Wittgenstein and the Tikanga of psychotherapy.
|Abstract:||The philosophical investigations of Wittgenstein revealed a non-dualistic and more immediate relationship between us and the world (including each other). A relationship not mediated by intellectual knowledge as Descartes had led us to suppose, but one based on active engagement. Wittgenstein's philosophy has been described as therapy for the Western intellect, and has major implications for psychology, therapy, and ecology. It also appears to be much closer to Polynesian epistemology. Shifts in accountability practices for mental health and the professions would allow the considerable benefits of these ways of being to be realised.|
|Publication:||Name: New Zealand Journal of Psychology Publisher: New Zealand Psychological Society Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2011 New Zealand Psychological Society ISSN: 0112-109X|
|Issue:||Date: April, 2011 Source Volume: 40 Source Issue: 2|
'When, after being persuaded by Wittgenstein to read The
Brothers Karamazov, Drury reported that he had found the figure of
Zossima very impressive, Wittgenstein replied: 'Yes, there really
have been people like that, who could see directly into the souls of
other people and advise them.' Ray Monk, The Duty of Genius, p.
'Ko te Maori te tuakana. Ko to pakeha te teina.' The Maori is indeed the elder brother and the Pakeha the younger brother. But the teina has refused to learn from the tuakana. He has sat sullenly among his machines and account books, and wondered why his soul was full of bitter dust ... James K Baxter
Whitaker (2010) has documented evidence that we are in the midst of a mental health epidemic, with a trebling of Americans on government disability in 25 years. Figures obtained from the NZ Ministry of Social Development show a similar trend here, with a doubling in the number of mental health sickness and invalid beneficiaries between 1997 and 2004. Although some blame 'Big Pharma' for the massive increase in diagnostic numbers and 'chronicity', especially amongst children (Applbaum, 2009; Baugham, 2006; Breggin, 2008; Caronna et al., 2008; Healy & Le Noury, 2007; Moncrieff, 2008; Ross, 2008; Stolzer, 2009), psychology has been 'charged' with 'being an accomplice' because of its largely uncritical emulation and support of psychiatry and its 'scientism' (Albee, 1998; Hacker, 2001; Simon, 2007). Hacking (1995) showed that the 'multiple personality disorder' epidemic, which flourished and shrank in the 1990s, was a product of faulty thinking about memory. I shall argue that this epidemic is also a product of confused thinking in the Western intellect, and it has generated an erosion of the social support systems some see as central to mental health recovery (Jablensky & Sartorius, 2008).
Allen Francis, chairman of the DSM IV taskforce, admits his panel "inadvertently contributed to three false 'epidemics'--attention deficit disorder, autism and childhood bipolar disorder" because "our net was cast too wide and captured many 'patients' who might have been far better off never entering the mental health system" (Francis, 2010). Family therapists have long criticised 'medical model' approaches that decontextualise people from their social milieu and internalise their problems. Social constructionists or postmodern writers claim that diagnosing in mental health is a disaster, and we can deliver effective treatments without them (Gergen, et al, 1996; Lock & Strong, 2010). However, many fear postmodern thinking will undermine the status of psychology as a science, and "like anthrax of the intellect, if allowed into mainstream psychology, postmodernism will poison the field" (Locke, 2002, p. 458). I will show that such fear and hostility is unfounded, and the decontextualisation partially driving this epidemic stems from conceptual confusions.
I will do this by sketching the clarity Wittgenstein brought to these confusions, and show forms of rational enquiry that are not modelled on the scientific measurement of natural phenomena, but lead to an understanding of social being that is pragmatic. This entails a shift to placing our ethical response to others ahead of and prior to any ideas we might have about them. In sketching Wittgenstein's later work I shall mention a number of other social constructionist writers, not in any depth, but to suggest that his exposure of our humanity is not isolated. Aware of the criticism that indigenous knowledge has all too frequently been plundered and reconstructed, I merely touch down lightly on some of the resonances I have found between Maoritanga and Wittgenstein on this way of being. A way of being that, I shall argue, if encouraged to flourish, will go some way to stem this mental health epidemic.
One of the central figures of postmodern philosophy or social constructionism, as it has been applied to psychotherapy, is Ludwig Wittgenstein. At first glance, his later philosophy is difficult to present as it is anti-theoretical; it is not presenting a theory of life and the world so much as clearing away a number of intellectual confusions so we can see the world clearly. It's as if someone had painted a picture of the world on a window, and only by scraping the picture off can we see the world as it is. Some have said that it is zen or jnana (intellectual) yoga for the western mind, as many of these intellectual confusions are a consequence of our attempts to 'picture' life (especially over the last 400 years under the banner of science), and are now deeply embedded in our everyday understanding of life. Scientific endeavours can only proceed once these conceptual confusions are clarified (Winch, 1958/1990).
