig and beef for cows, are classed as food in mode of ignorance. Spicy or hot food is in the mode of passion. Is Speciesism still a ‘lunatic- fringe’ term? Does it violate a universal ethic of mercy and non-violence that will have consequences, especially in our age of conspicuous consumption? At one time, the cow was sacrificed only rarely and with great reverence, as standing for a human life. How has the practise degenerated into social prestige alone? Schwartz (2001) eloquently debates the questions from the Jewish perspective of kashrut, citing scripture, including unequivocal statements from the very first few verses of Genesis! That which we allow through the gateways of our bodies will eventually define the limits of our consciousness. At a point, we can lose choice or use the capacity to and control our bodies and free our consciousness from dominance from our bodies. The spiritual laws are not ends in themselves, but a means toward spiritual liberation.
Closely linked to addictions, or more correctly, in DSM terminology, is Substance Use Disorder, both in terms of levels of controversy, as well as possible” co-morbidities”, such as Oppositional Defiant Disorder. A term that in itself begs many more questions is the diagnosis of Attention Deficit Disorder. It provides a useful example of the extremely disparate approaches taken by patients and families and various health care practitioners, (dieticians, nutritionists, occupational therapists, neurologists, psychologists and psychiatrists). I remain convinced of psycho-social primacy in its creation. Cortical asymmetry, right brain dominance or failure of the left brain to control the right brain, as well as developmental delay in the prefrontal cortex associated with impulse control and planning are brain structures supposedly involved. Like any muscle, why would they mature if not used? The writer reminds the reader of the concept of neuroplasticity. The prevailing psychiatric view now seems to be that it is a lifelong problem, requiring treatment usually using a stimulant such as methylphenidate, or, interestingly in many cases, even responding to some of the SSRI’s, which in itself should give some hint that our understanding of what pharmacological systems are involved and how, remains unknown, or at least that supposedly discrete categorical diagnoses exist or manifest on a continuum.
At one extreme we find arguments such as those proposed by Keirsey(n.d.) that no such disorder exists, that the child usually shows perfect attention when it is in an activity they enjoy, and that subjecting children to mind disabling narcotics verges on the criminal. Clearly ADD has a lot to do with a capacity for delay of gratification, perseverance and procrastination. All of these are behaviours that can be modified with clear consequences and the acceptance of the aspect of life called maintenance or regulated activity according to a routine that is inherent to any aspect of life. It suggests an over-reliance on external pleasant stimuli, rather than a capacity to find happiness in inner mastery. Keirsey takes a radical “abuse it or lose it” stance. He also implicates a poor educational system. The problem is more complex than academic or work stimulation and achievement, but involves the capacity for delay of gratification through the use of symbolisation , specifically language, to process emotions without acting out. It involves what Freud had in mind in contrasting primary versus secondary process. The child’s attitude is to act “because I feel like it”. The adult learns to accept that action often must be motivated by duty and principles. The point, however, is to show the child that rather than simple conformity to often arbitrary rules, this capacity can be liberating from enslavement to transient feelings, impulses and stimuli. The problem does seem to be multifactorial including parental consistency, self esteem and fear of failure, acceptance of limits and habits such as regulated sleep in accord with natural diurnal rhythms.
