Abstract
The origins of dynamic psychiatry, as is well known, centred on Salpêtrière in Paris at the end of the nineteenth century [1]. The ideas being developed at that time were resonant with a particular mood, or state of Western culture evident in the expressions not only of writers and painters but also figures from all walks of life, including psychologists and scientists. The notion of personal existence, the immediacy of going on being, was a dominant theme. It is shown for example, in the works of impressionist painters. Here is expressed the pleasure of ordinary life [2: p.3]. What is depicted, however, is not merely people lunching, or boating, or going to bars and having picnics but something also of that experience of wellbeing, of the movements of consciousness which are expressed in William James’ term ‘the stream of consciousness’. The rippling, dappled light of Renoir's work shows, as much as the actual subjects, the feeling of life going on.
In philosophy the ideas of Henri Bergson were particularly prominent. He was preoccupied by the notion of personal existence, of the nature of the present moment [3: pp.177,225] and with the idea that our experiences make up a reality which is different to the reality of Newtonian science. Neither zone of reality contradicts or cancels out the other. The statement that the sun sets in the west is true in one reality; that it does not set in the west is true in another. ‘No philosophical doctrine’, he wrote, ‘denies that the same images can enter at the same time into these two distinct systems’ [3: pp.13–14].
Bergson's focus on the nature of personal existence was shared by major figures in the foundation of dynamic psychiatry. The core of William James’ great work of 1890 ‘The Principles of Psychology’ is an examination of the fundamentals of this experience. He corresponded and conversed with Bergson. Both men developed a conception of the human time experience that differed from scientific time. Both men also described two forms of memory. ‘The first records, in the form of memory-images, all the events of our daily life as they occur in time’ [3: p.92]. The second kind of memory involves no such awareness of an event or episode from the past, but only the fact or movement that was learnt at that time [4: pp.648–650].
In psychiatry, the star of Paris was Pierre Janet. He had been to the same school as Bergson and continued his relationship with him into adult life. Janet was working towards a model of mind as the basic background to mental illness. The essential feature of this model was a hierarchy of mental functions. At the highest level was the function of présentification [1: p.376] the creation of the present moment, a concept which resembled Bergson's ‘attention to present life’ [3]; p.226].
Janet's studies of people suffering a disorder then called ‘hysteria’ became a principal basis of a kind of psychiatric practice in which the psychiatrist tries to understand the patient's illness in psychological terms. Jung wrote in 1908, when he was still a strong supporter and ally of Freud: ‘The theoretical presuppositions on which Freud bases his investigations are to be found in the experiments of Pierre Janet’ [5: p.10]. William James considered that Janet's ‘Mental State of Hystericals’ [6] was worth ‘all exact laboratory measures put together’ [7]; p.374].
A devaluation of personal being
The value given to the sense of personal existence, expressed in many different fields, was lost spectacularly and suddenly.
The watershed year was 1913, the year in which Watson announced his behaviourist manifesto, when Freud and Jung exchanged their last letters, and when Henry Ford started his assembly line, in which man functioned as part of a machine [8]. The shift was evident also in artwork and displayed in a large variety of works in which machine-like imagery and a patterning form of expression became dominant motifs [9]. Influential creators of these works based their expressions on the belief that the ordinary world of living, both human and non-human, had to be excluded in order to attain to something which was seen as purer and ‘higher’ [10].
The Western devaluation of that which was essentially human has impacted on both psychology and philosophy. James and Bergson lost influence. This was exemplified in conceptions of memory. The ‘personal’ form of memory which James described and which depended upon events from one's past being ‘viewed’, as it were, in the mind's eye, was no longer considered or discussed. In the new world of positivism and behaviourism memory was only something which could be measured.
Moreover, the notion of self, since it is not directly measurable, was considered to be beyond the pale of respectable scientific inquiry and was banished in what has been called ‘a radical behaviourist purge’ [11: p.226]. The same thing happened in philosophy. In England, the dominant philosophies of Russell, A. J. Ayer, and Ryle prevailed. Their ideology was most clearly expressed by Gilbert Ryle [12] in his Concept of mind, a hugely influential work in which his aim, as he himself admitted, was to deride the notion of an interior life and the metaphor of ‘the mind's eye’.
