Robert M. Young Online Writings
THE CONCEPTUAL FOUNDATIONS OF THE HUMAN SCIENCES
by
I wish I knew why each and every one of you is here. Perhaps you wish you knew.* Access to motivations — especially deep motivations — is hard to get. In my view psychoanalysis is the only theory which even begins to give us access to such explanations. And yet psychoanalysis is under greater fire than ever before for all sorts of reasons. It is said to be methodologically disreputable and to fail various tests which reputable sciences pass. It is said to be tainted because of things discovered (or thought to be discovered) about the character, the veracity, the evidence offered by its founder and some subsequent major figures in the history of psychoanalysis (Masson, 1984; Grünbaum, 1984; Crews, 1995; Webster, 1995; Erwin, 1996; Forrester, 1997; Lear, 1998). Not only is psychoanalysis per se said to be tainted, but the whole of the human sciences, including the helping professions, lie at or near the bottom of the pecking order of methodological and conceptual respectability of academic and clinical disciplines.
I have been asked this year, as I was last, to strike a keynote at the end of the residential week of the distance learning masters programmes offered by the Centre for Psychotherapeutic Studies. Last year I reflected on the ‘constituency of the rejected’, a phrase which her brother used in his funeral oration about Princes Diana, who had died shortly before my lecture (Young, 1997). This year, when one has to admit that our high hopes at that time have only been vindicated to a very modest degree, I want to cast my net more widely to think about the basis of what we do. I could give a very short answer: the basis of what we do is a mixture of curiosity and compassion and the need to earn a living: self-knowledge, altruism and self-interest. But I am after bigger game. I want to see if I can sketch some helpful ways of accounting for our work in the broad framework of ideas which give legitimacy to academic and clinical endeavours.
I toyed for a time with the idea of trying to develop my argument around a current event, as I did last year, but when I opened my Sunday papers I discovered, somewhat to my relief, that my voyeurism had reached its limit, and I did not want to read the Starr Report and trawl it for a way of thinking about our work. There is no doubt that it is psychoanalytically interesting, that those involved are — at least psychologically — disabled and that the interrelations between psychiatry, philosophy and society are more than amply instanced by the events involving President Clinton, Miss Welensky, Mr Starr and the others caught up in the labyrinthine events and motivations, not least the aphrodisia of power and of the groupie, as well as the projective denials of the fundamentalist witch-hunter: ‘I’m not dirty; he is’. We also see large and bewildering examples of the splits in people’s minds, e.g., between statesmanship vis a vis Ireland and Russia, on the one hand, and the pure naughtiness of giving and getting a blow job while the world’s most important leader talks to congressional colleagues on the phone. It is said that Brezhnev began every day with a blow job from a new maiden and that Chairman Mao had a new young woman brought to him daily for sex. Ceaucescu preferred to pick his own from the population of Romania. Kennedy kept two secretaries — dubbed Bambi and Thumper, I believe — for the purpose of lunchtime nude swims in the White House pool. Extreme power and polymorphous perversity are often found together. This, after all, was the basis of Freud’s account of pre-civilised life, before the primal horde stopped the patriarch from having his sexual way with anyone in any way at any time. We are told that the incest taboo is the first and most important law and that it is the basis of all others: curb your appetites for the sake of the group, with guilt as the main inhibiting force. Divert the energies which have been repressed in this way and let them out in sublimated forms as creativity, play, sport, altruism and constructive work (Freud, 1912-13, 1930).
You may think I have decided to make my talk centre on Clinton, after all, but I will stop here, except to dwell on two features of the tantalising sample I have given. First, the labyrinth which I have sketched above is very complex, indeed, especially once you add on the roles of politics and moralism (not to mention morality) on the part of all concerned, in particularly, the Congress, many of whose members must be hypocrites in the realm of sexual fidelity. While we are reflecting on the conceptual foundations of the human sciences, I just want to note in passing that the high standards of methodology claimed for the respectable sciences mean that they could not even put a toe into the water toward immersing themselves in trying to explain the breadth and depth and sheer complexity of any historical event and especially one where the private and the public aspects of people are so intimately intertwined.
The second feature I want to dwell on is a couple of words I used in what I said a moment ago: I spoke about guilt as the main inhibiting ’force’, and I spoke about diverting ’energies’. I was, of course, speaking loosely, but the use of such terms in talking about humans and what they do is profoundly noteworthy. In the revolution of thought which gave us modern science, certain forms of explanation were privileged above others. Scientific explanations were to be based on matter, motion and number. Every effort was to be made to reduce other phenomena to these parameters. A scientific explanation should be a mechanical explanation, and the goal was to reduce complex phenomena to these simple explanatory terms (Whitehead, 1925; Burtt, 1932; Young, 1979, 1989, 1996, ch. 1). This is why natural science has the pecking order it does. The more mathematical a discipline, the more trusted it is, The more an explanation is in terms of material particles, the more scientific it is thought to be. The pecking order from the most respectable to us goes something like mathematics, fundamental particle physics, the rest of physics, physical chemistry, chemistry, biochemistry, molecular biology, physiology, evolutionary biology, animal behaviour, human behaviour... then what? I cannot go on, since mechanical explanations and reductionism let us down at this point, and — unless we are militant materialists — we go into another realm. The scientific revolution did not only leave us with a set of rules for achieving respectable explanations. It left us with no help at all in explaining the inner world. Some versions of modern science simply deny that there is an inner world, while the other main one divides the world into material substances and thinking substances, i.e., minds and bodies (Young, 1990).