We have no doubt all encountered children literally bouncing off the walls, who cannot listen for long enough to hear one meaningful statement from the therapist. In such cases, short term carefully monitored drug therapy may be useful to give the child a preview of their ability, if only they were capable of listening. And the therapist may use the ‘window’ as an opportunity to be heard, and arrange for a carefully monitored therapy involving teachers, parents and the child and using the medication to create the therapeutic window and then gradually taper medication as parents and child learn to develop the capacity for self- inhibition. We witness these growing capacities in normal child development when initially one hears a child explicitly say “no mustn’t touch’ when engaging in a ‘forbidden’ behaviour. Later we infer that the explicit external and implicit verbal capacities develop our capacities to navigate our way through the seas of emotions and drives and emotions and winds of perception and external stimuli. Listening is not a modality much emphasised in today’s action, visually- dominated society. It takes surrender, patience, inner serenity, humility, and curiosity, which in itself requires a tolerance for not knowing, which the envious and arrogant may find difficult. And given the abuses of authority, in an age of hypocrisy, where we are all cynically unsurprised at corruption at every level and words have become trivial, which is not without profound consequences. Similar dynamics exist in therapy-Patients can go no further than we do ourselves. However, time-limited use of medication, provided that skills and feelings are dealt with using the window created through minimal effective medication seems justifiable provided the host of techniques and strategies, all readily available to the concerned educator and parent, are implemented in addition to the conventional psychotherapy.
The efficacy of Ritalin could be explained in many ways besides a neurological one, the first being that as a stimulant, we should recall that its initial use was as an antidepressant. Unlike stimulants like cocaine, it has a long half- life, so it does not result in the dramatic crash associated with drugs of greater addictive potential. In keeping with the theme of this paper, however, abuse is only marginally a property of a substance, the propensity to abuse being a very human one. It may well be the case that the stimulant effect is sufficient to enable a child to pay attention in the context of to poorly motivated teachers teaching mind numbing facts. To be fair, teachers are often competing with high intensity visual games which no human can match without flashing and emitting electronic vibrations. An internet search reflected just how dominated by the medical model and medication the literature is. At a fundamental level, I do not believe that simply passively taking the drug will result in the complex and profound developments of a capacity to delay gratification, and many implicit confrontations, such as the daily routine’s inevitability, being associated with conscious awareness of the ephemeral nature of life and our activities, of a lack of specialness, and ultimately, mortality. However, there is material, for example, positing an understanding of ADHD as related to depression, and reflecting the use of manic defences mobilised by the child against the depression. (Seitler, 2008) In my experience, and despite my admission of the limited usefulness of a stimulant in gaining initial access to the child, I regret to say my overall sense is that ADD represents one of the clear examples of blatant “disease mongering” (Shankar, P. Surbish, P., (2007 p.275). The concept of ADD as a manic defence is convincingly argued and substantiated in terms of response to treatment by Seitler (2008) , but needs also to be considered in the light of Bion’s(1962) seminal work on thinking as a means to tolerate frustration and symbolise lack, such that the actual situation or reality can be modified. Overall the present writer suggests understanding ADD in terms indicating disturbance in the synthetic, organising, and integrating effects of the ego. These are linked to difficulties in affect and narcissistic regulation, as well as self- and object representations. (Sugarman, 2006, 237-41) Unfortunately, it is also likely that the body-mind split, and may help ameliorate parental guilt regarding aetiological factors in many cases and substitutes hours of personal investment with a convenient pill.
Considerations Regarding Mind and Body
Several recent papers finally seem to espouse a close approximation to the Vaishnava view of qualified dualism. In fact, the capacity to tolerate paradox and not reduce one category to the other would seem to be the most evocative and exciting of approaches. Mind and Body coexist yet it is impossible to reduce or see both with equal clarity simultaneously. Imagine for example how and why the visual perception phenomenon in which both two faces and a white vase can be perceived, although not simultaneously.
Fina (2011, p1) reflects that the body is “a psychic object par excellence”, or a psychic object. This means the subject’s unity is recognized. Psychoanalysis was born from the phenomena of hysteria, patients who for various reasons are unable to transform perceptive and emotional experience into emotional meaningfulness. Ultimately, therapy requires us to transmute our experience into the symbolic register of language, and to communicate to another. Russo (2011, p.1) notes the many uses of body imagery used to qualify psychic experiences. “ I see what you mean, gut feelings, a taste for life, feeling touched deeply, heart wrenching experiences, a taste for blood or destruction”-are but a few that come to mind.
