Handbook of epistemology/The therapeutic virtues of autonomy
Psychic disorders are disorders of the emotions and the executive system that manifest themselves by abnormal behaviors that cause pain.
The executive system is the system that makes the will exist, that is, the system that makes it possible to make voluntary decisions and enforce them. In this book, it is explained with a model of a centralized administration without a central administrator.
The emotional system brings together all the subsystems that make us capable of having emotions.
Sensory or motor dysfunction does not necessarily affect the emotional and executive systems. In this case, the disorder is neurological but is not psychic, as defined here.
The emotional and executive systems work together. The good functioning of one is necessary for the good functioning of the other, because the executive system is used for the regulation of the emotions, and because the emotions are used for the decision making. This is why the psychic disorders are always at the same time disorders of the emotions and the will.
To understand the malfunctions we must of course understand the functions. From a theoretical point of view, psychopathology is therefore based on an understanding of the functioning of the executive and the emotional systems.
The concept of abnormality can be interpreted in the biological or sociological sense:
In the biological sense, behavior is abnormal when it is contrary to the satisfaction of basic needs. In the sociological sense, behavior is abnormal when it is contrary to social expectations, when it deviates from commonly accepted norms. Abnormal behaviors in the biological sense always cause pain and always manifest a psychic disorder. On the other hand, abnormal behaviors in the sociological sense do not always cause pain. Deviance does not necessarily make you unhappy. It manifests a psychic disorder only if it causes pain.
Most psychic disorders are manifested by behaviors inappropriate to their social environment, therefore deviant. It must be emphasized that most of the time these deviances are not voluntary. The individual would like to be normal, like everyone else, and suffers from not getting there. When deviance is voluntary and the individual suffers, we are in the presence of a self-destructive personality. When a voluntary deviance hurts others, it is an antisocial personality. This last case is extremely minor in the field of psychopathology. Most patients are people who are suffering and can not help it, not criminals.
The criteria of suffering and social abnormality can be questioned. If someone spends his time talking with the angels and if he finds happiness with them, without disturbing anyone, there is no suffering, but we are still tempted to talk about mental disorder. The importance of the criterion of suffering is not theoretical but especially practical. Psychiatry does not have the function of imposing social norms, otherwise it becomes an instrument of repression. Its vocation is to heal the suffering, not to make suffer. When deviant behaviors do not hurt, a psychiatrist does not have to intervene, he must tolerate them, like everyone else, and may even sometimes rejoice.
Even behaviors that respect social norms are sometimes morbid. There are barbaric customs, collective folly, social diseases. Here again the importance of the criterion of social abnormality is not theoretical but above all practical. A psychiatrist must first and foremost treat people who are suffering. Treating a sick society does not fall directly under his jurisdiction.
Defining psychic disorders as disorders of emotions and executive functions, we adopt an approach centered on the individual, which is sometimes criticized, with reason, as an error of perspective, because the individual disorders are generally part of a social environment itself troubled. For example, it is possible for individuals to be able to live in a completely normal way as long as they remain separated, and to adopt maladaptive behaviors as soon as they are together. In such cases, the disorder is collective before being individual. But here again it is about disorders of emotions and the will, limited to a particular social environment. A systemic approach, which takes into account the fabric of social relations in which individuals are inserted, is not excluded by the present definition of psychic disorders, because even the collective disorders of collective are manifested by individual dysfunctions.
To heal oneself
As far as possible, therapies should require the active participation of the patient. The patient is asked to use his intelligence and will to care for his will and emotional system. It may seem hopeless. If the will has become dysfunctional, how could it work to repair itself? In fact, in severe cases, when patients are on their own, they are often unable, even with the best of intentions, to cure their own disorders, and if they try anyway, the consequences are sometimes disastrous. Solitary self-medication is not recommended unless the disorders are mild.
When an individual suffers from psychic disorders, his executive system is both a damaged organ that needs to be repaired, a cause of aggravation of the disorders and the main instrument of healing.
