politics of the hap


I am not my blob, Or It’s all chemical baby // some sketchy notes.
March 3, 2014, 1:03 pm
Filed under: Grief, Mental health, Recovery | Tags: , , , , ,

Recently I have become engrossed in discussions around the shifts in psychiatric research toward the brain.

This shift includes a number of different activities occurring in different disciplines and domains, most notably:

  • Change in focus in mental health research from the psyche to identifying ‘biomarkers’. It is quite evident that funding is increasingly directed toward research interested in uncovering brain activity and biological causes that may underlie a mental condition, this also includes complicated grief.
  • Part of this change in focus has come about due to growing criticism of the DSM and standardised modes of diagnosis based on self-reported symptoms. The director of the National Institute of Mental Health (NIMH) Tom Insel, has been openly critical of the DSM, critiquing its scientific validity. In response he has created the Research Domain Criteria (RDoC) which proposes to improve diagnosis of mental illness by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. This framework is based on the assumption that mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behaviour, and that mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment. The RDoC aims to move away from using the DSM as the gold standard and base diagnosis on emerging scientific data.
  • On the level of theory there has in recent years been a flurry of interest in social and cultural theory toward affect, and thinking about neurobiology, the human nervous system and brain functions to explain the self, subjectivity, consciousness and what it means to be human (writers such as Deleuze & Guattari, Nigel Thrift, Brian Massumi, Lauren Berlant, Eve Sedgwick, are often cited as proponents of this move). However there are considerable problems with how ‘affect’ is used, and varying interpretations of what affective awareness means of implies, often supported by wrongly or selectively interpreted neuroscientific data.

What reading this literature has brought up for me is:

  1. How to understand the self/subject, and avoid lapsing into either essentialism (it’s all chemical) or relativism (it’s all socially constructed)
  2. What can we take from affect theory?
  3. What bearing these different explanations have for grief, and the increasing focus on defining complicated grief?

I will try to outline some of my thoughts on each point below.

i. It’s all chemical or it’s all socially constructed: Moving beyond duality

Human behaviour is increasingly explained in reference to the brain, implying that the brain fundamentally shapes who we are and our capacities and attributes. Yet the increasingly fashionable focus in psychiatric research towards finding a biological – neurological, genetic –  basis for mental illness speaks of a broader move to understanding the human as a biological organism that is no longer deterministic or essentialist as it was once criticised to be, but as providing an opportunity. The idea of biology as an opportunity, not destiny is becoming a prominent explanation for mental illness (Rose, 2013a). However as even my brief foray into neuroscience has shown, the more that is known about the brain, the more we realise we don’t know (ibid). It also produces basic or crude analysis of mental states where areas of ‘activity’ are pointed out on brain scans and sections of the brain are singled out as responsible for aspects of human functioning, when these areas of the brain involve billions of synapses of which little is still known. Studies into complicated grief (CG) have sought to identify what areas of the brain are activated in people with CG compared with people with ‘normal’ grief (O’Connor, 2012). Further a study (O’Connor et.al., 2008) revealed that the areas of the brain activated in people with CG is the same as the areas of the brain activated in people with addiction, a part of the brain concerned with reward. On viewing a picture of the deceased this part of the brain would be activated, thus leading the researchers to argue that people with CG find pleasure in their distress unlike people without CG. However whilst these provide interesting explanations and interpretations, often research that seeks out specific brain activities or biological markers ignores how the human organism works as a whole and how the brain is affected by its social environment. A project headed by Nikolas Rose seeks to understand precisely how experience gets under the skin, by situating the brain in its milieu. As Rose (2013a) states:

The scientist (is required) to realize that the conditions they are dealing with, whether they be psychiatric diseases, brain diseases, physical diseases are all diseases of human beings living in their social environment and they are not things that happen with genes in petri dishes in labs and that that’s a rather important scientific thing to recognize and not just, kind of, an addendum from the social sciences or from the ethics. Recognizing how the problem feels for those on the other side, for those who are experiencing it, and therefore what the solutions may look like for those on the other side.