Unlike science, Wittgenstein's philosophy isn't seeking the 'truth' or explanation, but rather exposes an ontology of human nature and our way of understanding each other, that turns out to be quite at odds with the self-centred individualistic subjectivity of Cartesian culture; and, as I will indicate, appears to be much closer to a way of life we find in Polynesian and other indigenous cultures. His writings suggested he despaired at times - "... it isn't absurd ...to believe that the age of science and technology is the beginning of the end for humanity" (1980a, 56e). He saw a "scientism" creeping over the world suggesting intelligent questions have a scientific answer or no answer at all. "Man has to awaken to wonder,... Science is a way of sending him to sleep again" (1980a, 5e). He was particularly critical of psychology for not seeking conceptual clarity first, for "(T)he existence of the experimental method makes us think that we have the means of solving the problems which trouble us; though problem and method pass one another by" (1958, 232e).
His philosophical method is a form of therapy, which some see as Socrates 'maieutics'; a method which can and is utilised in psychotherapy. For "(T) he problems are solved, not by giving new information, but by arranging what we have always known" (1958, [section]109). And this has direct relevance to psychotherapy for "(T)he way to solve the problems you see in life is to live in a way that will make what is problematic disappear. The fact that life is problematic shows that the shape of your life does not fit into life's mould. So you must change the way you live and, once your life does fit into the mould, what is problematic will disappear" (1980a, 27e). This method of 'disappearing' problems (which Solution Focused Therapy has developed well) leads to a clarity, and although in our civilization "clarity is sought only as a means to an end, not as an end in itself. For me on the contrary clarity, perspicuity are valuable in themselves" (1980a, 7e). "(F)or the clarity that we are aiming at is indeed complete clarity. But this simply means that the philosophical problems should completely disappear" (1958, [section]133). But Wittgenstein's philosophy does not lead to a simple moral relativism, as many critics of postmodernism claim. As we shall see, when the dualism of Cartesian thinking disappears, our ethical obligations become starkly apparent.
Like his contemporary Dewey, Wittgenstein began his later investigations with the public character of thought and language, and not with a search for intellectual certainties in private experiences as Descartes had. In an essay he was writing in the last months of his life, he argued that in order to live life, it is not an option to question or doubt everything, as Descartes had encouraged. We will always live with a certain acceptance that there are many things we have never doubted, and have no need to (Wittgenstein, 1969). For example I don't doubt this is my hand, or that the world existed before I was born. These socially shared 'certainties' precede any intellectual certainties obtained via doubt. Because knowledge and doubt are intimately related we cannot say that we (intellectually) 'know' these things ('this is my hand'), or that we don't 'know' them. He referred to these matters as being like the bed and banks of the river, which although not unchangeable, especially in the 'sandy spots', provide the channel in which our thoughts and conversations flow.
The word 'know' is placed in question here, as one of the keys to clarity is understanding our everyday use of and confusions about this word. As is well known, the developments Einstein made were initially conceptual ones; he realised that physicists had been using the word 'simultaneous' in a confusing manner (Winch, 1958/1990). Wittgensteinian psychologist John Shotter (2008) has facilitated a similar clarity by noting how we all too frequently confuse performance knowledge ('know how') with intellectual knowledge ('know that'), as we use the word 'know' in referring to both. The importance of this distinction becomes clearer as we trace the way in which Wittgenstein deconstructed the picture theory of language (i.e. the idea that a word or proposition stands for, represents or 'pictures' an object). This idea that language works by representing things is deeply embedded in our 'common sense'; but Wittgenstein argued "For a large class of cases--though not for all--...the meaning of a word is its use in the language" (1958, [section]43). Language cannot begin with representations, for if someone said "that is called 'sepia'", we would not understand what they meant, unless we already 'knew' that we were talking about (engaged in the activity off) naming colour, and not say, shape (1958, [section]30). That is to say, the 'know how' of the pointing and naming 'language game' has to be mastered first. 'Know how'precedes 'know that'.