From this temporal vantage point, the success of Ryle's polemic seems extraordinary. His argument, reduced to its fundamental form, depends on assertion. The principal assertion was that there is no such thing as inner experience since, in his view, those images that are a prominent part of this experience have no correlative physiology of the kind which is produced by external stimuli. ‘The opinion’ that ‘imaging is a piece of near-sentience’ is, he concluded, ‘completely false’ [12: p.251].
Ryle's opinion that this ‘opinion is completely false’ is, of course, itself, false. Even the imaging of the congenitally blind shows activation of the visual cortex [13]. That Ryle was so respectfully received suggests that his viewpoint was consistent with, and mirrored, an age of ideological brutalism, in which the ordinary verities of living could be trampled on and denied [14: p.167].
Although the humanistic approach of James and Bergson was kept alive by the existential philosophers and psychiatrists, viewpoints similar to that of Ryle were paramount. The conception of man as a machine, a system in which the personal world of feelings and imagination is ignored or devalued, was clearly expressed in scientific circles. For example, W. Ross Ashby who, with Norbert Wiener, was the originator of cybernetics, wrote in Design for a brain [15 cited in 16: p.200]: Throughout the book, consciousness and its related subjective elements are not used, for the simple reason that at no point have I found their introduction necessary… Vivid though consciousness may be to its possessor, there is as yet no method known by which he can demonstrate his experience to another.
Psychiatry and psychoanalysis could not resist these cultural influences. In psychoanalysis the change towards mechanism, and the conception of man as a machine, was evident when the world of ‘self’ embodied in the figure of Jung, was cast out into an oblivion in R. MEARES 691 which both he and his ideas were ‘shunned as though they did not exist’ [17].
In the new psychoanalysis, Freud's first model of mind was revised. ‘Ego’ became the dominant theory, particularly in the US. ‘Ego’ began to be talked about as a machine – ‘the psychic apparatus’. Critics recognized that this theory left no room for the self [18: p.149]. The language typically used to describe the mechanism of ego was as labourious and clanking, as removed from ordinary experience, as the contraption itself.
Psychiatry abandoned Janet, who by the 1950s and 1960s had become merely a footnote in many Anglo-American textbooks. His idea of basing psychiatry on a sophisticated model of a hierarchy of mental function was given up. We reverted to a muddled empiricism, of the kind embodied in DSM. The attempt to understand mental illness, to see it as a manifestation of a disruption of dynamism, was largely rejected by mainstream psychiatry. In 1980, the syndrome upon which Janet had developed his postulates was formally jettisoned by DSM and split up into its main constituent parts, as if they were unrelated [19].
A faltering revival
The hegemony of the positivist-behaviourist ideology began to fail around 1970. Ellenberger's great book renewed the reputation of Janet [1]. In 1972, the neuropsychologist, Endel Tulving, brought back into the discipline of psychology the notion of memory which had been described within their different disciplines by James and Bergson. He called it ‘episodic memory’ and distinguished it, as James had done, from another kind of memory system which involves fact and knowledge of the world. This latter memory function does not involve the double experience of an episode from the past which is linked to knowledge of a particular fact, for example the values of coins, the names of birds, and so forth [20].
In psychoanalysis, Winicott's Playing and reality, published in 1971 [21], was covertly and unobtrusively revolutionary. Implicitly, he placed the experience of ‘going on being’ as the central issue that confronts us in our work. In the same year, Heinz Kohut, in the US, overtly declared a revolution with his Analysis of the self [22]. In psychology the notion of self returned quite suddenly and James reappeared. Also quite suddenly, studies of mother–infant interaction began as if somewhere within this interaction the child's ‘self’ was emerging. Coincidentally with these changes was the emergence of a non-linear mathematics of living things, and a new kind of architecture began in which there was an escape from the rigidity of straight lines and box-like structures in favour of the curves and a symmetry of the natural world. Utzon's Sydney Opera House is an example.
This shift in consciousness included a return to some of the basic ideas which had preceded the shift of 1913. However, the new manner of thinking faltered. It seemed that in psychiatry it had very little effect.