The trouble is, and it is at the basis of the philosophical defensiveness of the human sciences, that modern science gave us no language for talking about mind. Indeed René Descartes, in what many consider to be the founding document of modern philosophy, A Discourse on Method (1637), wrote that mind is whatever does not pertain to matter. He defined it negatively, giving it no conceptual language of its own. When we try to think scientifically about mind we find ourselves borrowing vocabularies from other sciences, including especially those listed above. ’Force’ and ’energy’ are borrowed from physics, as is ’structure’, which also features in anatomy and physiology. ’Structure’ is paired with ’function’ in the biological sciences and both are used metaphorically to refer to mental structures and functions. The most elaborate attempt to systematize psychoanalytic theory sets out its points of view and assumptions in terms of mental structures, forces, energies, development, and so on (Rapaport and Gill, 1959; Rapaport, 1959). I have to say that when I read it as a medical student I was impressed. Now I think of it as scientism, the illegitimate extrapolation of scientific concepts into domains where they do not strictly and literally apply.
If you reflect at all carefully about the conceptual vocabulary of the human sciences, you will find them shot through with analogies. Even the concept of ’the association of ideas’ in psychology and psychoanalysis was based on the billiard-ball physics of Isaac Newton, which John Locke turned into the foundation-stone for psychology, on the basis of which grew up the associationist tradition which has been the main one in modern psychology, including psychoanalysis (Young, 1968, 1970, pp. 94-100 and ch. 5; Rapaport, 1974). But we also use terms drawn from chemistry, especially ’element’, ’compound’ and ’reaction’. We speak of structures and functions in societies, and the reigning tradition in the human sciences from the end of the nineteenth century to very recently was derived from terms used in the study of organisms. The tradition is called functionalism, and it is based on the analogy between society and an organism (Young, 1981, 1990a). I am not speaking loosely. The founders of this way of thinking drew explicitly from the organ-function view of the brain to the idea of a social organism, which its main exponent, Herbert Spencer, concluded was more than an analogy (Spencer, 1860). In the present we use concepts drawn from information theory and computing to supply the timeliest analogies for mind: feedback, system, modularity and so on.
I draw your attention to this fundamental feature of the human sciences — the use of analogies for lack of a language of its own — in order to try to make you more self-conscious about the terms and concepts we use. Part of the cachet of such terms is that they bring with them a spurious authority, as if we were really operating in the realm of natural science rather than mentalistic analogies. You could, of course, build a hierarchy of explanations along these lines and make it seem that it was all very respectable I tried it once, going from the clinical to the fundamental:
A patient is a dysfunctional person in a role.
A person is an organism.
Organisms are analysed in terms of functions.
Functions are the dynamics of structures and are about properties.
Properties are interpreted in terms of certain
(secondary) qualities (colours, odours, tastes, temperature) which are caused by primary qualities (shape, hardness) (Young, 1989, p. 397).
You could make more elaborate versions of this explanatory sequence, slipping in anatomy, biochemistry and physiology. You could go further up the scale to families, groups, societies, cultures. You could refine the hierarchy from particles to atoms to molecules to biochemical reactions to structures to functions to organs to organisms and so on. You could make it very tight, exhaustive, elegant, respectable.
But, of course, this is not how real people think about themselves, one another and the social and natural worlds. When we use the analogies drawn from natural science we are actually speaking ordinary language, not science, and when we speak about ourselves and others, we are telling stories, narratives of the kind we employ in conversation, letters, Starr Reports, fiction, fairy tales, films and so on. This way of speaking is not — usually intentionally not — striving for scientificity. It may strive for truth or, on occasion, deception, but it is not failed science. It’s something else. People sometimes try to give fancy names to what else it is , e.g., verstehen, hermeneutics, interpretation. Some try to make language and its structure provide the scientificity of the human world, making it more real, more basic that emotions and their vicissitudes.
When I was a graduate student in the History and Philosophy of Science in the early 1960s, models and analogies from physics were the prevalent model for good and trustworthy knowledge. Disciplines which could meet (or appear to meet) the methodological criteria of physics were considered to be objective. Those which could not were sometimes called — with a dismissive implication — emotive and were also sometimes called nonsense. Science was sense; all else was nonsense. There was a parallel orthodoxy in the human sciences, especially anthropology and sociology which advocated carefully recorded ethnography coupled with interpretation in terms of the functioning of social structures as they contributed to the stability of the social whole, considered organismically.