When the executive system is damaged, it loses, partially or completely, the ability to protect itself. This is why mental disorders have an unfortunate tendency to worsen. From this point of view, they are similar to immune deficiencies. When the immune system is damaged, the individual becomes prey to all the pathogens present in his environment. In the same way, the psychic disorders make the individual very vulnerable to all the psychic aggressions which he undergoes, because he has lost his capacity to protect himself. And this can be even worse, when behaviors become self-destructive. The individual becomes a danger to himself, even a torturer, by turning his will against himself.
It may seem very unreasonable to ask the patient to be his own doctor, as if asked to put his fate in the hands of a madman. But if it is well understood, this request is a necessary condition for a real cure. The will is naturally self-protective and self-healing. In general, life is not a long calm river, or it does not stay very long. It takes willingness to support and overcome the hardships it puts on us. Psychic disorders appear precisely when the will is no longer capable of exercising this self-healing function. To recover one's health one must restore one's ability to support and overcome the trials of life. Asking the patient to be his own doctor is not unreasonable because it is simply asking him to use his natural faculties.
The troubles may be so serious that such a request is quite futile. But fortunately this is not the general case. Most often, the will has retained a certain capacity to act on itself, to protect itself and to heal itself. It often needs to be advised and helped to carry out its self-healing process.
Even in cases where a drug treatment is sufficient for healing, where the patient seems to be purely passive, his active participation is part of healing, even if it has not been solicited. The drugs relieve the patient from some of his suffering and help him regain some control of himself. He finds the ability to make good use of his will and thus heals himself.
Criticism as a means of healing
To exercise one's will normally requires a minimum of lucidity about oneself and about one's living conditions. It also requires a minimum of ethical knowledge to make good decisions. These two forms of knowledge are generally disturbed by psychic disorders. The individual misunderstands what he has become and what he should do. Cognitive therapy aims to restore a minimum of lucidity. One does not ask the patient to know everything about himself, or to become an expert psychiatrist of his own troubles. He is only asked to use his natural powers of self-knowledge to adapt to the difficulties of his life and the consequences of a painful past. He simply has to know enough about himself to make good decisions.
False consciousness can prevent the will from playing its self-protective and self-healing role, because it prevents one from adapting to the denied inner reality. False consciousness is therefore usually a cause of aggravation of mental disorders. A cognitive therapy requires that one uses one's will to renounce the illusions which maintain the troubles, but for that it is necessary to start by identifying them, which is not easy, since one holds oneself to one's illusions precisely because one does not want to know.
Illusions are like false theories, or false models of reality. They are maladaptive beliefs that prevent us from adapting. The method to recognize their falsity is universal. As with any scientific activity, we must confront our beliefs to reality in order to gather evidence of their truth or their falsity, so we must be critical and self-critical. One must be like a scientist who gathers the best evidence to overcome prejudices or other obstacles to the progress of knowledge. One learns to know oneself, and thus to master oneself, in the same way that one learns the sciences, by activating one's critical mind. Inviting the patient to use his reason, to confront his beliefs with reality, to discuss them in a critical internal debate in order to recognize illusions and replace them with appropriate beliefs, is one of the main intervention used by cognitive therapies (Beck 1975). By helping to recognize good knowledge, knowledge about knowledge can give patients more critical strength to get rid of their illusions and thus heal their psychic disorders.
The work of awareness, of renouncing the illusions of false consciousness, is in general not enough by itself to cure suffering. The first effect of lucidity is often rather to intensify the suffering, because in general we take refuge in false consciousness to escape what hurts us. A work of conscience can be dangerous. It is not enough to face a reality that makes us suffer and that we have denied so far, we must above all be aware of the means that allow us to overcome this suffering and to find a minimum of inner balance.
Not only do we need lucid awareness, we also need healing experiences to heal. When one suffers from mental disorders, there are usually problems both on the side of the superego and on the side of the id, especially the emotional systems. The superego is unsuited to the external and internal reality and our emotional reactions make us suffer. To heal, one must correct the superego to adapt it to reality and thus make a work of lucidity, but one must also tame the id, to suppress or reduce the excessive or maladaptive suffering it inflicts on us.