Both Jung and Winnicott (1949) emphasized the psyche- soma unity. Sensation gives us information about what appears real to our senses, and thought enables us to understand its meaning and make connections and deepen the understanding of its meaning. Our bodies inevitably modulate conscious experience. The stream of somatic sensations and bodily sensations are turned into images that allow us to think and communicate our experience. It is precisely at this point that psychotherapy may intervene. A patient regularly had feelings of panic during sessions which she described as “feeling universey” (her idiosyncratic expression of her sense of depersonalisation and derealisation) during our work; we established that if I moved to sit close to her, the feeling subsided. I am again reminded of Bowlby’s (1952) seminal observations on separation phenomena. The work of this therapy then was to help her transform a feeling of being “universey”, into a meaningful realisation that she was experiencing profound separation anxiety and to begin to integrate her needs for closeness into her life, as well as to realise her abandonment as a child.
Russo (2011,p2) cites Jung (1962) as saying “just as the material of the body that is ready for life has need of the psyche in order to be capable of life, so the psyche presupposes the living body in order that its images may live.” She goes on to say that the traditional separation between them corresponds to different ways of looking at the same phenomenon. Quoting Jung (1926) again, Russo (2011, p2) [...] ”the two factors, psychic and organic present a peculiar contemporaneity. They happen at the same time and place, and are two different aspects, only because according to our mind, but not to reality. We see them as separate because of our inability to think of them simultaneously.”
Solms and Turnball (2002) have resorted to referring to the psychoanalytic-neuroscience debate as dual- aspect monism.” They mean, according to Russo, that the distinction between mind-body is legitimate simply because it is impossible to escape. It is, however, only a perceptual artefact, only depending on one’s point of view, appearing physical when viewed from outside as object, appearing mental when viewed from the inside as subject.
(Winnicott, 1958) He suggests that development of mind is a false quality. In fact, “the mind does not exist in the individual scheme provided the psyche-soma has been dealt with satisfactorily through the very early developmental stages.” (p.244). Assuming that health implies a continuity of being, initially requiring a perfect environment i.e. one that actively adapts to the needs of the infant, compared to a bad environment defined as one which by failure to adapt becomes an impingement to which the infant must react. The infants developing understanding allows the good enough mother to be released from providing a perfect environment. Ordinarily the good enough mother tries not to introduce complications beyond those which the infant can understand. The mind is rooted in the need for a perfect environment. Extreme erratic behaviour by the mother produces an over-activity of mental functioning to take over and organise caring for the psyche- soma, which in health the mind does not need to usurp. With lesser care the mind becomes a thing in itself, practically replacing the mother. Often an over-compliant adapted self may look after others perfectly for short periods, but ultimately break down in search of a mindless dependent psyche-soma.
Why the localisation of mind in the head, asks Winnicott, replying that he does not know, except to conjecture that the need to localise it as an enemy for control. The continuity of being is disrupted by excessive disruptions, to which the only possible response is cataloguing. Another function which the brain uses to cope with environmental impingements is memorising. Winnicott speculates as to the widespread trend toward localisation of cerebral functioning in the head, where even surgeons are persuaded to perform operations, meaning the brain is equated with the mind, felt by the ill person to be the enemy. In the first aim the intervention is successful; the patient is relieved of brain activity. Although referring to leucotomies, I suggest similarities exist with ongoing medication. Because as Winnicott (1958) continues, the patient still needs the full functioning of the brain tissue in order to be able to have psyche-soma existence, which surgery makes impossible, and I would suggest, medication seriously impedes. He concludes that there is no localisation of a mind-self, and there is no such thing that can be called mind. (Winnicott, 1958, p254)
Integration of Paradigms: Introducing a Spiritual Dimension
This author, recognizing the essential nature of our underlying beliefs as determining our perceptions and philosophical rationale, is inclined to assert a dualism, which requires acknowledging a spiritual dimension. From this perspective, dichotomies are inherent in material reality such as hot-cold, old young, rich-poor, dark-light. Even if one does not subscribe to a spiritual belief, as I assume is the case with Solms, there is at least recognition that there is a need for a differentiation. Hopefully, however, we can continue to explore the contradictions that arise from this debate. Some may be artefacts of our culture and language itself. Already in linguistics, the diacritical theory of meaning has shown convincingly that the connection between signifier and signified is arbitrary, and that the meaning of any word depends on all the words which it is not. But this is another debate.
