Philosophy and Psychiatry

For more years than I care to admit, I have been engaged in writing a book about psychiatry. Its current working title is Psychiatry as a Human Science. Psychiatric disorder raises many deep philosophical questions. There are questions about interpretation. What is going on in the mind of someone who expresses a belief that seems obviously delusional? Can they really believe it? If they do, what is going on in their psychology? Are they misinterpreting evidence? Or is their belief nothing to do with evidence? Why this delusion rather than some other one? There are questions about psychiatric explanation. How do causes at the level of neurology or neurochemistry mesh with causes at the psychological or "human" level? Can there be a coherent explanation that allows changes to the amygdala or changes in the dopamine level to interact with other causes such as abuse in childhood or exposure to the trauma of war? How should we think of the interaction between such disparate kinds of causes? This relates to a question about people who are profoundly changed by mental disorder. Biological psychiatry often can tell us a fair amount about the neurochemistry underlying the changes. But there are questions at the human level about what happens to the person's sense of identity. And there are questions about responsibility: psychiatrists as witnesses in court may be asked whether an act of violence came from the illness or simply from the person's own nature. How are such questions to be answered? Where the person has a disorder that radically changes character and personality, does the distinction between "coming from the person" and "coming from the illness" make sense? Psychiatry raises many other questions that are partly philosophical, of which perhaps the most fundamental is: on what basis do we decide that some conditions, but not others, are psychiatric illnesses?

The questions about psychiatry that most interest me are about:

The boundaries of psychiatric disorder.
The interpretation of the actions and mental states of people who have these disorders.
The links between psychiatric conditions and personal identity.
The links between psychiatric disorder and responsibility.
What is going on, and what should be going on, in psychotherapy.

My interest in these questions arises partly because of the way psychiatric understanding and treatment are enmeshed with some of the deepest and most interesting philosophical questions there are. But it also comes from the belief (reinforced by experience of psychiatric problems in people close to me, and by experience of the greatly varying quality of the professional responses to those problems) that more effective and more humane treatment needs both scientific progress and a deeper understanding at the human level. In one way this is a platitude. These days few people deny that biological explanations and treatments are often very important. And few deny that understanding at the human level, and interventions such as psychotherapy, are often very important. But there is an asymmetry. We have a fairly good idea about what progress at the neurochemical or genetic level looks like. But, partly because understanding at the human level is so bound up with unresolved philosophical issues, we are less clear here what kind of progress to look for. My hope is to make a contribution, together with others in the recently more flourishing field of philosophical psychiatry, to a more humanist psychiatry. The current working title of my book, Psychiatry as a Human Science, reflects a commitment both to scientific method in psychiatry and to humanism in psychiatry.

THE BOUNDARIES OF PSYCHIATRIC DISORDER.

Personality Disorders.

"Personality Disorders" tend to be thought of as rigid patterns of thought, feeling and action which are "maladaptive", and which either impair the person's functioning or cause the person distress.

It is only when personality traits are inflexible and maladaptive and cause either significant functional impairment or subjective distress that they constitute Personality Disorders.

Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).

One interpretation of what a "personality disorder" is suggests that it involves a distortion of character or personality that impairs the person's capacity for human flourishing. This Aristotelian approach is plausible, but raises questions about what we should count as flourishing or as impairment:

Obviously these huge questions should not be answered by giving a single blueprint of how everyone should live. What counts as flourishing may vary with age, gender, place and time. A modern American teenage boy will not flourish exactly as Proust's grandmother did. But, subject to this obvious and necessary pluralism, there still may be some things to say about the good human life which are not vacuous. Some features of good lives may fall into clusters...

It is a familiar thought that a battery chicken or a caged bird cannot flourish because such lives deny their natures. Part of a good life for a bird is to use its wings and fly. Are there similar aspects of human nature that set some of the contours of the good human life?...

One possible account of human flourishing would be in terms of our physical and psychological systems performing the functions for which evolution designed them. One worry about such an account is that it seems to ignore the way in which human culture allows us to move away from our biological origins. If reproduction was the original function of sex, can this approach avoid an echo of the bad old days of seeking to "cure" gays and lesbians? Do we really want to say that gays and lesbians have less flourishing lives?