When one is sick, one needs happy experiences to appease oneself and heal oneself, but one has just lost by falling sick the capacity to give oneself happy experiences, partially or totally. Critical work can help to reconcile with one's experience and find some happiness. The critical mind invites to see in any experience, happy or unhappy, a source of enrichment. Even a horrible past, a disgusting present, or an anguishing future is a rich empirical material for exercising and strengthening consciousness. We need experiences to confirm our good beliefs, those that help us live well, and to reverse and correct our misguided beliefs. The critical force can help us to reconcile even with misfortune, because it is sometimes a path of lucidity, and thus to better live the experience of the disease. Accepting one's illness is one of the first conditions for healing.
When the self is divided, every aspect of the personality feels threatened by others who deny its values and beliefs. Like anything alive, a natural reaction is to protect and defend oneself against this aggression. And since we often mistakenly believe that attack is the best defense, an aspect of the personality that feels threatened becomes aggressive and turns against its aggressors.
An aggressive superego, full of hatred and contempt for anything that does not obey it, is a factor that aggravates internal conflicts. The hated or despised parts of the self seek revenge for this aggression of the superego. And they can take revenge even if they can not appropriate the resources of consciousness and will. The ego then resembles a repressive state where the deployment of police means only exacerbates social anger.
A divided self sometimes behaves like a wind vane and, depending on circumstances, allows one or another aspect of personality to dominate and appropriate the resources of the conscious will. The ego then looks like a state where many governments succeed and strive to destroy what others are trying to build.
Live and let live is not only a principle of social life, it is also a principle of inner life. As much as possible we must seek a kind of peaceful coexistence between our various inner aspirations, so that each can develop without harming others, and we need a superego that allows this inner diversity to live, not that represses it unnecessarily. « Forgive us our doing wrong as we forgive others » is a principle of psychic therapy. We have to give ourselves a superego similar to a benevolent authority that encourages inner peace.
Thought is naturally intolerant. When we set principles, we deny everything that contradicts them. But reason is not reduced to that kind of understanding, rigid and fixed to its principles. It welcomes all points of view, all theories, all hypotheses. If one wants to develop one's thought and thus contribute to reason, one must set principles and stick to them in one's reasoning to develop a theory. If we did not do it, there would be no theory and therefore no reason. But we are not obliged to study a single theory, as rigid understanding might make us believe it, and we easily grasp that we enrich our knowledge by welcoming a great diversity of theories, which often contradict each others. Such diversity is not necessarily a threat to inner unity, because we can listen to it and feel that it deserves to be said and heard without necessarily always approving it. We can even welcome thoughts and opinions that we reprove without despising or hating them because they deserve to be expressed. This inner tolerance is rather likely to reinforce the authority of the superego, because it does not exhaust itself to fight against its adversaries.
Tolerance inevitably has limits, since we have to protect ourselves against those who threaten it. But even when some forms of inner repression are necessary, it is better to remain benevolent with oneself. An iron hand in a velvet glove. One can repress longings or desires without necessarily despising or hating them, and without hating oneself. Self-hatred only aggravates internal conflicts. An ego which exercises benevolent and tolerant authority over itself is like an ideal state where the police always come to impose respect for the law by the persuasion of reason, without being armed and without using violence.
Inner reactions are reactions to inner events. We react to external conditions and internal conditions. Our emotions, our beliefs, our desires and our decisions can make us react and awaken new emotions, new beliefs, new desires or push us to make a new decision.
Inner reactions are much more important than immediate reactions to external conditions, because our behavior depends on the sequence of all our reactions, immediate and inner. Without changing our immediate reactions we can completely change the way we react, simply by modifying our inner reactions.