By acknowledging the social embeddedness of neurobiological processes, and of biological processes this research is at the forefront of a new wave in thinking about mental health that seeks to bring together the knowledge from the social sciences and the biological sciences. It is argued that biological traces are produced through the practices and ideologies of modern social life and thus the biological and sociological life of the body and brain are inseparable. Both brain, body and environment all impact upon one another. The discourse that merely seeks to identify ‘biomarkers’ or ‘cognitive biases’ glosses over the complexities of understanding the situatedness of a mental disorder; of how the outside gets in.

This then poses a problem for how to account for the subject, the self, a self that is both social and biological and further is both social and biological in a way that the biological self and social self do not exist as discrete categories. Maurice Bloch’s ‘The Blob’ still perhaps for me presents the most convincing attempt at accounting for how a human – or the blob – can be both a process, a relational being and yet also have some type of biological consistency that makes the blob identifiably human. In thinking about grief, it has always been the potentially destabilising and disorientating power of grief that has been, for me, interesting to theorise. Borrowing from Judith Butler and Lauren Berlant I have been working with a description of grief as an instance which can make a person ‘come undone’. This is a coming undone of a self that was already not the sovereign person they took themselves to be. What this means is not that grief or loss merely breaks people down before they put themselves back together again (a recovery narrative that relies upon the self as normally integrated) but rather an instance that reveals the relational nature of their sense of self; the capacity to affect and be affected. Injecting some incoherence, ambivalence, resistance into the blob then, the question is less about what makes us come undone – the impact of trauma etc – but what holds us together. Grief might be one experience that can expose our potential or capacity to be different and yet we appear or tend to stay from one day to the next more or less the same. Or to take a Deleuzian line: how do we hang together when we are multiple?

ii) What can we take from affect theory?

I got drawn into affect theory as it promises a means of describing the self that incorporates ambivalent, irrational, and contradictory behaviours. Affect theory grew out of cultural theorists borrowing from the developments in neuroscience. What binds the affect theorists and the neuroscientists is their shared anti-intentionalism (Leys, 2011). Affects can be described as a non-conscious intensity, unlike emotions they exist prior and outside consciousness. Affects are only contingently related to objects in the world; they are non-signifying forces. What the establishment of a theory of affect has provided then is to draw attention to and elucidate the gap between a person’s affects and the cognition or appraisal of the affective situation. In other words, it gives space to suggest that behaviours are not always consciously directed, or further we are not always consciously aware of what might trigger a particular pattern of behaviour or action. Affect theory’s use of neuroscience has its own problems and contradictions which have been criticised (Leys, 2011; Rose, 2013a). However despite the precarious stance of arguing for anti-intentionalism, I don’t want to dispense with the contribution of affect theory mainly for how it emphasises a radical relational model of the self. Thinking about the capacity to affect and be affected I would argue goes further than talking about embodiment or materiality in that it places more focus on the spaces in between people; how people through interaction get caught up in an energetic exchange. This also avoids relying on a model of emotions that either go from the inside out or from outside in. Rather affect theory argues for the mutual interplay; where emotions belong neither to the individual nor exist somewhere outside. It opens up space for thinking about surfaces, impressions and atmospheres.

In terms of grief I have found these ideas useful to work with as it highlights how the experience of loss is one in which the self enters a space of liminality, of non-sovereignty, which involves violating an attachment to intentionality. But further there is an object in grief, the intense yearning for the deceased as described in complicated grief diagnosis, which gives grieving an intention – but this may not be easily available for conscious deliberation. This brings us back to the continuing bonds thesis, that provides little room to think about the how the grieving person’s sense of self is composed, rather an integrated self is presumed as the norm. It also glosses over contradictory and messy feelings, ambivalence, suggestibility, resistance and how these can all exist at the same time without necessarily being pathological. To reiterate the question above then; by thinking about the self in this way, the interest lies less in how people come undone – if we alternatively assume the subject is always somewhat prone to incoherence – but rather how do they hold themselves together, and what form this holding together takes and why.

iii) What bearing do these different explanations have for grief, and the increasing focus on complicated grief?

Attending a recent talk at St Christopher’s Hospice on complicated grief brought up some interesting questions around the diagnosis of complicated grief. Whilst the shift towards brain science is starting on the level of research, psychiatric practice still remains shaped by the diagnostic categories of the DSM and ICD.