From Towards Humanism in Psychiatry, Tanner Lectures in Human Values, Princeton, 2003, Lecture Two: Identity.

Antisocial Personality Disorder.

GWEN ADSHEAD

As part of a project with the psychiatrist Gwen Adshead, I interviewed some patients in Broadmoor, who had a diagnosis of "Antisocial Personality Disorder". My interest was in how they thought and felt about ethics. These interviews were the topic of part of a discussion with Alan Ryan at the London School of Economics:

LSE Meeting (parts 2 and 3)

TOWARDS HUMANISM IN PSYCHIATRY: INTERPRETATION.

It is not only in psychiatry that we may wonder about the reliability of our interpretations of other people. In Marcel Proust's great novel, the narrator describes his childhood discovery that Francoise, a family servant who he had always believed to be someone who liked him and was fond of him, had said some very hostile things about him. This led him to the thought that other people's mental states are not "a garden we see through a railing, with all its borders spread before us, but a shadow we can never penetrate, behind which there may burn the flame of hatred or love". There is obviously room for great disagreement about how far other people's inner states are relatively easy to interpret and how far they come closer to Proust's impenetrable shadow. Different people may vary in how hard or easy they are to read. And different people also vary in their general view of how far others are transparent or opaque.

But often there are additional problems for attempts to get a feel for the inner life of people with psychiatric disorders.

There are questions about how things said and done by people with psychiatric disorders should be interpreted. And, as part of this, there are questions about how people with psychiatric disorders interpret the world...

Some people with psychiatric disorders at times strike others as strange. They may behave in ways that seem unintelligible. They may look strange of have an odd posture or gait. They may laugh at unexpected times, or stare, or say things in ways that make it hard to have a conversation with them. At such times, it is hard to get through to them. They may seem unreachable.

Sometimes this inaccessibility has baffled their families and friends, and also psychiatrists. Eugen Bleuler, the inventor of the word "schizophrenia" said that people with the disorder were stranger to him than the birds in his garden. Karl Jaspers said it was possible to have empathy for those with mood disorders, but not for those with schizophrenia: "We may think we understand those with dispositions furthest from our own, but when faced with such people, we feel a gulf which defies description".

Since those hit by schizophrenia are not birds in the garden but people, their problems may be compounded by our inability to reach them. To psychiatric disprder may be added loneliness and isolation. Understanding them more intuitively, "from the inside", matters independently of any contribution to developing a cure. It is also a serious intellectual challenge to psychiatry, to psychology, and to philosophy. So far, our theories about knowledge of other minds have not much helped us here.

From Towards Humanism in Psychiatry, Tanner Lectures in Human Values, Princeton 2003, Lecture One: Interpretation.

KARL JASPERS

Download: Tanner Lecture One: Interpretation (121kb)

To understand the world we need to move from passively absorbing information to active interrogation and interpretation.

Reason... must approach nature in order to be taught by it. It must not, however, do so in the character of a pupil who listens to everything the teacher chooses to say, but of an appointed judge who compels the witnesses to answer questions which he has himself formulated.

Immanuel Kant: Critique of Pure Reason.

On the pervasiveness of our - often barely conscious - interpretations of people.

Even the simple act which we describe as "seeing someone we know" is, to some extent, an intellectual process. We pack the physical outline of the creature we see with all the ideas we have already formed about him, and in the complete picture of him which we compose in our minds those ideas have certainly the principal place. In the end they come to fill out so completely the curve of his cheeks, to follow so exactly the line of his nose, they blend so harmoniously in the sound of his voice that these seem to be no more than a transparent envelope, so that each time we see the face or hear the voice it is our own ideas of him which we recognise and to which we listen.

Marcel Proust: Swann's Way.

In defence of the "human" interpretations of people sometimes dismissed as "folk psychology".

PETER STRAWSON.

Still, we have the theoretical idea of the two histories, each complete in its own terms; we might call them the physical history and the personal history... Each story will invoke its own explanatory connections, the one in terms or neurophysiological and anatomical laws, the other in terms of what is sometimes called, with apparently pejorative intent, "folk psychology", i.e. the ordinary explanatory terms employed by diarists, novelists, biographers, historians, journalists, and gossips, when they deliver their accounts of human behaviour and human experience -the terms employed by such simple folk as Shakespeare, Tolstoy, Proust, and Henry James.