A panic attack results from a maladaptive inner reaction. One begins to feel an intense anguish, more intense than the anguish to which one is accustomed, and one reacts believing that it announces an impending death, that one will suffocate or that the heart will stop. The inner reaction to the anguish amplifies it excessively and causes panic. We are very surprised finally when we realize that we do not die. It is very painful but it does not kill, just wait until it passes.
A panic attack can be likened to a society invaded by superstitious fears confirmed by the state, which announces an imminent catastrophe instead of declaring that collective anxiety is unfounded.
To have an improper or criminal thought and to believe that one will go mad, or despised and hated by all, or thundered on the spot, or criminal, are common examples of maladaptive inner reactions. Improper or criminal thoughts are usually not so dangerous. They are an embarrassment because they reveal disturbing truths, but they are not incompatible with a balanced psychic life, provided they are judged properly.
Maladaptive inner reactions, when they are really too maladaptive, cause mental disorders. Even a simple phobia is not just a maladaptive response to an anxiety-provoking external situation. When one is phobic, one is not only afraid of the anxiety-provoking situation, one is especially afraid of one's fear, afraid of the anxiety that the anxiety-provoking situation will awake and reveal. One avoids the anxiety-provoking situation to escape one's anxiety. To cure oneself of a phobia, one must begin by becoming familiar with one's fear, one must learn to be less afraid of one's fear, one must welcome it and accept it in order to tame it, and reduce it to a level where it does not prevent any more from living normally.
All violent inner reactions against oneself are forms of self-hatred. One may be disgusted, enraged, distressed or anxious by one's own reactions. These are obviously maladaptive inner reactions. We would like to be another but we can not. We must adapt to the one we are because we have no other that could replace it.
By giving oneself a benevolent, tolerant and soothing superego, one gives oneself voluntary reactions adapted to oneself and one can thus partially correct the hatred of oneself. We renounce our hateful voluntary reactions and replace them with benevolent reactions that impose a good authority without violence. Most of our inner reactions are not voluntary, self-hatred is not only in the superego, it is also in the id, but as the conscious will naturally has a great inner power, provided it is lucid, even our hateful involuntary reactions can be appeased and disciplined. A painful id can be tamed.
Biographical and autobiographical truth
A patient has a split brain when the connections between the two hemispheres have been cut off, to cure his epilepsy. Each hemisphere is then partly independent of the other. One of the hemispheres, often on the left, is the place where speech is produced, real speech or only thought. Each hemisphere only sees half the field of view. In an experiment with a split-brain patient, a chicken claw was shown to his left hemisphere and a snow scene to his right hemisphere (Gazzaniga 1998, p.24-25). The exercise was to choose another image related to the first one. The patient chose a chicken with his right hand and a shovel with his left hand (each hemisphere controls the hand on the opposite side). When asked why he had chosen the shovel, his left hemisphere responded that it could be used to clean the hen house. He inevitably invented this explanation, since he did not know that the right hemisphere saw the snow scene.
This experiment with a split-brain patient blatantly shows the tendency of the brain to make up stories, but this trend is very general. We always invent a lot of explanations for everything we observe, outside and inside, while we are very often superstitious or blinded by illusions. Identifying the causes of an event and stating laws that are true at least most of the time is a difficult exercise, and we get lost most of the time. Must we conclude that autobiography is always a fiction? that the self is an illusion that makes up stories to give itself the illusion that it is more than an illusion?
The life of an individual is always infinitely complex. No account as precise as it could be can gather all the facts that build a destiny. It is out of the question to know everything about oneself, or to know everything about another one. To tell the story of a life, we have to select events that we think are meaningful. Many very different stories can be about the same life, even if they always bear on proven facts.
The story of a life is not just a succession of events. We also want explanations. We want to understand the sequence of causes and effects. But like all complex systems, human lives do not always lend themselves to causal explanations. The causes of a particular effect are often too numerous, too complex, or too difficult to observe to be known. Most of the time we do not know enough to give satisfactory causal explanations.
The story of a life always depends on an evaluation system. The significant events, the aims pursued, the means implemented, the qualities revealed are always presented in an ethical framework particular to the narrator. The same events can be interpreted as successes, or failures, or insignificant facts, or serious mistakes, depending on the value system used to interpret them.