In Colin Murray Parkes’ talk he focussed on the DSM-5 and the relevant developments and associated controversies as related to grief and bereavement. His presentation was quite skeptical and he felt that the DSM had put ‘too many eggs in one basket’. He also elucidated some of the politics behind the DSM-5 and the inclusion of the proposed criteria of ‘Prolonged Complex Bereavement Disorder’ (PCBD). According to Parkes, Holly Prigerson initially proposed ‘Prolonged Grief Disorder’ to the APA for inclusion in the DSM-5. This was then countered by Katherine Shear’s description of ‘Complicated Grief’, and in the midst of the controversy over the grief exclusion and Major Depressive Disorder, the DSM backtracked and ended up with PCBD, to be considered as a ‘condition for further study’. The definition of PCBD is quite evidently a mixed combination of symptoms lacking cohesion and agreement.

Here’s some of the criteria for PCBD:

To have at least one of the following symptoms for at least 12 months after death:

– Persistent yearning/longing for deceased

– Intense sorrow

– Preoccupation with deceased

– Preoccupation with circumstances of death

At least 6 of the following symptoms persisting for 12 months or more after death:

Reactive distress to the death

– Difficulty accepting death

– Disbelief/numbness

– Difficulty in positive reminiscing

– Bitterness and anger

– Mal-adapative appraisals about self

– Excessive avoidance of reminders

 Social identity disruption

– Desire to die

– Difficulty trusting people

– Feeling alone/detached

– Feeling life is meaningless/empty

– Confusion over one’s role in life

– Difficulty planning for future

Further this disturbance has to be deemed to be causing ‘clinically significant distress’ or ‘impairment in social, occupational or other important areas of functioning’. The ‘bereavement reaction’ is considered to be ‘out of proportion to cultural, religious and age-appropriate norms’.

There is a lot to comment on here, wading through the loaded language. What is quite striking as with most psychiatric diagnosis is how a pathology is defined by the extent to which it exceeds what might normally be expected, when someone becomes unable to function. As can be seen in the list of symptoms, it is pathological to either excessively avoid or be excessively preoccupied with the deceased and/or the death. The implied norm of functioning is understood to depend on the individual social context. This appears as a way to avoid stating a general norm of functioning and grieving for all people who have been bereaved. This apparent cultural sensitivity neatly hides the contradiction of why acting in excess of a norm – which is itself variable, arbitrary, and historically context-specific – is necessarily pathological, and further not recognising how by developing a standardised criteria, specific habits and behaviours have clearly been selected as being, in any social and cultural context, somewhat problematic.

At the St Christopher’s talk, whilst there was some interest in these broader debates around diagnosis, there seemed to be a feeling amongst the attendees that this was not relevant to their daily practice. One person commented that he felt it was distracting from the main issue which is helping people (to recover, we could add). This was not exactly a surprising perspective to hear but it does speak of the disjunctures between theory and practice. The actual process of diagnosing grief as complicated, prolonged or complex might not yet be regular practice in the UK, but some practitioners did speak of how a medical diagnosis of abnormal grief can/could be useful in referring people on to other services, or as means of protecting/preventing people from more severe mental health problems. In the end there was little conclusion and there was a sense that this sort of language was ‘clinical’ and hard to understand. Grief then continues to be an ambivalent object, at times medicalised, and at other times seen as part of the natural order of things. There’s more to say here but I think there is something interesting in this management of excess or the inappropriate that produces a certain form to a person (or perhaps rather it gives a person-like form to the blob). Similarly the person who doesn’t recover isn’t formless but has their own shape too. I still remain too clueless about the brain and genetics to talk in any conclusive way about a biological core of what it might mean to be human, and so the task remains to look to the discourses that might mould the form of the grieving blob into an identifiable recovering/recovered/not recovered subject. That is to say what are the discourses, structures, norms that may impinge, limit, obstruct the capacity for flourishing or for becoming otherwise. And perhaps by exploring what holds these identities together, space can be found for thinking about relationality, the non-conscious, and how experience gets under the skin.