In his deconstruction of the picture theory of language Wittgenstein likened words to tools in a tool box, each involved in numerous activities; "the function of words are as diverse as the functions of these objects" (1958, [section]11). As we well recognise words are also polysemous, as new uses for old words are constantly invented, especially by teenagers. (On the other hand, science begins only after we have reached philosophical consensus on just how we will use particular words.) However the important thing that Wittgenstein would have us note here is that outside particular activities, which he called 'language games', words have no intrinsic meaning. If a builder calls out 'beam' to another worker, is he naming an object or giving an order? A 'language game' is a communally shared activity as diverse as naming, commanding, speculating, courting, doing maths, arguing, telling jokes, and much more. There is a 'family resemblance' of features relating language games, but no one feature common to all. A language game is "a form of life" (1958, [section]23). In understanding language, it is useful to keep one's eye on the activity, rather than the word itself. Although the various conventions (even mathematics turns out to be agreed upon conventions, and thus mathematical 'discoveries' are 'inventions' (1976, p22)), for various language games can be expressed in terms of rules, the rules do not totally circumscribe the 'game', for "no more are there any rules for how high one throws the ball in tennis, or how hard; yet tennis is a game for all that and has rules too" (1958, [section]68).
Thus for Wittgenstein, language arises out of 'know how' activities; unlike the structuralism of Saussure or the mentalism of Pinker or early Chomsky, who all suggest that understanding results from a mental calculus performed on words and other sensations. According to Wittgenstein, we don't obtain our understandings by inference and deduction (intellectual activities), but because we have learnt shared semiotic (meaning-making) procedures (activities). We attune ourselves to each other to play the same language games ('get on the same page'); games that are mostly learnt in childhood like other games. The criterion people use to say someone understands them, is that they are behaving appropriately, not that they have formulated some intellectual theory. And although an image may come to mind when talking and thinking, understanding is not dependent on the generation of such images, but mastery of common language games is (1958, [section]199). Thus Wittgenstein is also rejecting Descartes and the empiricists view that knowledge begins with data (sense data or words; i.e., 'know that'); an idea that much of psychological science has been built upon (Baker & Hacker, 2005; Grayling, 1996; Maraun, et al., 2009). It begins with actions. And although this appears to bring Wittgenstein close to methodological behaviourism, he is neither a behaviourist nor Cartesian (Overgaard, 2004).
As we shall see, this has massive implications for our relationships with each other and the world, for they are not mediated by intellectual knowledge, although Cartesianism has spellbound us into thinking they are. Our relationships are far more direct or immediate. This becomes clearer when we examine Wittgenstein's 'private language argument'. Because language or meaning making is essentially a shared public activity, and not a hidden inner process of a ghostly mind, there cannot be a language created by and intelligible to a single person. This is a direct attack on Descartes' assertion that knowledge begins with the certainties he believed we had of our own inner sensations. Wittgenstein argues that I cannot be certain within myself that a recurring inner sensation is the same or not. We don't describe our inner sensations so much as we express them. For example, with pain, the natural expressions of pain, groaning, wincing, etc., are socialized into "exclamations and, later, sentences" (1958, [section]244). What we think of as private states have natural behavioural expressions which talk either replaces or supplements. "The origin and the primitive form of the language game is a reaction; only from this can more complicated forms develop. Language--I want to say--is a refinement, 'in the beginning was the deed'[Goethe]" (1980a, p.31).
For Descartes, first person knowledge of psychological states is unproblematic, but third person knowledge of others is (the 'problem of other minds'). So for Descartes, and many psychologists, we have to infer or deduce from behaviour the psychological state of others. For Wittgenstein, the reverse difficulty occurs. There are public criteria for how we shall use psychological terms; tacit ('know how') agreements how say, pain words are used, correcting each other when used inappropriately. This is because all states thought of as 'inner' have outer criteria. We can simply look and see what state someone is in most of the time. "'We see emotion'--as opposed to what?--we do not see facial contortions and make the inference that he is feeling joy, grief, boredom. We describe the face immediately as sad, radiant, bored, even when we are unable to give any other description of the features.--Grief, one would like to say, is personified in the face. This is essential to what we call 'emotion' " (1980a, [section]570). Keeping an eye on the 'know how'--'know that' distinction, we see that to use the word 'know' in relation to oneself, as Descartes does, generates confusion. Intellectual knowledge ('know that') can only follow in the wake of the certainty of performance knowledge--"The child learns by believing the adult. Doubt comes after belief (1969, [section]160). We don't doubt we are in pain. Descartes' doubts are hollow. "It can't be said of me at all (except as a joke) that I know that I am in pain. What is it meant to mean--except perhaps that I am in pain?" (1958, [section]246).
