‘Sin your way to heaven and get slaughtered: A byzantine general problem of the self’ (part twenty-four)
The
basic phenomenology of RojciewiczJr. and Rojciewicz and those similar found in
psychiatry are questioned by Lisa Blackman in her book ‘Hearing Voices’.
Considering it a ‘problem of hallucination’ she argues this view of
hallucination, whilst an interesting phenomenology, is framed in a particular
way by modern psychiatry, structured as it is through a combination of
biological and psychological explanations and interventions. She begins her
critique by exploring how the meaning of hallucination “has been created
through the kinds of concepts and explanatory structures, which are embedded
within psychiatric theorising and experimentation… [and which] claim to be
based on an understanding of normal and abnormal biological and psychological
functioning.” (p.15).
Blackman looks at some of this positioning within the discourse as follows:
“within psychiatric discourse some of the broadest assumptions are made about
what is natural) i.e. can be located within neurology for example), and what is
social. Psychiatric discourse, despite its commitment to examining the social
as well as the biological, is preoccupied with causality. This causality is
ultimately rounded within materialist explanations, which seek to locate the
exact neurophysiological mechanisms, which produce the possibility of the
hallucinatory experience.” (p.18). Blackman notes that despite the focus on the
biophysical aspect to psychiatry there is no unified explanation within this
context, she notes a shift from a focus on dopamine to brain lipids (the book
was published in 2001), circuit malfunctions, deficiencies in glutamate. She
also notes that as well as the focus on neurology and genomics there also
focuses on the social aspects of psychiatric experience e.g. the role of race
and ethnicity with regards both outcomes and misdiagnosis. There is an
epistemological shift within parts of the discourse towards the symptoms being
put in the context of the lives of the patients, this is associated with a
concern with treatment-resistant symptoms, where there is a sense the patients
should be listened to more. This has been associated with the rise in
techniques such as CBT. All these aspects Blackman locates in what she calls
the ‘problem of hallucination’. This ‘problem’ is in fact two problems: the
first (that we are dealing with here) is how to differentiate between
‘pseudo-hallucinations’ and hallucinations; the second the problem of non-compliance
and treatment-resistant symptoms (the governance of which is dealt with in the
rest of this series of blog posts).
Blackman goes on to ask, what it means to hallucinate. Blackman reads
psychiatry as treating voice-hearing as usually pathological. She argues that
psychiatry sees “this pathology [as] articulated as both an internal pathology
(paying attention to those mechanisms and deficits producing the possibility of
such an experience), and a social pathology. The voice hearer is viewed as
having, or potentially losing contact with, the social world, and simultaneously
losing certain capacities of social existence, such as the ability to function
in work and social relationships. The voices are viewed as a sign that
individuals can no longer self-regulate and control their behaviour, and are at
the mercy of the voices’ demands and wishes.” (p.19).
Blackman points out that “it is not enough then, to say that somebody is
hearing voices for their experience to necessarily be pronounced as a sign of
illness and disease.” (p.20). In a vein similar to Rosciewicz Jr. and
Rosciewicz’s typology Blackman also looks at the range of concepts and
explanatory structures that psychiatry uses to distinguish ‘real’
hallucinations from ‘pseudo’ ones. These include “vividness, duration, location
and control.” (p.20). Blackman takes each example one by one. The concept of
source is “articulated in relation to the location of the voices and whether
the person attributes them to an internal or external source. Are they perceived
as coming from inside or outside his/her head?” does the person locate them within
an object such as a television, or are they viewed as coming from the person’s
own head? However, Blackman argues that within the literature it is not so conceptually
clear cut “despite the inside/outside distinction, there are also seen to be voices
which are attributed to the person’s own psychological processes, and not
located in external sources. The distinction made is that these voices are ‘different’
from a person’s so-called normal thought processes. They operate in an
authorial mode of address, running a continual commentary on the person’s own
behaviour and conduct; insulting, judging, commanding or directly addressing.
Most of the literature focuses upon the disembodying feeling generated by this
constant retort, where a person is seen to lose the capacity to attend to
outside experience.” (p,21). She continues “this ‘inner-directed’ focus,
produced by third-person commentary, does not allow the inside/outside
distinction to be the only means of differentiating the ‘real’ from the ‘pseudo’
experience. (p.21).
The criterion of vividness “focuses on the vividness of the experience, and the
extent to which the intensity of the voice or image allows the person to
distinguish between self-generated images or thoughts, and those objects
external to him/herself.” (p.22). As an example, daydreaming, may indeed be vivid
but it is still deemed to be within the ‘normal’ bounds of experience because
the person can distinguish between the inside and outside. “It is not so much
the vividness of the voices or imagery therefore, but to the extent to which
individuals can recognise their self-generated nature. Vividness cannot
therefore stand alone as an index of disease… the important discriminating
principle therefore, is whether the person has an insight into their pathological
nature, and can judge and control them (i.e. not act upon them).” (p.22)
“Control is a discursive concept used to make the distinction between the
normal (‘pseudo’), and the pathological (‘real’) hallucination. It is an
explanatory structure, which organises the dispersal of other concepts, which
link together with this assemblage of elements. There may be a whole myriad of
vivid imaginings or sensory misperceptions which a paerson may engage in,
illusions, vivid imagery, creative thought and so forth but those signalling
pathology relate to the degrees of control a person has over these imaginings.