It can be suggested that the faltering was a consequence of the success of the totalizing positivistbehaviourist era, which had destroyed an intellectual world by neglect and derision. Kohut, for example, could not define ‘self’ [23: pp.310–311]. There was no intellectual background against which he could work. Such a failure to find a suitable foundation upon which to build the psychology of ‘self’ is clearly a massive impediment to the development of the theory. It is necessary to develop a theory, which has a scientific value, of what might be called ‘personal being’. This is so, not only to develop logically based treatments for personality disorder, upon which Kohut focused, but also to approach the whole range of mental illness. All mental illnesses involve disturbances of ‘personal being’ or ‘self’. This is a complex experience, involving multiple dimensions such as affect state, body feeling, cohesion, continuity, temporality, spatiality, privacy (boundedness), the feeling that it is one's own, and the sense that we control its movements. It seems possible that each form of mental illness is underpinned by disruptions of particular dimensions of ‘personal being’. For example, certain kinds of anxiety states might depend upon a diminished sense of ownership [24], obsessive compulsive disorder may be related to a deficiency in boundedness [25, 26], borderline personality disorder to a failure of integration and the reflective function [19] and eating disorders to a very limited sense of control of inner life [27].
Psychiatric care is concerned with the vicissitudes of our ordinary sense of personal existence, with the variations in the ‘myself’ who appears in the following statement: ‘I was not myself when you saw me last’. If psychiatry is to move forward as a science we must develop a model of this central experience in order to understand the manner of its disruptions. The way in which such a model might be built is illustrated in the work of Hughlings Jackson (1835–1911), the first person to use the word ‘self’ in the medical literature [28: vol. 2, p.96].
The Jacksonian self
Jackson has been called the father of English neurology. A large part of his opus, however, is devoted to the concept of mind and a theory of mental illness. These theories influenced James, who corresponded with Jackson and quoted him in his main work. Jackson also influenced Janet in his attempt to build a hierarchy of mental function. Jackson's ideas anticipate, to a remarkable extent, ideas which are current at this moment.
Jackson's approach was logical and methodical. He saw the study of mental illness as, at bottom, an experimental investigation of mind, or self. Accordingly, the first step must be to identify and define this experience. He conceived it as double, consisting of subject and object, or as he put it, ‘subject consciousness’ symbolized by ‘I’, and ‘object consciousness’. He acknowledged that this distinction is an abstraction, remarking: ‘Each by itself is nothing, [each] is only half itself’ [28: vol. 2, p.93]. In essence, self depends upon the emergence of what he called ‘the introspection of consciousness’ but it is not equivalent to it [28: vol. 2, p.96].
Jackson's concept of a duplex self was echoed by both Janet [6: pp.34–35] and James. James made the necessary experiential elaboration of the concept with his description of ‘the stream of consciousness’. I am taking this experience as implicit in Jackson's model.
The next task was to understand how this experience arises. Jackson argued that it had its basis in a particular kind of brain function. He warned, however, against the confusion of psychical states with brain states. Rather, there is a ‘concomitant parallelism’ between brain and mind [28: vol. 2, pp.42,85].
Jackson's idea about the kind of brain function which underpins the experience of self, was based in evolutionary theory. He considered that the organization of the brain was decreed by evolutionary history. He built his theory about what he understood to be the basic units of CNS function. These are reflexive, the smallest elements of sensory-motor function. Each of these units he considered to be a representing system. In organisms at an early evolutionary stage, these simple representations are relatively uncoordinated. At a later period of evolution, when the brain is larger, rather than new representations being recorded, there is re-representation and greater coordination [28: vol. 2, p.42]. At a higher stage still there is a re-re-representation and a still further and more complex co-ordination. This idea must have seemed exotic, even outlandish, in Jackson's time. In our era, however, his supposition has been confirmed. In the visual cortex, for example, it has been shown that there are multiple representations of the visual field rather than a single neural map [29: p.636].
The appearance of self, Jackson suggested, is a manifestation of the most recent evolutionary changes and so emerges late in human development. The evolution and development of ‘self’ is a reflection of a more complex co-ordination than encountered at early phases of evolution and development. Self, seen in this way, is not a structure, or a series of representations, but a process, as James was to later maintain.