As we have seen, "(I)t is correct to say 'I know what you are thinking', and wrong to say 'I know what I am thinking'. (A whole cloud of philosophy condensed into a drop of grammar)" (1958, 222e); because I express what I am thinking/feeling and can see the natural expressions of your thinking/feeling. Now although I can attempt to take an observational stance towards you, as perhaps forensic psychologists might, to shore up intellectual knowledge ('know that') about you, it is not the primary type of relationship we have with others. More basic is a "being-with-others" (Heidegger called it "being-in-the-world"); a performance based way of interacting where we are expressing our mental lives in our behaviour, and responding in kind to the other's expressions. In Maoritanga this is called 'whanaungatanga', a sense of communion, or "we-ness". (Other indigenous cultures also name this, e.g., 'Ubuntu' in Zulu, and 'shimcheong' in Korean.)
In most social situations, there is no homunculus intellectually interpreting the 'other'. "The idea of the ego inhabiting a body [is] to be abolished" (1993, 225). Although there is no passive Cartesian observer within, there is a bodily subjectivity inhabiting the world. "The human body is the best picture of the human soul" (1958, 178e). The performance based knowledge of people is expressed in attitudes. "My attitude towards him is an attitude towards a soul. I am not of the opinion that he has a soul" (1958, 178e). An attitude is an expression of my subjectivity, and not ('know that') knowledge about something. "In general I do not surmise fear in him--I see it. I do not feel that I am deducing the probable existence of something inside from something outside; rather it is as if the human face were in a way translucent and that I were seeing it not in reflected light but rather in its own" (1980c, [section]170). You don't have to look inside yourself to recognise the joy, indifference, fury, and so on you see on the face of another; "it is there as clearly as in your own breast" (1981, p220). "My thoughts are not hidden from the other, but are just open to him in a different way than they are to me" (1992, pp 34-35).
Recently a number of Wittgensteinian psychologists have taken the discipline to task for the claim that people function socially as a result of a Theory of Mind (Leudar & Costall, 2009). There are a number of ToM theories being researched, but all are Cartesian and make the error of defining the phenomenon they claim to be investigating. There is no denying that at times we do resort to inference or simulation of another in order to understand that person, but to suggest that this is the main vehicle for intersubjectivity only ensnares us in Cartesian dualism. As has been pointed out before in the literature, it should have been obvious to ToM proponents that there are some learning disabled people, young children, and even cats and dogs which get on very well with people, but lack the capacity to make meta-representations. It turns out that the only people who need a ToM are those attracting a diagnosis of autism, because, as one put it, "to make up for the instincts I don't have" (Williams, 2009, p.156). As Wittgenstein noted, it would be to put the cart before the horse if we were to think (as ToM proponents do) that our reactions to others are primarily a result of thought (1981, [section]541-542). In the beginning was the reaction. A drop of Wittgensteinian grammar relegates this research to the minor and supplementary position it holds on intersubjectivity.
As it currently stands, most schools of psychotherapy and 'best practice' standards demand a comprehensive assessment of a client prior to the commencement of therapy. These are demands for therapists to emulate people who attract an Aspergers diagnosis, and surely this is not a position that puts the profession in a favourable light. Although for 3rd party reports (e.g. forensics) an intellectual description of other is necessary, there is no evidence that this is necessary for successful psychotherapy (Duncan et al., 2004). Although there will be aspects of other that transcend me (I can see that you are upset, but may not know why yet), it is this immediacy that invites (moves me to) conversation or expression by me. I may not need to (intellectually) know what is upsetting you to help you, my expression of care may suffice. There may be various ways to facilitate a rearrangement in what you already know, such that a clarity is achieved whereby you can say, in best Wittgensteinian fashion, "I know how to go on" (1958, [section]154).
Because there will be aspects of 'other' that escape my immediate comprehension, that transcend me, the Cartesian psychologist will complain there isn't sufficient certainty here. Wittgenstein has a similar exchange with his imaginary interlocutor: "'But you can't recognise pain with certainty just from externals'. The only way of recognising it is by externals, and the uncertainty is constitutional. It is not a shortcoming" (1980c, [section]657). The externals trigger my concern, or as Vygotsky (1986) puts it, this concern is completed in my spoken sentence. Of course the subject of my concern is not interested in my 'body language' per se, but whether that expression of concern by me is genuine or feigned. As we shall see shortly this can be the beginning of the therapeutic conversation, which in itself gives rise to a third way of knowing; what Shotter (2008) calls 'knowing from'.