P.F. Strawson: Skepticism and Naturalism: Some Varieties.

TOWARDS HUMANISM IN PSYCHIATRY: IDENTITY AND SELF-CREATION.

I AM.

I am -yet what I am, none cares or knows;

My friends foresake me like a memory lost;

I am the self-consumer of my woes-

They rise and vanish in oblivions host,

Like shadows in love frenzied stifled throes

And yet I am, and live -like vapours tost

Into the nothingness of scorn and noise,

Into the living sea of waking dreams,

Where there is neither sense of life or joys,

But the vast shipwreck of my lifes esteems;

Even the dearest that I love the best

Are strange -nay, stranger than the rest.

I long for scenes where man hath never trod

A place where woman never smiled or wept

There to abide with my Creator God,

And sleep as I in childhood sweetly slept,

Untroubling and untroubled where I lie

The grass below, above, the vaulted sky.

JOHN CLARE.

Psychiatric illness can change people so profoundly that they can feel their central core is under threat. When they behave strangely, others (judges, doctors, social workers, or just family and friends) may ask the question it is so hard to get into focus: "Was that her or did it come from her illness?". Psychiatrists may wonder if the medication is containing the illness or rather changing the underlying person. It may be important to a person with depression to incorporate the dark times as part of his self rather than to see them as alien. Someone taking the medication may find her sense of self changed radically. Sometimes part of the escaping and recovery from illness is a conscious process of self-examination and self-creation. In all these ways, there are complex and elusive links between psychiatric disorder and personal identity. The necessary process of tracing out these links, a central task of humanist psychiatry, is one we have hardly started on.

When someone has been profoundly changed by psychiatric illness -or through some other cause- it can be very important that the person behind the changes is still recognized.

In the magical children's book Finn Family Moomontroll by Tove Jansson, when the children are playing hide and seek, Moomintroll hides in the Hobgoblin's hat and comes out unrecognizably changed:

"You aren't Moomintroll", said the Snork Maiden, scornfully. "He has beautiful little ears, but yours look like kettle-holders!"

Moomintroll felt quite confused and took hold of a pair of enormous crinkly ears. "But I am Moomintroll!" he burst out in despair. "Don't you believe me?"

"Moomintroll has a nice little tail, just about the right size, but yours is like a chimney sweep's brush", said the Snork.

And, oh dear, it was true! Moomintroll felt behind him with a trembling paw.

"Your eyes are like soup-plates", said Sniff. "Moomintroll's are small and kind!"

"Yes, exactly", Snufkin agreed.

"You are an inpostor!" decided the Hemulen.

"Isn't there anyone who believes me?" Moomintroll pleaded. "Look carefully at me, Mother. You must know your own Moomintroll."

Moominmamma looked carefully. She looked into his frightened eyes for a very long time, and then she said quietly: "Yes, you are my Moomintroll."

And at the same moment he began to change. His ears, eyes and tail began to shrink, and his nose and tummy grew, until at last he was his old self again.

"It's all right now, my dear," said Moominmamma. "You see, I shall always know you whatever happens."

Tove Jansson:Finn Family Moomintroll, translated by Elizabeth Portch.

Rainer Maria Rilke's jubilation at emerging from an emotionally dark time includes celebrating the dark times themselves:

How dear you will be to me then, you nights of anguish,
Inconsolable sisters, why didn't I kneel to you, submissive,
And lose myself in your dishevelled hair?

By looking through our bitter times towards their end
We squander our sorrows. But they are a season of us,
Yes, our winter foliage, our dark evergreen. Not only a season,
But also our landscape, settlement and fortress,
Our depths and our home.

Rainer Maria Rilke: Duino Elegies, Tenth Elegy.

KAY REDFIELD JAMISON.

Lithium prevents my seductive but disastrous highs, diminishes my depressions, clears out the wool and webbing from my disordered thinking, slows me down, gentles me out, keeps me from ruining my career and relationships, keeps me out of a hospital, alive, and makes psychotherapy possible. But, ineffably, psychotherapy heals. It makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Psychotherapy is a sanctuary; it is a battleground... But, always, it is where I have believed -or have learnt to believe- that I might someday be able to contend with all of this...

