A psychoanalyst walks into a bar(red subject)

A psychoanalyst walks into a bar with a book on logic and set theory. He orders a whisky. And another. Twelve hours and a lock-in later, all he has to show for the evening is a throbbing headache and some indecipherable nonsense scribbled on a napkin.

That’s the only conceivable explanation for these diagrams from The Subversion of the Subject and the Dialectic of Desire in the Freudian Unconscious, by Jacques Lacan (published in the Écrits collection):

But, I hear you ask, surely this notation means something? After all, Lacan is famous and studied across the world, and f(x) is well-recognised as a function, f, applied to argument x. So the I(A) and s(A) must mean something?

Here is a brief interlude on functions. The Fibonacci sequence, which pops up in all kinds of interesting places in nature, can be defined as following:

f(0) = 0,
f(1) = 1,
f(n) = f(n-1) + f(n-2), for n > 1.

In English, this says that the first two numbers in the sequence are 0 and 1. The numbers following are obtained by summing the previous two: 0, 1, 1, 2, 3, 5, 8, 13, 21, 34, …

If you tell it a number (e.g., 0, 1, 2, …) then it replies with the respective number in the sequence (first, second, third, …). It might look a bit scary if you haven’t seen the notation before, but check out these examples demonstrating how the arithmetic is carried out:

  • f(0)  =  0
  • f(1)  =  1
  • f(2)  =  f(1) + f(0)  =  1 + 0 = 1
  • f(3)  =  f(2) + f(1)  =  1 + 1 = 2
  • f(4)  =  f(3) + f(2)  =  2 + 1 = 3
  • f(5)  =  f(4) + f(3)  =  3 + 5 = 5
  • f(6)  =  f(5) + f(4)  =  5 + 3 = 8

The point here is that the function notation “does something”. It provides a way of defining and referring to (here, mathematical) objects.

Less well-known, but appearing in university philosophy courses, is the lozenge symbol, ◊, which means “possible” in a particular kind of logic called modal logic. It seems plausible that there is something meaningful here in Lacan’s use of the symbol too.

Here is Lacan, “explaining” his notation for non-mathematicians:

Huh?

Lacan doesn’t try to explain what the notion means; he doesn’t seem to want readers to understand. Maybe he is just too clever and if only we persevered we would get what he means. However, elsewhere in the same text Lacan uses arithmetic to argue that “the erectile organ can be equated with √(-1)”. Personally, I am unconvinced.

Alan Sokal and Jean Bricmont have written a book-length critique of Lacan’s maths and others’ similar use of natural science concepts. Having read lots of mathematical texts and seen how authors make an effort to introduce their notation, I think it’s entirely possible Lacan is a fraud. That might sound harsh, but just look at how he writes. I reckon anyone can see for themselves that Lacan is writing nonsense if they take a look and forget for a moment how famous he is.

 

Lightly edited 18 Sept 2018, hopefully making clearer!

On evidence in psychological therapy

It sometimes feels that the demand for evidence for psychological therapies is seen as offensive. How dare researchers, commissioners, and policymakers reduce therapeutic relationships to tickbox questionnaires and symptom reduction! Therapy is something larger, broader, more holistic than that.

There are clearly problems with using short questionnaires consisting of a handful of closed-questions, and then summing these to a distress score before and after care. But the other extreme, trusting the professionals who are paid to provide therapy to say how effective their therapy is, doesn’t sound convincing either – especially for therapists in private practice who charge by the session. If a therapist depends on long-term therapy for their income, it might be challenging for them to think through different perspectives on how helpful their brand of therapy actually is.

Improving Access to Psychological Therapy (IAPT) is criticised for being heavily manualised, too brief, and offering only a narrow range of therapeutic approaches. However, perhaps IAPT is helpful for some people; for instance people experiencing panic attacks triggered by certain situations or specific phobia, in the context of an otherwise typically but not unusually bumpy life. The research evidence and testimony seems to lend support to this.

I am particularly suspicious of wealthy “woke” psychoanalysts arguing passionately for their Freudian or Lacanian approach. People can need long-term – in some cases life-long – and frequent support, especially for conditions and predicaments which have complex causes and in the context of brutal cuts to social security (welfare “benefits”). It is not obvious that this support needs to be steeped in psychoanalytic jargon.

Having someone there who is kind, listens, and is trustworthy might make all the difference to someone’s quality of life and ability to survive a harsh world. There is no need to run a multi-million pound clinical study to demonstrate the efficacy of kindness. However, therapeutic relationships need to foreground honesty concerning their limits. A paid professional who is there for us each week is not the same as a friend, and that needs to be clear before a relationship begins.

Why can psychological therapy be helpful?