Science, therapy, and Mohiotanga
There have been a number of scientific developments that have occurred since Wittgenstein's death that are worth acknowledging in passing. The first of these is the relatively recent "discovery" of 'mirror neurons', which come as no surprise to Wittgenstein scholars (Mascolo, 2007). The social responsivity Wittgenstein pointed to would strongly suggest there must be some motor neuron 'resonances' when people are in dialogue (Rizzolatti & Sinigaglia, 2010). There is a great deal of speculation as to the meaning of this finding; and Wittgenstein warned against the lure of neurology without first obtaining conceptual clarity. He may have been bemused by the recent shift from psychobabble to neurobabble; he wrote: "(t)he best prophylactic against this is the thought that I don't know whether the humans I am acquainted with actually have a nervous system" (1980b, [section]1063). However, it is noteworthy that motor neurons for the hand fire when the word "grasp" is heard, or for the leg when "walk" is said, showing that action and perception are interdependent in language comprehension (Pulvermuller & Fadiga. 2010). The finding that mirror neurons are far more active when we are engaged in complementary activity, rather than pure mimicry, is also consistent (Newman-Norlund et al., 2007).
In psychology 'embodied cognition', the idea that we 'think' with our bodies, is emerging largely from Wittgenstein's musings (Anderson, 2003). But I will focus here on developments in the science of perception that have benefited from Wittgenstein's observations (which were not too dissimilar from those arrived at independently by Merleau-Ponty (1962) and Dewey (1933/1960)). Although the initial developments of Wittgenstein's ideas for perception were made by Austin (1961) and Gibson (1979), Noe's (2004) work in recent years has brought these ideas dramatically to life. Noe has been harvesting evidence to show that the primary function of perception is not so much for identifying things in the world ('know that'), but is the development of sensorimotor skills for the purpose of keeping track of our relationship with the world. Attunement! After cataract surgery, the congenitally blind cannot see until they successfully integrate the perceptual apparatus within a sensorimotor framework. Held & Hein (1963) showed that a new born kitten never learned to see until it had developed the appropriate sensorimotor skills. There are more feedback neural pathways to sensory systems than input. Noe suggests the appropriate metaphor for enactive perception (and cognition) is that of the blind man with his cane, using his senses to probe the interdependent relationship he has with the world for a way forward. 'Blindsight' is a particularly startling demonstration of this sensorimotor skill to perceive without images; a recent report describes a man with 'blindsight' even 'sensing' facial expressions of fear, anger, and joy on another (de Gelder, et.al., 2008).
The common factors research in psychotherapy have been indicating a similar sea change in priorities with their call to shift the focus of practice from the 'medical model' to a 'contextual model' (Wampold, 2001). The medical model developed from Cartesian dualism, calls firstly for an accurate explanatory assessment/picture (usually in the form of a diagnosis), and then an intervention plan that utilises a specific empirically supported treatment. Common factors researchers have consistently shown that the specific remedial ingredient of the empirically verified treatment, claimed to be the 'silver bullet', is largely irrelevant, and at best contributes only 1 to 8% of the variance of change (Duncan et al., 2010; Wampold, 2001). Often significant change has occurred before the 'silver bullet' is delivered, or even when it has been actively withheld. In fact Wampold cites a growing body of evidence that the more strictly the practitioner adheres to the medical model, the poorer the outcome (in Duncan et al., 2010). By contrast, the contextual model places emphases upon developing an attunement with the client, in order to assist the client recover his/her attunement with the world. Wampold notes that a 'healing setting' will facilitate this, as well as a rationale for change that is plausible for both the therapist and client (although not necessarily "true"). Further evidence that therapy is a matter of developing 'know how' skills and not learning 'know that' ideas, is the finding that professional training has little effect on outcomes; licensed professionals have not been found to do better than unlicensed unless called to deliver specific treatments (Atkins & Christensen, 2001; Nyman et al., 2010).
Part of the problem here is that the philosophy of science that dominates is Cartesian; and Cartesian (Newtonian) science is based on a search for an explanatory picture, a hypothesis, that lies behind phenomena or mere appearances. Its focus is 'know that' rather than 'know how'. Goethe described Newtonian science as an 'empirico-mechanico-dogmatic torture chamber', as the scientist is encouraged to de-contextualise the phenomena, or turn away from it, and "cudgel" his/her brain to find a theoretical schemata that explains it. Descartes and his followers made it clear, this was for controlling things; an exploitive ethos. As Bateson (1972) noted, Cartesian science seems to have led us into an intellectual cul-de-sac, as it has placed us dangerously out of tune ecologically despite numerous explanatory pictures on how to control the world (Bateson, 1972). In health, this kind of science all too easily leads the practitioner to treat the diagnosis and not the client. Wittgenstein, strongly influenced by Goethe, especially via the work of Spencer, wanted to do away with explanations and replace them with pure descriptions. He did not think that science should be a search for explanatory truths so much as useful descriptions. "What a Copernicus or a Darwin really achieved was not the discovery of a true theory but of a fertile new point of view" (1980a, p.18). Psychiatric diagnoses are usually offered as explanations; and social constructionists are calling for them to be dropped in favour of 'case formulations'. Fertile descriptions developed in collaboration with the client, and open to constant revision (Johnstone & Dallos, 2006).