References

Fitzgerald, D., Rose, N. & Singh, I. (2014). Urban life and mental health: Re-visiting politics, society and biology, Discover Society, Issue 5 February 2014.

Leys, R. (2011). The Turn to Affect: A critique. Critical Inquiry, 37: 434-472.

O’Connor, M.-F. (2005). Bereavement and the brain: invitation to a conversation between bereavement researchers and neuroscientists. Death studies, 29(10), 905–22.

O’Connor, M.-F. (2012). Immunological and neuroimaging biomarkers of complicated grief. Dialogues in Clinical Neuroscience, 14(2), 141–148.

O’Connor, M.-F., Wellisch, D. K., Stanton, A. L., Eisenberger, N. I., Irwin, M. P., & Lieberman, M. D. (2008). Craving Love?: Enduring grief activates brains reward center. Neuroimage, 42(2), 969–972.

Prigerson, H. G., Horowitz, M. J., Jacobs, S. C., Parkes, C. M., Aslan, M., Goodkin, K., … Maciejewski, P. K. (2009). Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS medicine, 6(8), 1–12.

Rose, N. (2013a) The Human Sciences in a Biological Age. Theory, Culture & Society, 30(10): 3-34.

Rose, N. (2013b) What Is Diagnosis For?’, Talk delivered at the Institute of Psychiatry Conference on DSM-5 and the Future of Diagnosis, Kings College London, 4th June 2013.

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Reflections on Recovery: Research notes, Part I: Beginnings, complicated grief and happiness.
March 12, 2013, 9:41 pm
Filed under: Grief, Recovery | Tags: , , , ,

31st January 2013

As a way into thinking about the current debates surrounding recovery I have been quite drawn by the debates around the omission of the grief exclusion in the DSM-5’s definition of major depressive disorder and how that has raised issues surrounding the normative boundaries of grief. Complimenting this is the establishment of a category of ‘complicated grief’, or sometimes referred to as prolonged grief disorder. The proponents of the establishment of a ‘complicated grief’ diagnosis include Katherine Shear and Holly Prigerson and colleagues who have outlined a ‘scale’ or ‘inventory’ of complicated grief. The boundaries of what constitutes CG however seem to still be in flux, yet its supporters argue a concrete category is necessary in order to separate those that have ‘difficulty in progressing through the natural healing process’. The implication here is that there is a natural and instinctive healing process that is impeded in some way and thus requires correcting in order to reach the appropriate recovery.

Omega also dedicated a journal issue in 2006 discussing CG which highlighted some interesting points. Neimeyer in his article interestingly commented how the existence of grief as a real phenomenon is not the issue but rather the ways in which it is constructed by various groups. His argument was thus that ‘complicated grief’ was not a thing to be essentialised but a social construct reified in discourse. Whilst in agreement with viewing grief and complicated grief as a socially constructed, or at least socially manipulated emotion, Neimeyer’s argument that CG is comparable to abstract concepts such as ‘democracy’ or ‘power’ I found unconvincing. For while Neimeyer seems to admit that CG does not exist as a ‘real’ thing, diagnosing individuals with CG does become a real thing in terms of a labelled, categorised aspect of someone’s personality or emotional landscape; it becomes something to overcome. In the same Omega issue, Walter made some poignant points in asking ‘What is complicated grief?’ and listed some of the key contributing factors that have brought about the idea of CG. One point he made that I thought was salient was how the only thing that separates CG from ‘normal’ grief or from mourners in general is the time period in which feelings of grief last. As Walter remarks:

This reflects popular notions that grief is something one should get over quickly, and that it is embarrassing and/or inconvenient if colleagues or family members’ functioning is impaired by grief for extended periods. Indeed, it reflects a widespread duty in American culture for its members to be self-determining individuals and, moreover, happy.

Further Walter put forward an argument for the usefulness of complicated grief as a political tool and thus not something to be ‘therapied away’ but something that may lead to a more just society. I feel this is a particularly neglected line of enquiry and reminded me of Sara Ahmed and how she demonstrates the political and emotional uses and benefits of unhappiness in her book ‘The Promise of Happiness’. The way in which Walter linked the obligation to recover from grief with a wider sense of duty to be happy also paves a way for my own research.

