Book Review – ‘Madness and Modernism’ by Louis Sass (2017 Ed.)

This ground-breaking work revises traditional understandings of schizophrenia as ‘a form of encroaching dementia, regression, or dominance by instinct and the irrational’ and instead views it as ‘involving unusual forms of self-consciousness together with associated alienation and withdrawal – not only from the surrounding world and other human beings, but also from one’s own thoughts, feelings, and bodily presence.’ (Preface).

It is a work of ‘comparative phenomenology,’ which uses modernist art and literature as a tool to help us better understand schizophrenia. By placing both next to each other, Sass draws out some striking similarities to illuminate a potential logic that might underpin them both.

Sass argues that both modernist art and schizophrenia can be understood as evidencing ‘hyperreflexivity’ and a concomitant ‘alienation’. The range of material that he covers, and the detailed analyses of case studies of individuals with schizophrenia, make this book a brilliant attempt at better understanding a mental disorder that has, since its conception, baffled psychiatrists and researchers.  

My own academic background is in both psychology and literature, so I was extremely excited to see the disciplines used productively together to help us understand, phenomenologically, madness – and, by bringing its opposite into relief, sanity as well. Sass doesn’t try to explain the aetiology of schizophrenia, other than gesturing towards the likely conclusion that it will involve several primary and secondary factors, in unpredictable combinations, and this is a good thing. His aim is to understand, rather than explain, and this book does a fantastic job in making sense of symptoms and behaviours that have typically been distinctive by their complete incomprehensibility. I thoroughly recommend this book to anyone interested in phenomenological psychopathology and/or modernist art.

I’d be very interested to know whether any other scholar has attempted a study of contemporary, 21st century art and thought, in its relation to another form of madness? It seems that Sass is right in identifying the parallels between 20th century modernist art and schizophrenia, but times have changed, and I wonder what the contemporary parallel could be? The present day has moved interestingly away from the ‘modernist/postmodernist’ zeitgeist that Sass studied, into new territory, and I think one deserving the same kind of scrutiny that Sass gave the 20th century!

A Common Criticism of CBT

Some critics of Cognitive Behavioural Therapy (CBT) have focussed their attack on its underlying theoretical assumption that our ‘beliefs’ cause mental distress. That’s a pretty easy target, though, once you look at the correlations between factors like poverty, abuse, systemic oppression; and mental distress – in those cases, would you really call their thinking ‘faulty’ when it reacts against these conditions? It seems more mistaken not to be distressed in those cases. So naturally, CBT theorists adjusted and now recognise that external factors play a significant role in contributing to mental distress.

In practice, that meant that CBT moved away from the ‘C’ and towards the ‘B’ (Behaviour): instead of telling the individual to change their thoughts, the idea now was to get them to change their behaviour, which would hopefully go some way towards fixing their unhelpful environment. For example, if poverty is making you depressed, why not get a job? If your husband’s drunken violence is causing you anxiety, why not go to a friend’s house next time this happens?

There are obvious problems with this – most glaringly that the focus is still on the individual (rather than the structural or societal), however, I do understand that psychologists are limited in the areas that they can help with – they aren’t politicians or social workers, after all.

Another way that the CBT theorists tried to update the underlying philosophy of CBT was to think in a less linear (‘x causes y’) fashion, replacing this with a cyclical framework of our thoughts, behaviours, emotions and physical feelings as all interrelated and mutually reinforcing.

CBT formulation - 80ss Anxiety - POINT-1

This served to disperse the blame, so now we can’t ever quite say for certain which came first: the faulty thoughts or faulty environment… Do we pick poor husbands because we think badly of ourselves, or do we think badly of ourselves because of our abusive partners?

The 5 Areas Model we are taught appears comprehensive, but I still get the feeling that the CBT-based approach is missing out on some vital aspects of human life. Predominantly, I begrudge the lack of a detailed discussion on affects and moods as non-propositional, and the importance of intersubjectivity. CBT seems to be based on some unhelpful and out-dated conceptions of how we exist in the world. The underlying theory describes the human being in a mechanistic, representational manner – someone that understands the world in propositions (or mental images) and then acts accordingly.