Research explaining how therapy might help is filled with very technical terminology, e.g., invoking “transference”, “extinction”, heightening access to “cognitive–emotional structures and processes”, “reconfiguring intersubjective relationship networks” (see over here for more).

Could simpler explanations be provided? Here are some quick thoughts, inspired by literature, discussing with people, and engaging myself as a client in therapy:

  • You know the therapist is there to listen to you — they’re paid to do so — so there’s less need to worry about their thoughts and feelings. One can and is encouraged to talk at length about oneself. This can feel liberating whereas in other settings it might feel selfish or self-indulgent.
  • The therapist keeps track of topics within and across sessions. This can be important for recognising patterns and maintaining focus, whilst allowing time to tell stories, meandering around past experiences, to see where they lead.
  • The therapist has knowledge (e.g., through literature, supervisory meetings, and conversations with other clients) of a range of people who may have had similar feelings and experiences. So although we’re all unique, it can also be helpful to know that others have faced and survived similar struggles — especially if we learn what they tried and what helped.
  • Drawing on this knowledge, the therapist can conjecture what might be going on. This, perhaps, works best if the conjectures are courageous (so a step or two away from what the clients says) — and tentative, so it’s possible to disagree.
  • There can be an opportunity for practice, for instance of activities or conversations which are distressing. Practicing is a good way to learn.
  • Related, there’s a regular structure and progress monitoring (verbally, with a diary, or using questionnaires). Self-reflection becomes routine and constrained in time, like (this might be a bit crude but bear with me) a psychological analogue of flossing one’s teeth.
  • (Idea from Clare) “… daring to talk about things never spoken of before with someone who demonstrates compassion and acceptance; helpful because allows us to face things in ourselves that scare us and develop less harsh ways of responding to ourselves”
  • (added 27/10/2014) The therapist has more distance from situations having an impact on someone than friends might have so, e.g., alternative explanations for interpersonal disputes can more easily be provided.
  • (added 27/10/2014) It’s easier for a therapist to be courageous in interactions and suggestions than for a friend as — if all goes wrong — it’s easier for the client to drop out of the therapeutic relationship without long-term consequences (e.g., there’s no loss of friendship).
  • (added 15/01/2015) Telling your story to a therapist gives you an audience who is missing all of the context of your life. Most of the context can feel obvious, until you start to tell your story. Story telling requires explaining the context, making it explicit. For instance who are the people in your life? Why did you and others say and do the things they did? Perhaps this act of storytelling and making the context explicit also makes it easier to become aware of and find solutions.

Some thoughts…

“How I became an analyst” by Arthur Valenstein

Interesting multidisciplinary background — some excerpts from Valenstein (1995):

“When I was sixteen years old I built my own short-wave receiver and transmitter and became a ham radio operator. This bent towards electronics motivated me to enter the engineering school at Cornell University in 1931 with the intention of becoming an electrical engineer…”

“But those were depression years, and it seemed unlikely that I could make a sufficient livelihood as an electrical engineer.”

“… from early years I had been curious about people, how and why they were as they were. I was puzzled about myself as well, feeling myself to be something of an ‘outsider’ in school. As I learned later, this is one of the elements contributing to psychological-mindedness, a predisposition that is conducive to psychoanalytic inquiry.”

“I have always had one foot in hard science and one foot in literature and the humanities, and fortunately I don’t seem to have fallen between the two.”

“George Henry was carrying out a heavily funded research project on homosexuality. This opened a whole world to me that I had never known, especially the gay world, and I learned something about it, even getting to know some of its colloquial terms. Later Henry and his research assistant, who in retrospect I realize was homosexual, published several books on homosexuality from a descriptive point of view.”

“… I came to be in Boston, which I never left except for one year in neurology with Foster Kennedy (a colourful man, a Northern Ireland Orangeman of great sartorial splendour and the gift of marvellously eloquent, elegant speech) at Bellevue Hospital in New York, and my years in the military.”

“My initial exposure to the activities and ambience of the Hampstead Child Therapy Clinic [now the Anna Freud Centre] forty years ago, and my continued contact with it and with Anna Freud over many years, greatly influenced my identity as a psychoanalyst, both theoretically and clinically. Before my sabbatical in London in 1955, I had become interested not only in what nowadays seems to be called ‘cognitive developmental psychology’ and ‘attachment theory’, but also what might be termed ‘affect developmental psychology’.”

Reference

Valenstein, A. (1995). How I became an analyst. Bulletin of the Anna Freud Centre, 18, 283–291.