Goethe offered an alternative philosophy of science, one that is more consistent with this idea of keeping track of our relationship with the world, and is being 're-discovered' today in a number of sciences (Robbins, 2005). He called this science 'a delicate empiricism', because it is the art of developing a participatory understanding of phenomena (Seamon & Zajonc, 1998; Shotter, 2000; Drury 2006). The method consists in making oneself utterly identical with the phenomena being studied until we gain a sense of the phenomena as a process-in-context. For those familiar with indigenous knowledge systems, such participatory understanding or appraisal is well known. Ngapuhi elder Hone Sadler (2007) calls this the hakapapa method of Polynesian science. The task is to find the connectiveness of all things; by the researcher forming an intimate relationship with the phenomena until the whanaungatanga can be sensed and named. This occurred in a major way when Polynesians first settled in Aotearoa and had to adjust from being principally a sea-focused (Tangaroa) culture to a land or forest-focused (Tane) culture. New relationships, new connections, a different world needed orienting to. A 'fertile new point of view' was needed. But this was also ongoing (Henare, 1998). This is a form of empiricism that is based on self-discipline, or 'know how', and the 'know that' utterances are an expression of that attunement with the phenomena. The primary scientific tool then is the practitioner, and it comes as no surprise to read that the pre-colonial Polynesian navigators could be recognised by their blood-shot eyes from lack of sleep (Salmond, 2005).
The 'know how'--'know that' distinction also appears to have been present in Maori thinking. In Royal's (2004) exposition on Maori epistemology the word matauranga appears to correspond closely with the idea of 'know that' as he says it can be passed between people, and is frequently used in such contexts as learning Biblical text. By contrast he says that 'mohiotanga' refers to knowing that belongs to the 'heart' and can be viewed as 'internalised or embodied knowing'. "An example of this kind of 'knowing' is the knowledge of the new-born child to suckle, ..the movement of the leaf towards the rays of the sun, .a bird building a nest" (p.39). He also notes: "mohiotanga might be a higher form of knowing than that suggested by matauranga" (p.39). A further parallel to Wittgenstein's maieutic method can be found in a metaphor Royal brings from the work of Maori Marsden; the student completes his studies not just by cleansing the lens of their perception, but by removing the lenses to see the world as it actually is (p.42). Complete clarity.
Wananga--knowing from dialogue as therapy
Royal (2004) notes that the general purpose of wananga ('discourse') is to generate new knowledge and understanding. Similarly, Wittgensteinian psychologist, John Shotter (2008) suggests that there is a form of knowledge that is relatively unexplored by psychology, which he calls 'know from'. A third form of knowledge. It is from within dialogue that new language games or ways of life emerge, as we pick up and expand upon the primitive reactions we have with and to each other. We are 'moved' by each other. As we come into dialogue we co-ordinate our perceptual and speech sensorimotor activities. Daniel Stern (1995) calls this 'affect attunement'. To the degree that we can become entwined or relationally responsive to each other, the conversation becomes spontaneous, and doesn't have to rely on logic or analysis to proceed (despite the claims of Theory of Mind). Bakhtin (1986) notes that if conversations begin to rely on analysis they lose their dialogical form and become monological. Being able to follow a person in a conversation involves being able to partially anticipate or predict (but not with the head), what they are going to say, where they are taking this. As Noe has it, it is more about getting the orientation than the picture. There is 'withness thinking' here rather than 'aboutness thinking', a matter of know how rather than know that (Shotter, 2008). It is then that the conversation can take on a life of it's own; and when it does we can both be changed (moved). Shotter invites us to imagine a chiasma here, as the speakers discuss a topic. For Cartesians, thinking is occurring in an imaginary mental space (perhaps in our heads); but in the Wittgensteinian approach outlined here, thinking is occurring 'out loud' so to speak, in bodily gestures. The chiasma centres on the conversational 'ball' we are tossing around between us. In therapy, we are 'hosting' new ways, new games, of 'ball' tossing to arise.
New language games can begin anytime, anywhere. Wittgenstein: "We can easily imagine people amusing themselves in a field by playing with a ball so as to start various existing games, but playing many without finishing them and in between throwing the ball aimlessly into the air, chasing one another with the ball and bombarding one anotherfor a joke and so on" (1958, [section]83).