Nowadays there is a different version of science held up as the standard which all explanations should met: Darwinian Psychology. There is, of course a warrant for this claim. Humanity and all our works evolved over a long time from lower organisms, putatively solely by means of the mechanism of natural selection — competition for mates and having the greatest number of fertile offspring. There are those, and they are very articulate and forceful in their claims, who seek to base all of psychology on selectionist explanations. To explain a given behaviour you must explain how it is derived from or at least not inconsistent with natural selection. The boldest claimant for the explanatory potential of evolution by natural selection claims that it explains everything, that it is, in Daniel Dennett’s words, ‘a universal solvent’ (Dennett, 1995, p. 521) .
Needless to say, the more militant Darwinian psychologists leave no room for the kinds of explanations psychodynamic psychologists, and especially psychoanalysts, make. One of them, Frank Sulloway, wrote a book in which he tried to represent Freud as a ‘biologist of the mind’ (Sulloway, 1979; critique: Young, 1986), leaving aside Freud’s writings on the Oedipus complex, unconscious mechanisms, group psychology, culture and civiization. He went on, in a recent elaborate study, to argue that sibling birth order is the most important determinate of a persons intellectual and political styles (Sulloway, 1996).
Nevertheless, a way has to be found to relate intrapsychic theories such as psychoanalysis to Darwinian theory, since Darwinism indubitably forms a, and perhaps the, foundation stone of the human sciences. Indeed, Darwin’s theory of evolution by natural selection is the most important idea in the history of science, perhaps in the history of thought, as far as the histories of science and of thought centre of the place of humankind in the great scheme of things. Indeed, Darwin’s theory came to replace the deep and pervasive theory which held everything — the cosmos — together from ancient times to the mid-nineteenth century, ’The Great Chain of Being’, with its principles of plenitude, continuity and unilinear gradation (Lovejoy, 1936), beautifully evoked in Epistle II of Alexander Pope’s ’Essay on Man’ (1733), where we find humanity placed as the middle link in the chain:
Know then thyself, presume not God to scan;
The proper study of mankind is Man.
Plac’d on this isthmus of a middle state,
A being darkly wise, and rudely great:
With too much knowledge for the Sceptic side,
With too much weakness for the Stoic’s pride,
He hangs between; in doubt to act or rest;
In doubt to deem himself a God, or Beast;
In doubt his Mind or Body to prefer;
Born but to die, and reas’ning but to err;
Alike in ignorance, his reason such,
Whether he thinks too little, or too much:
Chaos of Thought and Passion, all confused;
Still by himself abused, or disabused;
Created half to rise, and half to fall;
Great lord of all things, yet a prey to all;
Sole judge of Truth, in endless Error hurled:
The glory, jest and riddle of the world!
(Pope, 1733, Epistle II, pp. 125-26)
Treating this question of significance somewhat more narrowly, it is said that there have been a number of blows to human arrogance. The concept of the solar system dethroned the Earth from being regarded as the centre of the universe. Darwinism showed that humanity is not the specially created pinnacle of creation. Marxism showed that what humans do is fundamentally conditioned by economic and ideological forces. Freud showed that we do not even have access to the greater part of our motivations, which are unconscious. These explanations mitigate our conception of the human species and our planet as central in the universe and our humanity as characterised by rational intentionality and conscious control over our actions (Young, 1988).
If we look at Darwin’s theory as one of the great ideas in the history of science, we can characterise it in two ways. Evolution ranks with gravity, the central concept in physics, and affinity, the key idea in chemistry, as one of the most basic concepts in the natural sciences. Beyond that, however, evolution by natural selection is an all-embracing theory in two senses. It is the law which binds all of life together and defines its relations to the physical environment. And, of course, it binds humanity to the rest of life and nature. Evolution by natural selection is the process which accounts for the history of living nature, including human nature.
All of the above is arguably common knowledge. However, there is a huge problem which is left unresolved by evolution. If we take evolution to be an all-embracing explanation of living, including human, phenomena, then it includes human psychology, society and culture within the causal nexus of deterministic scientific laws. If this is so, what is the basis for morality? Put another way, how should we think of the role of values and morality in human nature? At its most stark, as I said, evolution by natural selection proceeds by competition for resources for mates to achieve viable offspring which live to reproduce. How can this conception of the interrelations between creatures be subtle enough to include processes which transcend competition — altruism, charity, generosity, including what T. R. Malthus (Darwin’s inspiration for natural selection; see Young, 1998, on which I have drawn for this portion of my talk) called ’moral restraint’? How can it explain the diversity of customs and mores in different cultures? Providing such explanations is, I take it, part of the project of the new Darwinian sciences, in particular Darwinian Psychology. The answers they tend to provide often strike me as less useful than the ones we can gain from more traditional ones employing human purposes, consciously conceived and/or discerned in unconscious motivations which do not rely, in the unmediated way those psychologists claim, on selfish genes and competition for mates.