Hallucinations (proper), are not random occurrences, related to specific times
or situations, such as day-dreaming or sleep, but systematised, all-powerful,
all-pervading ‘events’ which engulf a person’s cognitive capacities. They are
viewed as overwhelming individuals’ normal psychological propensities, leaving
them unable to control themselves.” (p.22-23).
“How then,” Blackman asks “is the concept of control articulated and made intelligible?
Control is to be taken as a measure of social and work functioning, where the
focus is upon specifying how well a person is seen to be functioning within the
external milieu.” (p.23). The DSM III R for example distinguishes between the
normal and pathological based on whether there is a reduction in work or social
functioning. “Control is therefore not measured in relation to vividness, but
with a person’s relation to the external world. It is a measure of behaviour
and conduct, and not a measure of the quality of a person’s own internal
reverie. Within this division, ‘pseudo-hallucinations’ are those which do not
interfere with the person’s daily functioning. In other words, the person
appears to maintain an element of control over them.” (p.23). So, the time of occurrence
is another factor such as falling asleep or waking up, in which case hypnagogic
or hypnopompic hallucinations would be pseudo hallucinations, they are merely
viewed as “the twilight state between dreaming and consciousness, when we are still
living in both worlds; the mundane and the fantastical.” (p.23).
Lastly, “duration is combined and articulated with the other concepts already
discussed, and reduces the complexity of explanations forming the object,
hallucinations, into a differentiation, based upon the length of time the
hallucination has endured within the person’s psyche. Pseudo-hallucinations are
transitory, fleeting occurrences, which do not affect a person’s general level
of social functioning. Hallucinations are viewed as more permanent and impermeable
aspects existence forcing individuals to lose contact with their external
surroundings.” (p.23). The Manchester Scale, the Positive and Negative Syndrome
Scale are both psychometric scales that measure duration as an aspect of
pathology. Thus, the concept of ‘duration’ ties together the various other concepts
in order to distinguish between the pathological and normal. Blackman argues that devices such as
psychometric testing are examples of what Latour calls ‘inscription devices’,
in attempting to make these concepts calculable, measurable and classifiable
(often through a process of commensuration) they become ways in which “the
prior assumptions and presuppositions of this explanatory structure are
rendered into a form which produces those very properties as amenable to
investigation. The object of study, in this case, duration, forms a perceptual
system whereby persons are viewed as embodying the very properties that the
prior assumptions embodied by the tests, presuppose. This way of approaching
the ‘psychology of individuals’ is one which assumes that in order to understand
human subjectivity, one needs to turn inwards, beyond the envelope of the skin.
These processes ae then viewed as amenable to investigation through devices,
which abstract the individual from their social environment, and attempt to
measure some characteristic, which has been privileged by the investigator as a
measure of psychological functioning. These ‘manipulable, coded, materialised,
mathematised, two-dimensional traces’ (Rose), can then be combined with other
traces, to render intelligible the gamut of human subjectivity… However, we can
see within this example, that these devices are always made in conjunction with
measures about social functioning which exist beyond the immediate
investigative context. Even when the hallucinations are present almost
continuously, the ultimate differential factor is how the person reacts to the voices
i.e whether the person judges them to be ‘real’ or not. These judgments, as we
have already seen, are made in relation to work and social functioning. In the
end, despite the conceptual armoury, which attempts to tie the gaps and
contradictions in ‘psy’ explanations together into a coherent set of
explanations, the ultimate measure of hallucinatory experience is made in relation
to social norms of conduct and functioning. Even though psychiatry… is a
biological discipline, it is not enough to dismiss it along those lines. It is
how a conception of the biological is combined with the social, and the
psychological, in order to create the meaning and consequent treatment of
experiences possible.” (p.24-25).
Blackman goes on to note that there have been changes in the conception of
schizophrenia, and looks at the problems with this type of psychiatry. I will
continue to explore this before looking at a conception of ‘voice-hearing’
experience elucidated by Marius Romme and Sandra Escher (Blackman refers to the
Hearing Voices Network in her book), before returning to Rociewicz’s version of
Merleau-Ponty’s ‘intentional arc’ behind their phenomenological typology of
hallucination (having looked at alternative conceptions), to then ask the
question of how this ‘intentional arc’ becomes slackened, which will take us to
another survey of Bateson and Laing.