Lowering my lithium level had allowed not only a clarity of thinking, but also a vividness and intensity of experience, back into my life; these elements had once formed the core of my normal temperament, and their absence had left gaping hollows in the way in which I could respond to the world. The too rigid structuring of my moods and temperament, which had resulted from a higher dose of lithium, made me less resilient to stress than a lower dose, which, like the building codes in California that are designed to prevent damage from earthquakes, allowed my mind and emotions to sway a bit. Therefore, and rather oddly, there was a new solidness to both my thinking and my emotions.

Kay Redfield Jamison: An Unquiet Mind, a Memoir of Moods and Madness.

In summary, I would like briefly to state my view of the essential aspects of recovery: There is inside of me a self, a spirit, which is gradually becoming more aware of me and others. That self is becoming my guide. It encompasses all that I am. My self includes, but is greater than, my chemicals, my background and my traumas: It is the me I am seeking to become in my relationships, in that moment of creative uncertainty when I make contact with another. From that moment of harmony, when, together, we defy the odds and say "yes", our lives will go on differently, regardless of how we live the following moment. We are all inventing our lives at each moment.

Dan Fisher: Hope, Humanity and Voice in Recovery from Mental Illness, in Phil Barker, Peter Campbell and Ben Davidson: From the Ashes of Experience, Reflections on Madness, Survival, Growth.

In coming to terms with schizophrenia and recovering a healthier concept of self, I have certainly been engaged in a deep communication with myself. It is a communication that has given me the most precious thread, a thread that has linked my evolving sense of self, a thread of self-reclamation, a thread of movement toward a whole and integrated sense of self, away from the early fragmentation and confusion I felt as I first experienced schizophrenia...

I have come to see that you do not simply patch up the self you were before developing schizophrenia, but that you actually have to recreate a concept of who you are that integrates the experience of schizophrenia. Real recovery is far from a simple matter of accepting diagnosis and learning facts about the illness and medication. Instead, it is a deep searching and questioning, a journey through unfamiliar feelings, to embrace new concepts and a wider view of self.

Simon Champ: A Most Precious Thread, in Phil Barker, Peter Campbell and Ben Davidson: From the Ashes of Experience, Reflections on Madness, Survival, Growth.

An indication of the power of medicine to reshape a person's identity is contained in the sentence Tess used when, eight months after first stopping Prozac, she telephoned me to ask whether she might resume the medication. She said, "I am not myself".

Dr. Peter Kramer: Listening to Prozac.

Prior to Prozac, when asked to describe my early history, I would tell a story of depression with roots so far-reaching even my earliest memories came up gray... But having been on Prozac for ten years now, I notice my memory of my early life changing a bit. I still vividly recall the whiteness, the fear, the cold, the cuts. But the lifting of illness, incomplete though it is, has brought other, more colorful glints as well. In altering my present sense of who I am, Prozac has demanded a revisioning of my history, and this revisioning is perhaps the most stunning side effect of all.

Lauren Slater: Prozac Diary.

Download: Tanner Lecture Two: Identity (111kb)

Download: Self Creation (1.49mb)

Psychiatric Disorder and the Reactive Attitudes

ROLE MODELS FOR PSYCHOTHERAPISTS: FREUD OR SOCRATES?

I was asked by The Journal of Family Therapy to write about a commentary on four papers they published. The commentary indicated the content of the points selected for discussion from the articles, but its central thrust was a consideration of what the aims and methods of family therapy should be. Here is the commentary:

Like the activities of other professions, family therapy is practiced in ways that range from the abysmally bad to the utterly brilliant. Since the service given to families depends on how good therapists are, some reflection is in order on what "good" therapy is. Each of these four papers provides relevant evidence or raises relevant issues. Views on what counts as good family therapy will vary with the answers given to three inter-related questions. Do most of the family problems that therapists are trying to help sort out have a common structure? What should the aims of the therapist be? What strategies should the therapist adopt? Each paper makes a contribution to one or more of these questions.