I am not breaking new ground by arguing that CBT feels impoverished in these respects – Anthony Ryle’s psychoanalytic alternative to CBT, CAT (replacing ‘Behavioural’ to ‘Analytic’), attempts to redress this individualistic approach by creating a space for ‘Reciprocal Roles’ formed in our early relationships with caregivers. I have not yet read as much about CAT as I would like to (I’ve only just started reading Introducing Cognitive Analytic Therapy [Ryle & Kerr 2020] – and am very much enjoying it so far), but I think there’s a chance that it also remains too firmly representational, and doesn’t fully conceptualise things like affects and moods that couldn’t easily be formulated into propositions. From what I know so far, and as suggested by its name, CAT takes a similarly computational approach to the human psyche, only it has broadened the roots of these cognitions to include our early relationships, instead of keeping the focus on the individual as a separate being. It sees cognitions as arising within intersubjective relationships and from the roles we assume within those relationships. I like this expanded concept, and perhaps I’ll find that it is a good enough update to the theory, but I will save that conclusion until I’ve finished the book. From where I stand now, however, I don’t think that we should limit ourselves to cognitions that can easily be translated into propositions or even mental images.

I’ve developed this view through my reading of phenomenological approaches to psychology, starting with Maurice Merleau-Ponty who argued that perception is direct (and hence against the subject-object distinction), similar arguments put forward by the ‘Ecological’ psychologist James Gibson, the philosopher of psychiatry Thomas Fuchs who writes of affects and moods as existing in the ‘backdrop of an experiential field’, and Enactivist philosophers of mind (Varela, Thompson, De Jaegher) who stress the ‘embodied, embedded and extensive nature of mentality’…  

Perhaps it’s a matter of temperament, but these thinkers seem to capture something that fits more with my experience as a human being. I can’t convince myself that ‘representations’ or mental images play as large a role in our thoughts, feelings and behaviour as cognitive scientists seem to believe. Maybe I have a distinctly empty inner world, but I hardly ever seem to be thinking of any clear representations of things, or even thoughts in words. From his case studies it sounded like Beck’s clients had similar difficulty in formulating what they were thinking. Of course, if I were to be asked, as they were, ‘what thought went through your mind when you last felt sad?’ I could probably think of something (as they did) but I have a feeling that I’d be creatively guessing rather than faithfully reporting what was going on my mind. Usually when I feel low it is due to a more vague sense of wrongness, more like a mood that colours my entire environment, rather than a clear ‘negative thought’; and might be due to some kind of interpersonal shift in atmosphere that I will have picked up from my partner, for example. These are distorted once they are forced into the form of a clear proposition – ‘my boyfriend doesn’t like me’ – would be the forced answer I’d give to Beck, but that wasn’t really what I thought, so if he started listing reasons as to why that might not be the case I’d find it a waste of time, or if he did a bad job and didn’t persuade me, insulting.

At the same time, I don’t believe that we need to make this an either/or dilemma – I don’t want to say that cognitive representations do not exist full stop – they may well do when we are more explicitly remembering or imagining. I just don’t think that ‘internal representations’ are all that we have – more often it feels as though we are behaving in a more automatic-pilot way – perceiving and responding to the world as it happens, and as we move through it. And I think that our moods and feelings are born and played out within interpersonal relationships and situations, rather than our inner mind observing and formulating its own little images.

The counterargument could be made, however, that maybe the CBT ‘philosophy’ doesn’t quite capture it all, but this isn’t important because the therapy works. My tutors on the Psychological Wellbeing Practitioner course are always drilling it into us not to think too much about our client’s past experiences or even their thoughts – because it’s their behaviour that we need to change, as this will have the biggest benefits. How would I go about shifting someone’s mood anyway, if it really is that nebulous thing that I have described? Beck wanted to make a practitioner’s science, not a philosophy of mind. But the low intensity CBT approach in IAPT is getting only 50% recovery rates at the moment, so I don’t think anything’s decided yet, and we should probably keep thinking and revising…