Some claims psychology students might benefit from discussing

  1. It’s okay if participants see the logic underlying a self-report questionnaire, e.g., can guess what the subscales are. It’s a self-report questionnaire — how else are they going to complete the thing? (Related: lie scales — too good to be true?)
  2. Brain geography is not sufficient to make psychology a science.
  3. Going beyond proportion of variance “explained” probably is necessary for psychology to become a science.
  4. People learn stuff. It’s worth explicitly thinking about this, especially for complex activities like reasoning and remembering. How much of psychology is the study of culture? (Not necessarily a criticism.)
  5. Fancy data analysis is nice but don’t forget to look at descriptives.
  6. We can’t completely know another’s mind, not even with qualitative methods.
  7. Observation presupposes theory (and unarticulated prejudice is the worst kind of theory).
  8. Most metrics in psychology are arbitrary, e.g., what are the units of PHQ-9?
  9. Latent variables don’t necessarily represent unitary psychological constructs. (Related: “general intelligence” isn’t itself an explanation for anything; it’s a statistical re-representation of correlations.)
  10. Averages are useful but the rest of the distribution is important too.

Individuals versus aggregrates

“Winwood Reade is good upon the subject,” said Holmes. “He remarks that, while the individual man is an insoluble puzzle, in the aggregate he becomes a mathematical certainty. You can, for example, never foretell what any one man will do, but you can say with precision what an average number will be up to. Individuals vary, but percentages remain constant. So says the statistician.”

The Sign of Four by Sir Arthur Conan Doyle (hat-tip MP)

“… something more besides [psycho]analysis…”

“When the ego has taken its defensive measures against an affect for the purpose of avoiding unpleasure, something more besides analysis is required to undo them, if the result is to be permanent. This child must learn to tolerate larger and larger quantities of unpleasure without immediately having recourse to his defense mechanisms. It must, however, be admitted that theoretically it is the business of education rather than of analysis to teach him this lesson.”
—Anna Freud (1966, pp. 64-65)

Reference

Freud, A. (1966). The ego and the mechanisms of defense (revised ed.). New York: International Universities Press.

FIGJAM-based practice

Alternative to evidence-based practice: FIGJAM-based practice.MM0726_Fig_Jam__66623_std
(F**k I’m Good, Just Ask Me.)

Evidence is for the bureaucrats.
Trust us, we’re experts.
Join the school of the FIGJAM.
Throw your positivist randomised trials on the fire.

“I used the FIGJAM approach and I felt better.”

Coming to a social enterprise near you soon.

Book review: High-quality psychotherapy research by Areán and Kraemer (2013)

Randomised controlled trials (RCTs) are great, the gold standard of empirical research. The only thing better than RCTs are systematic reviews of lots and lots of RCTs. (So the story goes.) The reader may have noticed that RCTs evaluating CBT for psychosis have been vigorously debated for many months after a review was published in the British Journal of Psychiatry (Jauhar et al., 2014). Maybe not everyone agrees that RCTs are great (disclosure: I have analysed a couple), but I think it’s fair to say they are unavoidable whether you are trying to design or demolish them.

High-quality psychotherapy research by Patricia Arean and Helena Chmura Kraemer sets out to be a “practical, step-by-step guide” to designing and running RCTs. So why bother with an RCT? Observational trials, the authors explain, might involve studying participants who choose one of two or more interventions of interest by simply observing how they get on. This is problematic as differences in outcomes might be due to whatever factors led to them ending up receiving an intervention rather than the effect it had. RCTs use randomisation to overcome this problem so that people differ only in terms of the intervention received. That’s about it for the “why”: don’t expect debate on the epistemology.

The book’s strengths emerge as it develops: it catalogues issues that should worry study investigators and the authors draw on their own experience to offer hints. The Delphi consensus-building approach is introduced to solve the problem of developing an intervention manual and examples are given of how to word a letter asking for feedback on the proposed result. Randomisation techniques are introduced including horror stories of how they have gone wrong and invalidated RCTs. Ideas are provided for control groups, e.g., waiting list, usual care, and “gold standard” controls, and their strengths and drawbacks. The importance of not using pilot study results to determine sample size choices is explained. Guidance is provided on the people required; for example you need three or more therapists, at least two research assistants in case one takes ill, and a good statistician amongst other people. The Appendix includes a sample budget justification. All practical advice.

The text runs to under 200 pages so this could never be a comprehensive guide to all aspects of RCTs. What this book does do well is provide a systematic menu of options and ideas for things to consider. It might possibly give some ideas of what to demolish too, should you be so inclined, but this book is really only for those who are already sold on RCTs and want to get on with the seemingly painful task of designing and running one.

References

Areán, P. A., & Kraemer, H. C. (2013). High-quality psychotherapy research: from conception to piloting to national trials. Oxford University Press.

Jauhar, S., McKenna, P. J., Radua, J., Fung, E., Salvador, R., & Laws, K. R. (2014). Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. The British Journal of Psychiatry, 204, 20–29. doi:10.1192/bjp.bp.112.116285