The shifting boundaries of CG also provides a rich basis to explore the ranging definitions of what constitutes abnormal and normal grief. As Arnar Arnason also highlighted in his work, bereavement counselling exists as a way to make ‘visible’ feelings that ‘already exist’ but remain incomprehensible to the mourning individual. Bereavement counselling and the increasing medicalisation of grief can be seen therefore as a way of re-ordering the chaos of grief into tangible categories. This clearly brings up thoughts of Foucault and the medical gaze as well as Nikolas Rose’s work on psychotherapy and the normalising role of medicine. Intervention is made on the basis of the correct naming of things. The questions that arise for me so far from beginning to read the literature around CG, is to ask why does grief need to be defined or categorised in this particular way. CG is an example of how boundaries can be placed on grief and certain grief experiences can be labelled as pathological, which in turn assumes a normative healthy grieving process. In this act of naming CG – which as Neimeyer remarked does not exist as a ‘real’ thing – there is the sense that something is being created; grief is being ‘made-up’, or performed, in a certain way. Throughout some of the literature there is also a – I feel problematic – assumption of grief and feelings of grief as something that already exists out there, the process of naming and categorising thus becomes a way to capture them and act upon them. Yet I am interested in posing the question: Rather than identifying what is ‘already out there’ are we not creating categories, symptoms and pathologies where they do not exist? For how do we know things exist if we cannot name them and why do we think these categories, say CG for example, are the best means to capture them?

13th February 2013

I have been tentatively exploring the historical contexts of the contemporary conception of recovery. There are a few intersected factors that have emerged from some very preliminary readings, those being the impact of WW1 and WW2, the creation and proliferation of cognitive behavioural therapies and increased experimentation with psychiatric disciplines. One of the key impacts of war was the prevalence of ‘shellshock’. Shellshock as a non-physical injury posed an interesting problem to the medical profession that allowed what was arguably the first wide-scale intervention into the mental health of the population. The treatment of shellshock is a key instance of mental illness becoming a matter of ‘social hygiene’ (Rose, 1989). The sheer quantity of cases of shellshock shifted the perception of madness from something that was dependent on individual personal history and childhood trauma to something less discriminating and capable of affecting all individuals. Viewing shellshock as a treatable disorder promoted the idea that the individual was open for intervention and further that intervening into individual mental health was a matter both of public health and individual autonomy and freedom. This perspective has its legacy in contemporary healthcare as displayed in the Foresight report (2008) – a government directed project into ways to create ‘positive mental capital’ and well-being:

Positive mental health has an important societal value, contributing to the functions of society, including overall productivity. It is an important resource for individuals, and nations, contributing to human, social and economic capital.

Indeed another recent document published by the Department of Health was entitled: ‘No health without mental health’ (2011). It could be argued that following the world wars emerged an opportunity for mental health to become far more central to the understanding of what it means to be well, and further that positive mental health became a requirement for a productive and efficient workforce. Mental disorders such as shellshock thus became something that needed to be treated and to be overcome, which stimulated the experimentation with new behavioural therapies at places such as the Maudsley hospital (Marks, 2012). The indiscriminate nature of shellshock – the fact it was a mental disturbance produced from the experience of war rather than an internal trauma based in family history – complemented the rise of CBT that dispensed with Freudian heavy psychoanalytical approaches while retaining the element of the unconscious and unconscious drives.

This in some ways mirrors the view of positive psychology. Positive psychology believes the potential for happiness lies in our own hands and is something that can be achieved through correct training and adjustment. In the UK, Action for Happiness is an organisation that established itself with the aim to promote the way to achieve happiness. One of its slogans found on its website (http://www.actionforhappiness.org/) is quite instructive of the idea that positive mental health is a individual choice: ‘If you can’t change it, change the way you think about it’. I can’t help but draw parallels with the NHS website and their slogan: ‘Your health, your choices’. The emphasis on individual choice and the fostering of the idea of autonomy frames the way recovery is understood. Recovery from unhappiness or illness becomes a matter of making the right choices; unhappiness is a product (or defect) of the individual not the social context. For if you can’t change it you can at least change how you think about it. Unhappiness becomes synonymous with the inability to act on ones own and take responsibility for ones own life (Binkley, 2011). To fail in taking steps towards attaining happiness is a shunning of responsibility but also autonomy – making ones self happy becomes a matter of individual freedom.

