The Schizo-Stroller

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.