All the preceding arguments suggest that it would be wrong to speak of biographical or autobiographical truth, that there would be only fictions, but it is a senseless conclusion.
We often have illusions, but not always. Our observations can be very accurate, very precise and very true, as soon as the conditions are right for them to be so. One deceives oneself inadvertently, by weakness of the will or lack of critical mind. But if we use properly our natural powers of concentration, firmness of will and reflection, we are often very capable of observing the truth and distinguishing it from illusions or lies.
No story can tell the complete truth about a destiny. This does not prove that all stories are false, only that they can never say more than a part of the truth.
We can never tell the story of a life in the manner of physicists, who can sometimes explain a movement by identifying all its causes and predicting all their consequences, but it would be wrong to conclude that we must give up causal explanations when talking about human life. All of our voluntary skills, without exception, rely on our ability to identify causes and effects, or conditions and consequences. Without causal predictions, we could never find ways to achieve our goals, so we could not do anything voluntarily. We want causal explanations because they increase our ability to act and control our destinies. Causal explanations are not to be rejected from biographies or autobiographies, because they are an essential element, which reveals the mastery, or lack thereof, of the protagonist on his or her life.
Life and mind do not put all the particular ethical possibilities on an equal footing. To live well and to develop one's mind well, one needs a good ethical knowledge that invites us to respect life and develop spirit. Nature as a whole invites us to cooperate with all that lives. And to be fulfilled like a spirit, we have to live to make the spirit live. That is why nothing that is human is foreign to us (Terence). The story of a life always involves values that speak to us, even if it is part of a culture very different from ours. Ethical diversity does not prevent the recognition of universal values.
The therapeutic virtues of narration
We do not just live our lives, we spend a lot of time telling them, to ourselves in thought, or to others by word and writing. We comment, we interpret, we explain, we evaluate, everything we live.
Narration is often inseparable from experience. What we feel and what we do depend on how we think about it (Angus & Greenberg 2011).
Narration is not only retrospective. It affirms or denies abilities and values. The will builds and projects itself into the future by commenting on its decisions (White & Epston 1990). One can write one's future by telling it to oneself.
All the thoughts we give ourselves to explain and justify what we do manifest the autonomy of the will. It affirms what it commits to and evaluates itself from its commitments. By telling stories, we can use our will to strengthen it. But we can also annihilate it, pushing ourselves to despair.
If we believe that nothing deserves to be done then life becomes senseless. To give meaning to the life we live and tell ourselves, we must believe that what we are doing makes sense, otherwise it only remains to wait for death, bearing that everything is vanity and nonsense. Life loses its meaning if we do not want to give it some.
Narration is the greatest power given by the autonomy of the will. By telling stories about our lives we decide what we do with them.
If we tell ourselves false stories to give us a good conscience, to flatter our vanity or to flee the very real problems that we should face, we obviously do not give ourselves the means to develop in an intelligent and adapted way. To face reality and respect the truth are necessary conditions for the proper use of autonomy.
Respect for the truth is not submission to fate, because the future is not written in advance (Cf. Quantum theory of multiple destinies). What is done can not be undone, but the past can be passed. When we tell our life, we have to respect past truths, but they do not determine the future, we are free to interpret them as we want, to write and live the rest of the story.
The good news is that there is good news, that our word can be a good word. When our word says that it can be a good word, it is already a good word. But of course this is just the beginning of the good news. It proves that it is truly good news when it keeps its promise, that it is good news, that is, when it bears fruit. To say that the word can be good, intelligent, wise and that it can make us better by sharing its wisdom with us is a good and wise word. But in the beginning the proof is not complete, we have to live the continuation. When one believes that speech can be a good word, one immediately gives oneself the means to prove it, because one seeks the good word, a word that one could never find if one did not seek it. But a life is not too much to prove that one is not mistaken when one believes that the good word is worth being sought.