It seems to me to be approaching things the wrong way up to claim that Darwinian explanations provide the most basic accounts for the subtleties and complexities of human relations when literature, philosophy, analytical psychology and other cultural approaches evoke and explore them so well. Perhaps I should say, rather, that it seems wrong-headed to me to offer Darwinian explanations as superior to or as replacements for traditional explorations of such matters in the arts. It may be, of course, that evolution explains humanity and all its works, but we must still find a way of paying due respect to established forms of reflection on human nature and not run headlong into a single explanatory paradigm. One way of putting this is that evolutionary explanations need not all be selectionist ones of the kind found in Darwinian Psychology. Most importantly, we must not use a less subtle and resonant explanation when we have access to a more textured and resonant one which moves us and respects our humanity, whether it illuminate our love or our hate. Sociologists argue for the autonomy of the social; historians for the autonomy of the historical. Each discipline defends its own appropriate level of analysis and explanation. The same should be claimed for the autonomy of the intrapsychic. Psychological explanations have their own legitimacy and appropriateness.
This point becomes an urgent one when science gains access to the mechanisms for altering genetic processes and begins to allow us to reconstruct the genomes and achieve cloning of other species and ourselves. It is too easy to collapse the issues involved and to allow too much authority to scientists in the debates which it is appropriate for us to have about these matters. There is also a common elision which needs to be avoided. It is sometimes thought or implied that since evolution can, in principle, explain everything human, then evolutionists — by which I mean biological scientists — have special insights and authority across all of knowledge. I find this implied in the aggressive stances taken up by some (not all) of the public spokespersons of science. I have in mind, for example, Richard Dawkins (1976) and Louis Wolpert (1992), both of whom strike me as delighting in putting down people whose disciplines they assert are made less important and even a waste of time, e.g., philosophy, history and philosophy of science, cultural studies, the human sciences. There was, as I have said, a similar arrogance associated with positivism in earlier decades. There was science on the one hand and confusion on the other; testable hypotheses and muddle, logic and poetry. A whole series of dichotomies was posited with one side reliable and the other markedly less so:
fact-value
science-ideology
nature-culture
science-arts
primary qualities-secondary qualities
mechanism-purpose
outer-inner
rational-emotional
Sophisticated students of evolutionary psychology are not reductionists. As one wrote in an email message,
The whole thrust of... evolutionary psychology in general, is that psychology forms an autonomous and irreducible level of explanation. However, psychology must have theoretical continuities with biology since human beings did evolve. Hence the theory of evolution by natural selection links psychology to biology, but does not eliminate it, since every concept in psychology cannot possibly be reduced to simpler concepts in biology. Homo sapiens and earlier hominids have lived in social groups for millions of years and, as at least 50% (c. 50,000) of all genes are expressed in the brain (compared with 26 in the red blood cell), it seems reasonable to suspect that natural selection might have operated to produce a cognitive-emotional architecture adapted to social living (Pitchford, 1998).
We are here in deep water. You do not have to be reductionist to be intolerant or to argue that one line of research is more important and more likely to be fruitful than another. Lines of enquiry wax and wane simply by virtue of the resources which get devoted to them. At the moment psychiatry departments are more likely to appoint a professor who works with brain hormones or does drug research or even molecular biology than they are to appoint someone who does research in psychotherapy or care in the community. Psychology departments are more likely to support computer modelling or Darwinian Psychology than personality theory or psychoanalysis. Experimental research on the metabolism of a neurotransmitter such as serotonin is much more likely to be supported than conceptual or clinical research on the unconscious mechanism of projective identification. Psychiatrists are more likely to prescribe Prozac than psychotherapy, especially since there are very few psychotherapists in the National Health Service, and very few psychiatrists have become properly trained in psychotherapy.
I am arguing along two lines. First, I am granting that the hierarchy of explanations legitimately takes us from fundamental particles in physics through a series of explanatory levels right up to humanity and society. One section of this hierarchy is evolutionary biology, the discipline which, at least in principle, can explain humanity and all its works. However, advocates of different levels of explanation and different disciplines have the unfortunate habit of arguing that their explanations are so much more important than others that it is a mistake, a misallocation of conceptual and economic resources, to give much of our research or clinical or intellectual resources to the less strictly scientific and materialist disciplines. There is a broad tendency to go for neural mechanisms over mental ones, for drugs over talking cures, for hormone imbalances over the close analysis of emotions and their vicissitudes.