Do most of the family problems have a common structure?

Family therapists could reasonably sigh when confronted with Tolstoy's famously confident assertion that all happy families are alike, while an unhappy family is unhappy in its own way. Questions can be asked about both claims, but family therapists have a particular stake in challenging the second one. Part of their claim to expertise rests on experience of what has previously been useful in understanding, and helping with, the problems of other families. Total absence of any common patterns would make such experience useless.

The five family therapists interviewed by Ceri Bowen clearly believe there are common patterns. Their comments, in response to a clip of a family episode of blaming, were centred on a few themes. These include relationship problems: strereotyping or having unrealistic expectations of each other, poor communication, intolerance, and vicious circles of mutual interaction. Another theme is negative attitudes: low self-esteem, excessive criticism, and an "unhealthy allocation of responsibility for problems". Another theme is parents' own past family problems, particularly with their own parents.

How persuasive is this? Are we learning about patterns actually present in the families or just about the belief system of therapists? Some scepticism arises about interpretation at a detailed level. One instance cited of "unhealthy allocation of responsibility for problems" is " "illness" as responsible for problems". A therapist expanded on this: "putting all the problems in some sort of externalized thing like Dad's depression or Mum's anxiety. It seems a very helpful thing for them." Perhaps. But equally a family's difficulties really may stem from one of their members getting Alzheimer's, schizophrenia, or depression. Obviously families may sometimes deceive themselves, using mistaken causal accounts to rationalize their problems. But there is a troubling hint of "therapist knows best" when these comments are presented without discussing what evidence is needed to justify over-riding a family's own understanding of their situation.

Although these themes are presented as an "exploratory model", Ceri Bowen et al. say they are "not claiming a causal sequence". Yet there are obvious causal conjectures. The past family problems might have a causal influence on the stereotypimg, the unrealistic expectations and the poor communication. The vicious circles of interaction might increase the level of mutual criticism and blame. It would be good to have empirical studies at this detailed level of causation. If this account is a model, rather than a mere series of disconnected observations, some causality needs to be postulated, at least as a hypothesis.

The account of a common structure of bad spirals of mutual interaction sounds plausible as a working hypothesis. Given this picture, how should therapists proceed?

What should be the aims of family therapy?

John Stancombe and Sue White give a similar picture of mutual blame: "when families come to therapy, their members... are usually engaged in some kind of mutual recrimination". They say that the therapist is usually seen as moving family members "from unhelpful and morally-loaded positions to ones in which positive change can more readily occur". They raise doubts about whether this needs neutrality between rival narratives of family members, but do not challenge the goal itself.

Families with different problems will generate different aims for therapists: helping the familiy cope with the needy and demanding grandparent who has come to live with them; helping homophobic parents listen to their son who has come out as gay; helping the teenager to talk about previously hidden childhood traumas and helping the parents to listen.

Therapy may take the form of helping families live with conflicts or disagreements that cannot be eliminated. ("Our religion still tells us that homosexuality is sinful, but we see you have to decide about your own life.") It may take the form of helping family members to listen to each other's narratives and to see that no single person's narrative has the whole truth. It may involve helping people escape from bad cycles of interaction, including mutual blame (in Ceri Bowen's phrase "lifting the vision towards more positive possible futures").

At this level of generality these aims inevitably sound platitudinous. The controversial issues concern how to bring them about.

What strategies should family therapists adopt?

How should therapists help families escape bad cycles of mutual interaction, mutual misunderstanding and mutual blame? Katja Kurri and Jahrl Wahlstrom use a therapy session for a couple to illustrate help in escaping these cycles. They also bring out some associated moral problems.

One therapist ivites the husband to consider the possible role in his agitated shouting of his critical thoughts about his wife's "emotionality", and asks him to consider why she reacts as she does. The therapist implies that the husband might accept some responsibility for the situation. But later the therapist is said to emphasize the good intentions of both husband and wife: "The therapist's statement emphasizes the reformulation of the transactional pattern as expressing good intentions on both sides. The therapist appears here to deconstruct blame... If the intentions are good but the outcome undesired, then it appears as if something like bad luck or fate is in operation. In that case none of the participants could be held responsible for the course of events. The responsibility is given to the transactional pattern, so to speak."