Those primitive reactions that lead to new language games are more likely to occur earlier than later in the dialogue. It is in the early stages of the encounter when my responsivity to his/her way of being, and vice-versa, are going to be most pronounced. It is then that we are most 'other' to each other. Our own primitive reactions (intuitions) are worthy of exploration as they arise, as they may not be so noticeable later. Research bears this out by way of showing that therapeutic change is more likely to occur earlier than later in therapy (Duncan, et al., 2010, p.91). Unfortunately institutionalizing practices (Foucault, 1971), based upon Cartesian dualism, all too frequently interfere with this early opportunity for change, due to incessant demands for 'comprehensive assessments' and/ or diagnoses prior to any intervention. Cartesian thinking doesn't trust that a 'fertile viewpoint' will emerge from the dialogue itself. The evidence continues to mount that such missed opportunities are contributing to the epidemic (Duncan et al., 2010; Whitaker, 2010).
As the 'common factors' research continues to provide support for this 'contextual model' over the 'medical model', a number of suggestions come from dialogical analysis as to how we might create climates where new language games can arise. For example Bakhtin (1986) holds that dialogical trust is facilitated when the listener is "without rank" so to speak, and then the speaker is more likely to "reveal his internal depths" (p.97). Anderson and Goolishian (1992) describe this position where the therapist has renounced their position as a 'know that' authority on how to live life (but not the 'know how' of conversational skills), as the 'not-knowing' stance.
When Sartre described intersubjectivity, he painted a rather dismal picture, as he saw it as basically hostile. He thought that each was trying to objectify the other, or that each was endeavouring to confirm their own freedom by escaping or transcending the objectifying efforts of other. As we have seen Wittgenstein's thinking exposes a different facet to the politics of intersubjectivity; for the other is not merely an object with features, but a person who automatically elicits a response from me. As Overgaard notes, this is why Wittgenstein is not a behaviourist, for "to perceive another human being is essentially to be presented with something like an ethical demand" (p.9, 2007). We can't make sense of Other without an empathic response on our part; in order to understand their way of life (i.e., attune to their 'language game'). This also finds expression in the philosophy of Emmanuel Levinas (1998). For Levinas, the face of other appeals to my goodness or responsibility, it invites my hospitality. One may of course refuse this duty or obligation, but both philosophers agree that the reflexive response, or primitive reaction, of humans is to be 'called' by the face of other. There is a "primitive reaction to tend, to treat, the part that hurts when someone else is in pain; and not merely when oneself is....,--a response of concern, sympathy, helping" (Wittgenstein, 1981, [section]540). Because of this innate responsivity both Levinas and Wittgenstein expressed a strong resonance with the Dostoevsky quote, "everyone of us is responsible for everyone else in every way, and I most of all" (Dostoevsky, 1958, p.339). Similarly, mutual mana enhancement is central to the tikanga (lore) of Maori communities (Durie, 2003). Indeed it has been suggested that an 'economy of affection' by way of obligatory reciprocity of gift giving, instead of the capitalist economy of exploitation, was a defining feature of Maori society (Mauss, 1990).
The 'heady' individualism of Cartesian dualism has fostered the idea that recovery in mental health is a matter of creating a strengthened ego from a shattered ego, one that can cope with the vicissitudes of life. In contrast, the idea emerging here is that recovery involves reconnecting with one's 'heartfelt' obligations or responsibilities to, for and from each other. This is the meaning of whanaungatanga; a very rich territory to be mined in therapy.
As we move from the dualism of Cartesianism, where we are separate observers of the world, to the embodied engagement of Wittgenstein's intersubjectivity, there is a shift from perceiving human relations as primarily a natural science to the moral science it is. Cartesianism has engendered this strong impulse to stop our active engagement, step out of the relational flow, and pretend we are external observers. It would have us decode nature into known forms ("it constrains nature to give answers to questions of reason's own determining"--Kant). By contrast the shift outlined here, encourages a spontaneous responsivity to our clients, trusting that the conversation itself will provide a sense of where to go next. Most schools of therapy have ways of talking about these primitive responses that can signal the start of new language games, variously called 'unique outcomes', 'exceptions', etc. Schools of therapy can be thought of as 'training wheels' or 'water wings', which can be let go of as we find our confidence to stay in dialogue. Our task as therapists is to stay in the dialogical flow; perhaps slowing it down enough to allow new connections to emerge. An expression of this approach is Seikkula's 'Open Dialogue' in Finland, which has superb outcomes for treating psychosis. (Very few are ever exposed to antipsychotic medication, and at the end of five years 80% are working or in school (Seikkula, 2008).)