Why is this so? I believe it is because we are living in times when it is very tempting to seek external answers, to search for truths which are merely truths of the surface, to go for technologies and quick fixes and, as Jonathan Lear puts it in an eloquent defence of psychoanalysis, ’to ignore the complexity, depth and darkness of human life’ (Lear, 1998, p. 27). Lear goes on to say,
It is difficult to make this point without sounding like a Luddite; so let me say explicitly that psycho-pharmacology and neuro-psychiatry have made, and will continue to make, valuable contributions in reducing human suffering. But it is a fantasy to suppose that a chemical or neurological intervention can solve the problems posed in and by human life. That is why it is a mistake to think of psychoanalysis and Prozac as two different means to the same end. The point of psychoanalysis is to help us develop a clearer, yet more flexible and creative, sense of what our ends might be. "How shall we live?" is, for Socrates, the fundamental question of human existence — and the attempt to answer that question is, for him, what makes human life worthwhile. And it is Plato and Shakespeare, Proust, Nietzsche and, most recently, Freud who complicated the issue by insisting that there are deep currents of meaning, often crosscurrents, running through the human soul which can at best be glimpsed through a glass darkly. This, if anything, is the Western tradition: not a specific set of values, but a belief that the human soul is too deep for there to be any easy answer to the question of how to live (Lear, 1998, p. 28).
I want to turn now to the domain of the clinical. It may seem that I am making an abrupt leap, but part of my point in discussing this topic here is that I am not. The clinical is messy, just as real human nature on the hoof is messy. It is the domain where the suffering individual meets up with the practitioner whose expertise, humanity and empathy are, it is hoped, fused to be helpful, supportive and healing without undermining the dignity and personhood of the individual in the patient role. It is a tremendously complex space and a multi-layered relationship, among the most complex in human relations (Young, 1971). I take it that people in Disability Studies, in Psychoanalytic Studies and in Psychiatry, Philosophy and Society all have an interest in the clinical domain. I suspect that those in Psychoanalytic Studies are favourably disposed toward this domain, while those in the other two programmes are deeply suspicions, since medicalisation has had significantly baleful effects for the disabled and for psychiatric patients. Both groups claim, which much justice, that heir humanity has been sacrificed to a process of treating the relations between people as if they were relations between things, i.e., reification. At the heart of this kind of dehumanising process is the classification of human difference as syndromes, the pigeon-holing of individual differences as stereotyped disorders. This process affects both the patient and the carer, especially the hospital nurse.
The classic study of these relationships is Isabel Menzies Lyth’s 'The Functions of Social Systems as a Defence Against Anxiety: A Report on a Study of the Nursing Service of a General Hospital', which, although first published almost forty years ago, still provides the best insight into clinical relationships (Menzies Lyth, 1959; see also Young, 1994, on which I draw in this portion of my talk). Among the problems that led to commissioning the study of nursing was the high dropout rate among trainees and those who completed the training. This amounted to a wastage rate of 30-50% in various hospitals (Menzies Lyth, 1959, p. 61), and those who left were among the most sympathetic nurses. There were also problems in the internal arrangements which threatened a complete breakdown in the system of allocation of practical work (p. 45). The rate is much the same today, as is the malaise in the nursing service. You may have seen or heard discussions about the urgency of this situation in this week’s news.
What she discovered is what we would expect from the work of W. R. Bion (her analyst) and Elliot Jaques (on whose work hers was modelled; both are discussed in Young, 1994): nursing is highly stressful work which evokes primitive anxieties, so that the institution will go to absurd lengths to avoid its staff having to experience them. The trainees are socialised into these arrangements, however bizarre and inhuman they seem, because they unconsciously want a place to hide from psychic pain.
The objective situation confronting the nurse bears a striking resemblance to the phantasy situations that exist in every individual in the deepest and most primitive levels of the mind. The intensity and complexity of the nurse's anxieties are to be attributed primarily to the peculiar capacity of the objective features of her work to stimulate afresh these early situations and their accompanying emotions (pp. 46-7).
She provides a lucid exposition of the parallel between the infant's developmental experiences and their revival in the stressful, existentially life-threatening hospital setting. I shall not attempt to summarise her account but heartily commend it to you.
The accumulated, relentless evocations of infantile anxieties lead members of the organisation to develop 'socially-structured defence mechanisms, which appear as elements in the organisation’s structure, culture and mode of functioning' (p. 30). Menzies Lyth spells out the relationship between the individual and the institution. Individual defences come to match those of the social defence system. If the discrepancy is too great, some breakdown between individual and institution ‘is inevitable' (p. 73), whether it be illness, acting out, becoming a rebel, getting expelled/sacked, leaving. The chances of an individual bringing about reform are slight, and those of a group doing so are remote.