Perhaps it is inviting scepticism to ascribe responsibility for the relationship going wrong not to human agency but to fate, to bad luck or to "the transactional pattern". Yet there are cases of mutual misunderstanding, despite good intentions on both sides. In such cases, exposing the good intentions may help the couple escape from mutual recrimination. But intentions are not always good. What should happen when one of the couple is open to reasonable criticism for being selfish or insensitive? The authors rightly see it as a problem for the moral neutrality of therapists that there may be no morally neutral way of formulating this issue.

The way the authors set up the problem is to ask whether therapists can be neutral between two "discourses", one of autonomy and one of "relationality". The discourse of autonomy emphasizes each person's right to make his or her own choices and to pursue his or her own interests. The discourse of relationality emphasizes emotional responsiveness to others. If, in a couple, he is strong on his autonomy and on the pursuit of his own self-interest and she feels he is too emotionally insensitive to her, what should the therapist do? The authors suggest, approvingly, that the therapists resolved the conflict between the two discourses by following a "principle of relational autonomy". This "indicates that identity and autonomy are generated from a matrix of relations". The therapists' interventions "produced a situation where the partners' autonomy was necessarily understood as relational".

The principle of relational autonomy seems too platitudinous and too vague to be much of a success in changing behaviour. ("Yes, I agree my identity and autonomy evolved in the context of relationships, but I still don't see why in this case I should put my autonomy second to what I see as my wife's unreasonable feelings.") And is it really true that therapists have to decide between "reinforcing" one or other of the values or else both? It is not for the therapist to decide on priorities for the couple, guided by some principle that somehow melds together the two values. What would be wrong with asking questions designed to make the conflict of values explicit and asking whether the couple are willing to explore compromises?

Here there seems to be a clash between two models of therapy, which (with some caricature) could be seen as the clash between the therapist as Freud and the therapist as Socrates. The therapist as Freud says, "I have special psychological knowledge -in this case knowledge of how identity is generated from a matrix of relations- and my interventions will be designed to help you understand yourselves as I do." The therapist as Socrates says, "I don't know the answers, but I will ask questions designed to make your values explicit. If you each turn out to have different values, I will ask questions designed to find out if you can still get on with each other. Everything will depend on the answers you decide to give."

An obvious limitation of the model of Socrates for therapists is that his questions explored only beliefs and not emotions. In that way Freud's approach was a clear advance. But his -more debatable- idea of the special psychological knowledge, possessed only by initiates, and the resulting idea of the therapist's privileged interpretation, continues to be highly influential, even if the esoteric knowledge now comes from systems theory more than from psychoanalysis.

The model of the therapist as Freud can lead to a worrying tendency towards being manipulative. This appears in Michelle O'Reilly's discussion of therapists' responses to families' complaints about their treatment by the police or the social services. One question is why the families think the therapist is the person to complain to. It may be ignorance: seeing all the professionals as part of an undifferentiated "them". Alternatively, they may have been persuaded into family therapy by being given misleading expectations of useful advice. Either way, Michelle O'Reilly is right that they need some recognition of their difficulties and guidance in seeking help.

No doubt she is also right that complaints are "not received positively in therapy". The manipulativeness surfaces in her account of "the interactional techniques used to close them down": the replies that do not address the complaints but steer the conversation towards how the person feels. The mother complaining that the social services are victimizing her children may be justifiably dissatisfied with the evasive response "and how does that make you feel?". ("And how does that response make you feel?" -"Patronised.") Instead of the concealed attempt to "close down" the complaint, why not a direct response, a clear, plain statement? ("These sessions are about helping you to cope with your problems. I can't change what the social services do, but the way to make a complaint is...")

A deep ethical issue in family therapy concerns the role of truth. On this issue the Freudian and Socratic models may pull different ways. Does it matter to what extent each of various family members' conflicting narratives are true? The therapist as Socrates may think this is worth exploring. If one person has paranoid fantasies about others in the family, those others may wnat to "put the record straight" (to whatever extent it is possible to do so). The therapist as Socrates may be open to discussing the evidence, while the therapist as Freud (who perhaps "knows" that the real problem are about systems and boundaries) may try to exclude the issue as unhelpful. Paradoxically, the Socratic approach sometimes may be more helpful, because of the importance people attach to their true history being recognized.