Jackson rejected the idea that mind or self requires a special new form of neural function to be built into the human brain. He wrote: ‘There is no autocratic mind at the top to receive sensations as a sort of raw material, out of which to manufacture ideas, etc. and then to associate these ideas’ [28: vol. 2, p.98]. Nevertheless, self is dependent on the evolution of existing anatomical structures. Jackson suggested that the evolutionary development of the prefrontal cortex is necessary to the emergence of self [28: vol. 2, p.399]. However, this is not to say that self resides in the prefrontal cortex. Rather, the new structure allows a more complex coordination of the fundamental units of the CNS.
Jackson's model is resonant with current work on the development of a neural model of ‘self’ of the kind undertaken by, for example, Damasio [30]. It also anticipates mathematical models of mind based on the emergent mathematics of chaos and complexity.
A testable model
The idea that the brain-mind system is, in essence, a machine is not, in itself, objectionable. The principal objection to the mechanical conceptions of human existence developed during the positivist-behaviourist era is that they exclude fundamental aspects of this experience, and that the conceptions are based not on how the brainmind system works but how a particular machine, such as a computer, operates. Jackson himself, was proposing a machine. He called the brain-mind system ‘a sensorymotor mechanism, a co-ordinating system, from top to bottom’ [28: vol. 2, p.41]. His hypothetical machine however, was built in the opposite way. Instead of working from machine to mind, he argued from mind to machine. He began with personal experience, with what seemed to be the central experience of self. The next step, based on meticulous observation of neurological patients led him to imagine a machine which underpins this form of consciousness. It resembles modern conceptions of a self-organizing system [31: pp.264–285,32].
Jackson's main hypothesis was that assaults on the brain-mind system cause a retreat down the hierarchy of mental function laid down in evolutionary history. He called this process ‘dissolution’. Those functions which appeared last in evolutionary history and emerge late in human development are the most fragile, the most easily overthrown. This hypothesis is testable and provides a means of understanding certain pathological states. Examples include dissociation [32] and borderline personality disorder [19, 32, 33].
Jackson's pioneering model of mind is, of course, limited and preliminary. It lacks, for example, the developmental perspective and the effect of environment. Nevertheless, this perspective is implied. Those functions, which include what Jackson was calling ‘self’, and which appeared last in evolutionary development, are, he pointed out, ‘incomplete’, relative to earlier functions. Maturation must depend upon environmental factors.
The complexity of maturation is evident when we reconsider the implications of the statement: ‘I was not myself when you saw me last’. The speaker here uses three words, ‘I’, ‘me’, and ‘myself’, which point to different aspects of personhood. Do they all emerge together? Since the experience of personal being is unified, the common sense answer is yes. However, the statement itself suggests something different. The speaker implies a certain stability for ‘I’ and ‘me’ but a variability for ‘myself’, a potential fragility. The Jacksonian ‘dissolution’ hypothesis predicts that ‘myself’ develops considerably later than ‘I’ and ‘me’. Developmental studies support this prediction.
The ‘I’, a system of awareness and response, is present in early form at birth [34]. The ‘me’ is evident at about 18 months when the child can point to his or her image in a mirror or photo and say: ‘That's me’ [35, 36]. However, such has been the scientific neglect of the sense of personal being, the self of Jackson and James, that the next major step in this maturation, the appearance of the third term, was not known until quite recently, when it was shown that the development of the concept of ‘inner’ experience is attained at about 4 years [37]. The dating of this milestone is consistent with the findings of Flavell and his colleagues [38], suggesting the child discovers the ‘stream of consciousness’ at 4, 5, or 6 years and also with inferences from so-called ‘theory of mind’ experiments [39–43]. The establishment of this milestone provides the starting point for the construction of a plausible schema for the development of the experience of ‘myself’ [32]. This schema suggests that it arises and is manifest in conversation [32, 44–46], the idea which underpins what Hobson called ‘the Conversational Model’ [44, 47].
This idea offers a means of overcoming, at least to an extent, a major obstacle in the way of treating self as an object of scientific enquiry, which is that ‘self’ cannot be observed. However, the notion that the Jamesian self is manifest linguistically leads to the possibility of its fluctuations being charted by words, used in the natural manner, in conversation. Seen in this way, the structure of language reflects a state of self. Linguistic analyses conducted in our department in association with the linguistics department of Macquarie University, Sydney, are being employed to study the process and progress of therapy in an ongoing program for borderline patients [48, 49]. The analyses used include studies of cohesion [50], of transitivity [51] and of the complexity of the time-space domain [52]. A principal underlying idea is that human conversation is made up of a mingling of two main forms of language, one related to the environment and the other to self [32, 45, 46, 53].