I shall list the defensive techniques she discovered and then add a few examples: splitting up the nurse-patient relationship; depersonalisation, categorisation, and denial of the significance of the individual; detachment and denial of feelings; the attempt to eliminate decisions by ritual task-performance; reducing the weight of responsibility in decision-making by checks and counter-checks; collusive social redistribution of responsibility and irresponsibility; purposeful obscurity in the formal distribution of responsibility; the reduction of the impact of responsibility by delegation to superiors; idealisation and underestimation of personal development possibilities; avoidance of change (pp. 51-63).
Two examples rang painfully true to my own experience. The first falls under the category of 'depersonalization, categorisation, and denial of the significance of the individual’. She writes,
The protection afforded by the task-list system is reinforced by a number of other devices that inhibit the development of a full person-to-person relationship between nurse and patient, with its consequent anxiety. The implicit aim of such devices, which operate both structurally and culturally, may be described as a kind of depersonalisation or elimination of individual distinctiveness in both nurse and patient. For, example, nurses often talk about patients not by name, but by bed numbers or by their disease or a diseased organ: "the liver in bed 10" or "the pneumonia in bed 15". Nurses themselves deprecate this practice, but it persists. Nor should one underestimate the difficulties of remembering the names of, say, thirty patients on a ward, especially the high-turnover wards (p. 52).
The patient is not seen as whole person needing care but a number, an illness, or a damaged part of the body, that is, 'a part-object only, the retreat into part-objects being another feature Bion attributes to basic assumption group phenomena' (Menzies Lyth, 1969, p. 16).
A similar depersonalization occurs for the hospital staff through the use of identical uniforms with a rigid hierarchy of roles and tasks appropriate to various levels of seniority. The nurses become their roles and skills, and are thereby experienced and experience themselves less as individuals: charge nurse, staff, student, aide. Like a soldier or policeman, they are cloaked in their uniforms and positions in society and are thereby more respectable (one of Florence Nightingale's intentions), while both less vulnerable and less accessible. The starch is a powerful barrier; so are the colours of the uniforms and their quasi-military markings. The bizarre hats are part of a code whereby those in the know can locate a nurse's training hospital in the complex culture of the hierarchy of trainings, like a college or club tie or the insignia of a nun's order.
The problem of depersonalization is made even more acute by the fact that shortages — due to the factors here described — lead to increased use of agency nurses who are quite often present on a given ward for a single shift and in an entirely different hospital the next working day. Callousness can also be born of boredom and doing routine tasks with only prostrate bodies for company. If one is sitting alone in a recovery room waiting for a patient to come round from an anaesthetic, conversation with a passing colleague is very welcome and unlikely to take account of the fact that the patient may be taking in what is said as he or she regains consciousness. When I was thirteen, I was wheeled in my bed from my hospital room for a test. On the way back, when the nurses pushing the bed thought I was asleep or unconscious, they were discussing my alarmingly low pulse and respiration rates and speculating that I would not survive another night. Once I realised what was being said, I kept quiet for fear of being caught eavesdropping.
My second example is of underemployment of nurses and getting them to do stupid things. This is the example always cited from Menzies Lyth’s study, because it is so familiar to people who have spent time in hospitals. Hospital routines are 'routinely' followed slavishly to the point that common sense utterly disappears:
Underemployment of this kind stimulates anxiety and guilt, which are particularly acute when underemployment implies failing to use one's own capacities fully in the service of other people in need. Nurses find the limitations of their performance very frustrating. They often experience a painful sense of failure when they have faithfully performed their prescribed tasks, and express guilt and concern about incidents in which they have carried out instructions to the letter but, in so doing, have practised what they consider to be bad nursing. For example, a nurse had been told to give a patient who had been sleeping badly a sleeping draught at a certain time. In the interval he had fallen into a deep natural sleep. Obeying her orders, she woke him up to give him the medicine. Her common sense and judgement told her to leave him asleep and she felt very guilty that she had disturbed him (p. 69).
For both patient and nurse, human idiosyncrasy is reduced to medical classification and mindless routine. The same applies to arriving at the classification, the diagnosis. When I worked in a mental hospital in the 1950s, the longest time we spent with each patient was in the diagnostic interview. Once we had the patient classified, we breathed a sigh of relief and were unlikely ever again to have such a prolonged and intense encounter with them.
Why is this? There are a number of reasons. Classification frees us from the anxieties of contingency, idiosyncrasy, individuality. A diagnosis takes us to a therapy without passing trough a real relationship with the individual. Second, classification, in the sense of a structured model of typing people according to syndromes, gives us the comfort, ersatz though it is, that we are dealing with natural kinds, in the way the classifier, called a taxonomist in biology, finds specimens and reduces them to the known or the newly typed and classified. One of the dimensions of being a field biologist is, as we saw in the film ‘The Collector’ (Terence Stamp), to capture, and pin to a specimen board, to drain it of its individuality, to imprison it as merely an example of a natural kid.