There are parallels to debates about political peacemaking, as between Israelis and Palestinians. Is it better to forget the disputed past and start afresh, or do both sides need acknowledgement of the truths in their respective narratives? And "we accept that your version is true for you, just as theirs is true for them" may not be enough. It may elicit the response that this account isn't just "true for us": we want some recognition that these events actually happened.

In the case of the mutually blaming couple, when the therapist suggests that actually they both had good intentions, is this said because it is true or because it is helpful? Of course, if true, it is likely to be helpful. But supposing it isn't true? Is it still acceptable to suggest it, because it may help the couple to escape the bad cycle if they both believe it? The therapist as Freud might say "yes", on grounds of understanding their problems better than they do. The therapist as Socrates, not claiming a privileged view, lacks this reason for deception.

The therapist as Freud seems to lurk behind John Stancombe and Sue White's very interesting discussion of the "paradoxes of neutrality". The goal of moving towards some shared view allowing the family to escape from the cycle of mutual blame is often assumed to require the therapist's neutrality between the rival versions. Showing empathy with one viewpoint may be seen as taking sides against others. This makes a case for therapists giving only "neutral" responses, neither rejecting nor endorsing the viewpoint expressed by a family member. As Stancombe and White report, this tends to result in the therapist either changing the subject, or else "reformulating" the blame-laden account in a non-blaming version. As they point out, either response may leave the person who expressed the view feeling that the core of his or her version has gone unheard and wanting to express it again. Hence the first "paradox": "neutrality seems to reinforce blaming in the session".

This problem only arises because of some disingenuousness in the practice of the therapist as Freud. The therapist has heard the expression of blame, but gives the impression of not having done so because of fear of the consequences of indicating this. Hence the evasive or off-the-point responses that give family members an irritating sense of being manipulated. The therapist as Socrates might feel that all points are worth taking seriously in the discussion. And doing so might not send a message about taking sides. (What about saying, "Sarah, I understand that you are blaming Henry for causing the problem by getting so angry. Henry, I know you may have a different view, and we will come to that in a minute. But for the moment, let's explore this account."?) This may open up the possibility of eventually moving towards a shared account that does some justice to both views: perhaps Henry's anger did contribute towards the daughter's anorexia, but perhaps Sarah's silent hostility contributed to his anger. The more complex account, brought out by acknowledging rather than evading the partisan points, could even be both helpful and true.

According to Stancombe and White, some such complex account, based on accepting or rejecting particular bits of the partisan versions, is what therapists construct for themselves. They are said to do this "in the backstage" as part of constructing a neutral version that can be "performed in the frontstage without compromising the therapist's "neutrality" ". The second "paradox" is that the neutral version is constructed by using the therapist's own non-neutral version.

The therapist as Freud is clearly visible here in this contrast between the therapist's backstage account and the frontstage account offered to the family. Why all this make-believe? Why not go for the Socratic version, using sympathetic questioning to coax the family into themselves constructing the complex account? I believe that this is what good therapists already do. Modest therapists are aware how little they can know of a family compared to what the family themselves know, and will expect the family's own complex account to be richer than anything concocted "backstage".

Part of the answer to the question of what marks of good from bad therapy is that good therapists, instead of being in the grip of a theory, have the human sensitivity that goes with being a good listener. And then, with Socratic openness in response to what they hear, they will help the family did themselves out of any trap they are in.

Another thing Tolstoy wrote was this: "Levin had often noticed in discussions between the most intelligent people that after enormous efforts, and endless logical subtleties and talk, the disputants finally became aware that what they had been at such pains to prove to one another had long ago, from the beginning of the argument, been known to both, but that they liked different things, and would not define what they liked for fear of its being attacked. He had often had the experience of suddenly in the middle of a discussion grasping what it was the other liked and at once liking it too, and immediately found himself agreeing, and then all arguments fell away useless." Of course this is a long way from the mutual recriminations. But to use gentle questioning -not to move families- but to help them move themselves even some of the way towards it, is a wonderful thing for a therapist to do.