Phenomena to theory
Science moves forward in a way which is represented in the progression from Linnaeus, who classified us and gave us the name of homo sapiens, to Darwin, who proposed a theory of our origins. Both approaches are necessary; one does not supersede the other. Between the two must remain an open pathway, so that between the two systems there is a continuing interplay, as intimated by Schiller [54] in his essay on the main themes of ‘matter’ and ‘form’.
Hughlings Jackson used the methods of both Linnaeus and Darwin in his attempt to develop a theory which provides a basis for understanding certain mental illnesses. He began with a precise observation of phenomena both psychic and neurological. These gave him the ground out of which a theory could grow.
Janet's approach was similar in confronting a condition which other observers had maintained was too protean in its manifestations to bring ‘together under one and the same formula’. He searched for the ‘rigorous laws’ [6: p.484], which underlay and determined these phenomena. In particular, his aim was to go beyond Briquet [55].
Briquet had worked at Salpêtrière in the 1850s. In the manner of an epidemiologist, he simply catalogued all the most salient clinical and biographical details of 430 people given the diagnosis of hysteria at that hospital. Such a method is useful as a ‘starting point’ as Janet acknowledged [6: p.487] but it offers no means of understanding the condition, no theoretical framework to guide the direction of treatment.
It is of interest that Briquet's catalogue became the basis for DSM-III's ‘somatization disorder’ when the word ‘hysteria’ was officially removed from the psychiatric lexicon. This diagnosis was based on a checklist, which failed to include essential features of the syndrome identified by Janet, most notably conversion and personality disorder. Although there have been rectifications in DSM-IV, the diagnosis of ‘somatization disorder’ is emblematic of the deficiencies of DSM.
DSM does not reflect a proper empiricism in the manner of Linnaeus in which phenomena are observed without preconception. Although the tradition of Linnaeus is maintained – a physician, he devised an early psychiatric classification – it is muddied by the interpenetration of various traditions, ideologies and viewpoints. One ideology and tradition which appears to be particularly influential is that which dominated Western thought in the years following 1913, and in which the phenomena of consciousness are devalued. The diagnostic criteria of ‘somatization disorder’, in a manual of mental disorders, include not one mention of psychic life. Janet's careful observations of the disturbed consciousness of his patients, remain disregarded. So also is his view that ‘retraction of the field of consciousness’, characteristic of the condition, is related to a disturbance of cerebral function. No state of consciousness is an isolated phenomenon. It arises as a consequence of the brain's interplay with the sensory environment. The possibility that the unusual life history of pain exhibited by those with so-called ‘somatization disorder’ is related to deficiencies in sensory processing, as demonstrated in a number of studies [56–58], is not contemplated in the DSM-IV narrative concerning diagnostic category 300.81. The approach is firmly behavioural, locked in the mode of thought epitomized in the expressions of Watson and Ryle. It is a diminished form of psychiatric practice, which is based in such limited conceptualizations.
In order to develop a psychiatric practice based on adequate theory, we need to create the data out of which to create such a theory or theories. The phenomena of consciousness which were once the main subject of philosophy and psychiatry, are no longer studied in any systematic way. In order to go beyond our present level of conceptualization and practice in psychiatry, we must employ the modes of thinking exemplified by Jackson, James and Janet, and return the psyche to psychiatry.
Karl Jaspers wrote that: ‘All life reveals itself as a continuous interchange between an inner and an outer world’ [59: p.12]. Out of this interchange arises the third thing, the experience of ‘myself’. Unless psychiatric institutions of teaching and research restore to the experiences of ‘inner’ life the value given to them before the shift in Western consciousness which occurred round 1913, we are in danger of developing and propagating a discipline which is, in a fundamental way, lifeless.
Footnotes
Acknowledgements
This article is a modified version of a chapter which appeared in: Fulford B, Morris K, Sadler J, Stanghellini G (eds) Nature and narrative: an introduction to the new philosophy and psychiatry. Oxford: Oxford University Press, 2003. I thank the editors for permission to publish this version.