Are syndromes natural kinds? I think not. Medical diagnosis is not like botanical or zoological classification. Syndromes are congeries of symptoms emanating from a set of interrelated somatic causes, hopefully stemming from something which can be demonstrated by a correlation of cellular pathology and causative agents, be they genetic, congenital, infective, invasive, immune, autoimmune, malignant, polluted or degenerative. You can show the physical causes and the physical lesions which produce the dysfunctions. Angina results from blocked coronary arteries. The hyperglycemia of diabetes results from a dearth of insulin. Shortness of breath is caused by damaged alveoli in the lungs. Spasticity is a result of brain damage. Parkinsonism results from lesions in the cerebellum. Cirrhosis of the liver is caused by abuse of alcohol. Septicaemia is caused by overwhelming bacterial infection. And so on.
Of course, there are unclear cases where no causative agent is known and others where the boundary between the psychic and the somatic does not exist. Typical examples are bronchial asthma, rheumatoid arthritis, ulcerative colitis, essential hypertension, peptic ulcer, neurodermatitis, thyrotoxicosis. Some argue that the fear of loss is of disease the cause — all disease. That is, there is a school of thought in psychosomatic medicine whose adherents argue that the precipitating cause of all disease, the factor which moves one from being potentially ill to actually ill, is psychological.
Which takes us to psychiatric diagnoses. The bible for this is, of course, DSM, the Diagnostic and Statistical Manual of Mental Diseases, now in its fourth edition — hence the nickname DSM-IV. I have written about this at length in two units of my module (Young, 1998a, 1998b), so I will sketch here. I asked earlier if a medical diagnosis, a medical syndrome, is a natural kind. The answer, once again, is no. It is something we can usually trace to natural causes and show the natural effects which cause the experienced symptoms. But it is only a kind in the sense that we decide to be interested in it, because it discomfits us. Angina, emphysema, arthritis and so on are just the consequences of natural processes. We focus on them because they make us suffer, something we dignify with the concept of disease.
If that is true of somatic diseases, what are we to say of psychiatric and psychotherapeutic disorders? First, we are right back to that fundamental point that discussion of the inner world occurs by the use of analogies, and the main one here is the analogy between somatic pathology and what has been called since the mid-nineteenth century ’psychopathology’ (Berrios, 1991, 1996). Psychopathology is a metaphor based on an very dubious analogy between the psychic and the somatic. One person who has reflected deeply on the concept of psychopathology wrote that psychopathology is knowledge (logos) of the suffering (pathein) of the psyche. As Levin puts it in a most interesting essay, it is all the ways of hiding, manifesting, communicating, sharing and, in brief, living out the mind’s experience of worldly suffering (Levin, 1987, p. 2).
The history of DSM is most interesting. It is like the history of encyclopaedias. It might be thought that encyclopaedias chronicle the accumulation of knowledge, that they are cumulative. But that would only be a part of the story. Not only does the content of knowledge accumulate, but the frameworks, the terms of reference, the assumptions or paradigms of knowledge change. For example, I am a collector of successive editions of The Encyclopedia Britannica. I am particularly interested in the changes which occurred between the eighth and the ninth editions. The eighth finished being published just before Darwin’s theory of evolution by natural selection was made public, while the ninth was published in the 1870s, after it had become the basis of many disciplines. The whole way of thinking changed. The long article on the Biblical Deluge in the eighth edition disappeared, while new ones on Evolution appeared.
Something similar is true of DSM. In particular, DSM-I and DSM-II were sympathetic to psychodynamic formulations of mental disorders. The man who was asked to take charge of the editorial team of DSM-III said he would do so on the condition that he would have a free hand, and what he would do with that hand was to purge DSM of psychodynamic and psychoanalytic concepts and analyses of disorders (A. Young, 1995, ch. 3, esp. p. 99). All descriptions of diseases were to be about behaviour, not about the inner worlds of patients. It was a palace revolution, a coup. I did not know this, and I had not read DSM-I or DSM-II, but when I read DSM-III, I found myself, quite spontaneously, inclined to mount a critique of its terms of reference. It was only after I had written two chapter of a book on this matter that I happened to read about this revolution and the reconceptualisation of nosology in psychiatry which ensued. Classifications are made by people who are not in touch with pure objectivity. They are individuals with belief systems and seek to make those the reigning ideas.
Early in 1973, Walter Barton, medical director of the American Psychiatric Association, initiated a task force ’to revise DSM-II and prepare DSM-III within the next two years’ (quoted in Shorter, 1997, p. 301 sqq., which I am paraphrasing here). Melvin Sabshin, a Young Turk, then succeeded Barton as medical director. Sabshin realized that if the group who had designed DSM-II were to take on the revision, DSM-III would become just ’a minor variant’ of its predecessor. What was needed was something completely different. In April 1974, Sabshin summoned Spitzer and Theodore Millon, another Young Turk who was a PhD psychologist at the Neuropsychiatric Institute of the University of Illinois Medical Center in Chicago, for an all-day conference. Out of this conference came the leadership team that would drive forward DSM-III, published in 1980.