Positive psychology reaffirms its status by claiming it has scientific measurable techniques that are proven to make you happy. The idea of happiness as a measurable entity is now widely assumed with the first national well-being measure carried out last year. Recently the department of health also put forward its support for a scheme that would promote 30 self-help book titles in GP surgeries and libraries. The idea is that when an individual turns up at the doctors showing signs of depression they will be directed to these titles which include much of the ‘Overcoming…’ series and self-help classics such as ‘Feel the fear and do it anyway’. This promotion of self-help books is seemingly an extension to the IAPT scheme which a government initiative to increase access to talking therapies throughout the UK.

What is interesting is how recovery became something individually directed to something guided by experts. Perhaps this is a bigger question that directs us to much bigger shifts in healthcare. To return back to positive psychology, the conception of the self is an interesting one. As mentioned above, positive psychology rejects psychoanalytic models that emphasis the unconscious or early childhood, employing in Binkley’s words ‘a strikingly truncated view of the human psyche’ (2011, p384). Yet positive psychology and the happiness proponents centre their belief in the need to guide and advice people about happiness by claiming we don’t always do the things we ought. We are prone to making mistakes about our happiness, says Paul Dolan (2011) and so we need our attention redirected to the right (happy) objects. Positive psychology thus seems to imply we have an unconscious that leads us to unhappiness and needs redirecting but this is something we need to be helped with – in the name of autonomy. I also feel this conception of the self and emotions echoes how bereavement counsellors and psychiatrists seem to work on the idea that feelings are already existent in the grieving individual, but simply need a language through which to articulate them.

With the ‘happiness agenda’ the problem occurs when the promotion of certain ways of living a life are at the expense of other ways of living, of being free to be unhappy, resulting in a decrease in the toleration of the different ways people live their lives. Indeed the pursuit of happiness can in itself mean happiness is decreased through failing to attain the objects that are designated as creating happiness. This is an argument put forward by Pascal Bruckner in which he attacks the ‘duty to be happy’. His argument also draws interesting parallels with Lauren Berlant’s idea of ‘cruel optimism’. Cruel optimism is when something you desire is actually an obstacle to your flourishing. The attachment to the desire (say to be happy, or to recover) becomes cruel only because the object that draws your attachment impedes the aim that brought you to it initially. These objects come in to represent happiness or freedom but ultimately by becoming attached to them they get in way of any chance we have of sensing freedom or happiness.

This has lead me to think more about emotions, and return to Sara Ahmed’s work on happiness and emotions (2004, 2010) and sociological explorations into emotions, in order to reflect on the understanding of grief I am assuming in my own analysis.

References

Ahmed, S. (2004). The Cultural Politics of Emotion. Edinburgh: EdinburghUniversity Press.

Ahmed, S. (2010). The Promise of Happiness. Durham and London: Duke University Press.

Berlant, L. (2011). Cruel Optimism.Durham and London: Duke University Press.

Bruckner, P. (2010). Perpetual Euphoria: On the duty to be happy. Oxfordshire: PrincetonUniversity Press.

Department of Health (2011a). No health without mental health: a cross-government mental health outcomes strategy for people of all ages, London: Department of Health.

Dolan, P. (2011, 8th February). ‘Absolute beginners: Behavioural economics and human happiness’. Department of Social Policy Inaugural Lecture delivered at the London School of Economics. Video of talk available here: http://www2.lse.ac.uk/publicEvents/events/2011/20110208t1830vSZT.aspx

Foresight Mental Capital and Wellbeing Project (2008). Mental Capital and Wellbeing: Making the most of ourselves in the 21st century. Final Project report – Executive summary. The Government Office for Science, London.

Marks, S. (2012) ‘Cognitive behaviour therapies in Britain: The historical context and present situation’ in Dryden, W (ed) Cognitive Behaviour Therapies. London: Sage.

Rose, N. (1989) Governing the Soul: The Shaping of the Private Self. Second Edition. London: Free Associations Books.