As we have seen, central to therapy, from this Wittgensteinian perspective, is our attunement with the client, and the client's to his/her world. One of the shifts that has occurred in the field of perceptual science with the move to embodied perception, has been a shift away from studying visual illusions and a greater focus on a phenomena called 'change blindness'. If the primary function of perception is to keep track of our relationship with the world (and not to see the world free of illusions as Cartesians supposed), it makes some sense to measure when we lose that track. Change blindness research illustrates Wittgenstein's observation that our intelligence is readily "bewitched" (1958, [section]109), by minor distractions, and ideas that get away on us; and no longer stay in touch with the world as it is. For example, experienced pilots landing a plane on a flight simulator, temporarily distracted by an instrument reading, failed to notice that another plane had moved onto the runway (Haines, 1991). There is now an extensive body of research that shows that therapists are poor at predicting many changes occurring in therapy, including clients preparing to take flight, or not noticing changes that are occurring in clients who have been attending therapy for a long time (Duncan, et al., 2010). As Wittgenstein might say, there are times when our intended therapeutic conversations "go on holiday" (1958, [section]38).
Fitting with the implications of Wittgenstein's work for the social sciences (Winch, 1958/1990) is the development of Patient Reported Outcome tools. These are tools that socially construct (via a collaborative endeavour with the therapist) the client's assessment of their changing relationship with the world, and the client's assessment of the clinician's attunement to the client. They are consistent with the consumer empowerment movement's call for greater accountability to the client. The extreme brevity of the tool's developed by Duncan, Miller, and Sparks (2004), make theirs highly feasible in real world situations; and they invite the client to situate themselves on a distressed-wellbeing continuum, rather than be symptom focused. They facilitate a continuous real time feedback loop between client and therapist, reducing the odds of change blindness. In Illich's terms they are 'tools of conviviality' (1973) in that they enhance our ability to get back on track, predict would-be drop-outs from therapy quicker, as well as show that our clients are achieving their goals. For the professions, this 'practice-based evidence' facilitates a shift from 'competence' to 'effectiveness' as clinicians engage in "ongoing monitoring of patient progress" (APA, 2006, p.280).
Research to date indicates that the introduction of practice-based evidence is making significant inroads to the mental health epidemic. In clinics utilising this approach, programme costs have been reduced from 10 to 35% (Bohanske & Franczak, 2010). Length of stay in psychotherapy was reduced by up to 50%, and cancellation rate and no shows have also massively declined. Success rates have more than doubled in a number of studies; and the number of clients who become long term users of mental health services has also been radically cut (Duncan, et al., 2010). As these tools create space for the contextual model, which does not require diagnostic assessments, this accountability system may reduce the proliferation of psychiatric labelling into the public lexicon over time. In turn, this may lessen the disabling effects such labels have on the public (Gergen et al., 1996).
An understanding of Wittgenstein's thinking leads to the conclusion that current mental health practices do not model mental health. The ecological crisis should have alerted us to that (Bateson, 1972), if not the current epidemic in mental health. The philosophical paradigm underlying much of our current philosophy of science and ways of being are developments of Cartesian thinking which alienates us from the world and each other. A matter of living on the world rather than with it. Wittgenstein offered a totally different way of thinking; one that has us realise our living engagement with the world and each other. Whereas Cartesian thinking imagines that social engagement is mediated by intellectual knowledge, Wittgenstein shows us this is immediate and direct. A matter of 'know how' rather than 'know that'. Indigenous cultures are also built on participatory knowledge, and in Maori culture this sense of living connection is called whanaungataunga; a phenomena largely absent from the living experience of Pakeha culture. I am suggesting that Wittgenstein's therapeutic method allows us to recover that living connection.
Research in common factors indicates that Cartesian philosophy of science has misled mental health practitioners into searching for specific treatments for specific problems, and unwittingly invited practitioners to develop allegiances to particular treatments. Common factors research has also suggested a paradigm shift to what Bruce Wampold has called the 'contextual model'.
Unfortunately, because of accountability concerns, managed care has intervened, and in many places blocked a shift to a contextual model, by auditing for adherence to the 'medical model'. However, with the recent advent of Patient Reported Outcome management systems, an opportunity exists to facilitate mental health as "attunement". With some reflection, it can be seen that the tikanga or ethic being embraced here is also one which situates care of 'other' as central to all, placing care back into the vernacular world of face-to-face encounters. As such, it opens the possibility of putting ourselves out of business. Problems can disappear and the perspicuity Wittgenstein sought found.
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