Spitzer headed the task force. Also serving on it were Clayton and Woodruff from the Guze group (a third of the task force had trained at Washington University); Donald Goodwin at the University of Kansas who had studied with Guze was on it, as was Z. J. (Bish) Lipowski, a specialist in delirium, which is an organic psychiatric condition. There was Donald Klein, a psychopharmacologist and psychiatrist who in 1978 became professor of psychiatry at Columbia, as well as thirteen other members. Just as previous DSM task forces had been weighted in favor of psychoanalysis, this one was weighted against it and toward biological psychiatry, though the members did not use that then inflammatory term. As Spizer later said, ’With its intellectual roots in St. Louis instead of Vienna, and with its intellectual inspiration derived from Kraepelin, not Freud, the task force was viewed from the outset as unsympathetic to the interests of those whose theory and practice derived from the psychoanalytic tradition’ (quoted in Shorter, 1997, pp. 301-2). Of course, if you are a student coming to these matters for the first time, you can easily be led to believe that the terms of reference of DSM-III or the newer DSM-IV are the only natural and appropriate way of writing about psychiatry.
I tell this story, complete with some of the relevant names, to make it clear to you that how we think about human suffering, how we conceptualise and classify it is deeply ideological in the sense that all facts are theory-laden, all theories are value-laden and all values are instanced inside a value system, an ideology or world view. The person who became the tsar of DSM-III was a traditional, objectivist biological psychiatrist, deeply committed to purging psychiatry of intrapsychic concepts. When the opportunity to make his point of view a new orthodoxy arose, he did so quite ruthlessly and systematically. Of course, larger historical forces led to his being invited to be in the role of co-ordinator of this important compendium in the Nixon/Reagan era. Indeed, there was a coalescence between the growth of biological approaches to human nature, on the one hand, and biological psychiatry, on the other, which has been chronicled by Donna Haraway as part of her magisterial book, Primate Visions, which analyses the history of ways of thinking in several of the human sciences and their links with primatology (Haraway, 1989; Young, 1992). The general point being made is that the leading ideas of an epoch are the ideas of its ruling elites, and ideology becomes a material force in theory and practice by virtue of who gets to write the textbooks and manuals and edit the journals which define the norm in a give field.
By the way, the ideological determination of ways of thinking in the human sciences does not always militate toward conservatism. DSM-III was dominated by a biological, objectivist approach at the expense of psychodynamic concepts concerned with the inner world. But there was also a very significant omission. Homosexuality, which featured as a mental disease in DSM-II, vanished and simply did not feature in DSM-III (Shorter, 1997, pp. 303-5). Does this mean that new cases ceased to occur as happened with poliomyelitis? Not at all; it was de-pathologised as a result of the rise of the gay and lesbian movement for the rights of the homosexual. This is a striking example of how social and political forces change our concepts of who is ill and who is just different.
I want to close with that example, but I want to take stock as well. Human nature is certainly part of nature, part of physical nature and part of living nature. But it is other things as well, things which have themselves evolved but which emphasize the evaluative dimension both in its day to day actions and in its conceptions of nature and human nature, including, especially theories of the foundations of the human sciences, whether theoretical, applied or clinical. The evaluative dimension is striking in the human sciences. Other disciplines stress what and how but seek to eschew why questions. Human nature, a much maligned concept, but one which is turning out to be a hardy perennial, able to survive onslaughts from relativists Lacanians and postmodernists, has at its centre values and moral issues. These can best — and finally can only — be plumbed by addressing people’s inner worlds, their hopes, dreams, integrity, sincerity. As we try to understand these levels of our humanity, we make stories, narratives to account for what we do and experience and to help us to manage and as we suffer and as we bear our vicissitudes. The evaluative dimension is inescapable in the human sciences, no matter what we discover about the brain, hormones, neurotransmitters and the evolution of our characteristic ways of acting and expressing our emotions. Values, as embedded in approaches to nature and human nature, also set the parameters of our philosophies of science, of physical and living nature and of ourselves. They determine our world views and set the terms for what counts as an explanation and what we can hope to achieve. It takes me back to the eighteenth-century vision of our task, to the first lines I quoted from Alexander Pope’s ‘Essay on Man’:
Know then thyself, presume not God to scan;
The proper study of mankind is Man.
*This talk was given as the keynote lecture to the residential study week of the MA programmes in Psychoanalytic Studies; Disability Studies; and Psychiatry, Philosophy and Society at the Centre for Psychotherapeutic Studies, Department of Psychiatry, University of Sheffield, 18 September 1998. I would like to acknowledge the help of Ian Pitchford in providing information and clarifying my thoughts.
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