Bion’s concept of “faith in O” seems to be his way of expressing a notion of the divine or spiritual and or transcendent, a capacity to make a personal connection to a non-random beautiful ultimate reality without the pre-conceptions associated with these usual words. Modern physics has for decades been more comfortably making explicit references Vedic literature. It is explicitly forbidden to attempt to meddle in or convert another person’s faith and I humbly submit that my presentation of these views is in no way proselytizing, but is hopefully, shared as a rich perspective that can enrich one’s existing faith or even specific non-theistic world view. Buddhism appeared as a way for atheists to engage in a spiritual discourse.
According to Easwaran (1985, pp1-45), the view expressed in the Bhagavad Gita is that our perception of separate things outside of ourselves is a product of our senses. The world is a sea of energy; mind a river of impressions, thoughts, desires and moods, together constituting a flux of fields of forces. The specific techniques loosely called yoga usually involve mental, bodily or behavioural routines or practises which allow one to withdraw consciousness from mind and body, allowing observation from the point of having entered a state of singularity from which the sense of separate ego disappears. In observing the so-called outside world, we are actually observing our own mental and sensory structures. Looking at unity, the diversity which we see is true of the percept of experience, not of ultimate reality. The mind is considered one of the working senses, since it directs the others, such as speech, hands, feet, reproductive and excretory functions, and one of the knowledge-gathering senses because it depends on the eyes and sight, hearing, touch taste and smell. The brain is considered a conglomeration of one the five gross organs and the motor- action organs. The mind, called sankalpatmaka, means the act of choosing and deciding, sifting through the data received via the senses, accepting or rejecting what it gathers. The parallel between this conception and the mind operating in accord with a psychoanalytic pleasure-pain principle is evocative. The mind is one of four functions of the inner self, known as citta-contaminated consciousness, ahankara-(false) ego, the identification of self with the body and its actions, and buddhi-intelligence. (Puri, n.d. p178). The Sankhya system posits five great elements, air, earth, water, fire, and ether, which evolve into the five sense objects; odour, flavour, sight, touch and sound. These then are followed by corresponding senses of knowledge; smell, taste, vision, feeling, and hearing and five working senses; speech, hands, feet, excretory and reproductive organs. Added to all these is time, kala, which literally means to impel, to set the entire process in motion and creating cause and effect. Easwaran suggests that the use of seemingly antiquated terms such as earth, air, fire, water and space are made up as we perceive them in the mind. They are principles of perception. In the act of knowing, the mind conditions that which is known. There is a causal connection between what we see and the eye and related nervous system, meaning that the objects we see are conditioned by the way that we see. Sense and sense objects make sense only together.
Easwaran (1985) explains that Vedic philosophy and key texts posit that our contact with sense objects results in the temporary experiences of dualities such as, for example, hot and cold, pleasure and pain. The practise of detachment is recommended in order to avoid being enslaved to likes and dislikes. Thoughts are considered to be packets of energy which become more solid and manifest in desires, habits and then ways of living with physical consequences. Praktri refers to the field of forces, which under the influence of time become differentiated into three basic states of primordial energy.
The system of the three gunas, or the three modes of nature, is specifically expounded in chapter 14 of the Bhagavad Gita. (1984) Easwaran(1985, p29-35) suggests that a way of understanding the phenomena of the three gunas is to think of them in terms of their three states of water, with tamas being akin to frozen energy. Rajas is like flowing water associated with activity, whereas sattva is likened to steam channelled into a constructive equilibrium. Each state can be converted into the others and the human personality tends to be dominated by one of the states although they always exist in a complex mixture. Personality may be described as a field of forces, and simplistically one could describe the rajasic person as full of energy, the tamasic person being sluggish, indifferent and lazy, whereas the sattwic person is ideally calm and resourceful harnessing energy in an organised and regulated way resulting in awareness and knowledge. A person dominated by tamas may need to become more rajasic or active and even the Sattvic person may become attached to following the rules without regard for their real purpose, although generally a Sattvic state is recommended not as an end in itself, but one from which it is easier to detach from material entanglement and begin an explicit effort to attain self-realisation. The author believes that the triadic system has the advantage of moving beyond the dichotomous ‘good-evil’ categorisation of human activities and personality.
The Veda teaches that the human’s dharma-our quintessential purpose or final cause is service. The realisation requires practices in service and renunciation of attachment, as attachment ultimately gives rise to frustration and anger. Renunciation does not mean living in a state of deprivation, but rather learning to be free of attachment especially to the results of our actions. Activity is inevitable for the living being, but non- attachment to results ultimately offers true freedom. The impersonal Buddhists would aim for moksha or liberation in a state of merger or loss of individuality, whereas Vaisnavas, for example, see liberation in surrender to eternal loving service to the divine, which implies attainment of the ultimate goal attainable in one’s lifetime depending on the degree to which one realises opportunities for bhakti or loving devotional service. I have tried to explore the possibilities of applying the three modes to psychological problems, and an ongoing project is to identify various ways of augmenting specific gunas or relating them to psychoanalytic activities and concepts. Every aspect of material activity and elements are classified in terms that are accessible to observation and modification, such as time of sleep and waking, or types of foods eaten, which in itself evokes major change in personal disposition and facilitates certain psychological states, whereas others, both following the authority of the great Vedic scholars and pundits, as well as logic and reason, would seem to hinder others. There are numerous dimensions to each of the gunas, which apply to foods, colours, modes of speech, time of day, preferences for creative, destructive or maintenance type activities and many other variables. Returning to Bion’s ideal for the analyst to strive for a state beyond desire or memory, the parallel to a meditative state is clear.
The material universe undergoes transformations caused by the effect of three modes of nature- Sattwa or purity, knowledge, maintenance, preservation, regulated activity, Rajas or activity, production, creativity, passion, and lastly Tamas- ` ignorance, indolence, inactivity, destructiveness. Different occupations such as a psychologist, or merchant or trader, a soldier, a builder require different combinations and dominances of the three modes. The self is not the material mind, it is the soul which is the spark of conscious spiritual energy which is self-illuminating. The mind merely reflects this illuminating consciousness.
In conclusion, this writer proposes that we explore the profound notion that consciousness is the substratum of reality (Sridhar, B.R. 1989).
Many modern thinkers are examining consciousness going far beyond Hegel and Berkeley’s idealism, including perspectives from physics, linguistics, anthropology through to neurochemistry and psychology, to name but a few. For a taste of this complex but tantalising oeuvres, the reader is referred to the website for the Journal of Consciousness Studies listed amongst the references below.
We have become almost blasé with regard to the discovery that the act of observation affects that which is observed in the sub-atomic realm of quantum physics. Contemplating the ramifications of this idea leads to startling questions regarding the mystery of consciousness awareness.
Forman (1999) argues convincingly that consciousness or the sense of ‘I’ equals awareness. He proposes that meditative states allow access to phenomenological descriptions of pure consciousness, unadulterated by the usual instrumental consciousness necessary for functioning in the material world. This involves controlling and acquiring objects in the material world, simultaneously entangling awareness with material objects. Deikman (2000) also proposes a distinction between instrumental and receptive consciousness. Receptive consciousness can only be revealed through the attainment of a state of surrender, service and meditation. Accounts of the meditative receptive state, or what Forman (1999) describes as pure consciousness events all reveal awareness of a non-localised special field, marked by a profound sense of interconnectedness.
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