At a Philadelphia Association open evening this May, a participant asked about the different theories favoured by different psychotherapy trainings: Kleinian, Freudian, Lacanian, and so on, wanting to know where the Philadelphia Association stood in relation to these ideas. A colleague replied with elegant simplicity that most psychoanalytic trainings ask you to see the client or patient through the lens of their favoured theory as the way to truly understand the position that person is caught in; in contrast at the Philadelphia Association we want to try and meet the person (of course seeing the person in front of you involves many complexities, and with or without theories we bring all sorts of expectations, prejudices, hopes and desires which may distort or influence the way any meeting may go). My response, not so elegant, was perception is part of the world, language is part of perception, and theories inform or regulate the language used and therefore our way of seeing or perceiving. What we want to do is to find, if there is such a thing, “wild perception”2, untutored perception, astonishment at the world and each other, to break out of captivation by our preformed ways of seeing. And somehow do psychotherapy with or within this way of being.
The Philadelphia Association was founded by R.D. Laing with others. Laing, who was an extraordinary person, wrote some extraordinary books, influenced many doctors to come into psychiatry, including myself, and influenced many to criticise psychiatry, including a number of psychiatrists. Arguably Laing was part of the large scale social critique that resulted in the eventual change in the law from the 1957 Mental Health Act to the 1983 Act, which gave many more rights to psychiatric patients than previously. The 2007 amendments to the Act took some of those rights away again, making it easier to justify detention for a ‘mental disorder’, a change that many psychiatrists opposed but was forced through regardless.
The Philadelphia Association started with the once famous/notorious ‘therapeutic community’ at Kingsley Hall in 1965, which has been much written about. A year or two later, led by Dr John Heaton, originally an ophthalmologist who became interested in perception and philosophy especially phenomenology, and trained as a psychoanalyst, the PA developed a psychotherapy training. The training was and is based in philosophy and psychoanalysis, particularly developing a phenomenological and existential critique of psychoanalytic approaches. The PA is now a locus for a critique of psychiatry and the many and various psychotherapies based in psychoanalysis and academic psychology, such as CBT. The ‘style’ of therapy offered is outside any simplistic divide between objectivity and subjectivity, inner world and outer world, mind and body, strongly opposing a scientistic world view in therapy that sees only the measurable as real.
The Philadelphia Association currently runs two houses in London for people struggling with life, and who may have been (this is not essential) through psychiatric services and therefore in some sense a survivor. These houses require people to self-refer, and then once invited by the residents, to attend at least one and sometimes more meetings with the house residents, along with the house therapists. One has to ‘find one’s way’ to the house, you cannot be referred by your community mental health or social care team, although that said social workers or community mental health teams may be involved in some way to encourage a person to look into the houses. The houses have therapists who conduct group meetings for the residents three times a week, and residents also need to have individual psychotherapy, often at a ‘low cost’ rate. This is mostly paid for through benefits, sometimes disability allowance. Residents may have paid employment, not organised through the house, and pay rent themselves. The houses are therefore not a drain on NHS or social care resources, and are amazingly cheap compared with more formal residential care ‘placements’ or inpatient care.
The house therapists do not participate in the Care Programme Approach (CPA), although some residents remain involved with their community mental health team. Some residents are on medication. When the PA was founded in 1965, there was an idea that residents would not have any psychiatric medication. There is still a debate about this, and certainly it is an option if someone is on medication that they can come off it while living in the house. If the person wanted medical oversight for this reduction or cessation of medication, this would need to be by a doctor outside the PA. Alternatively, the individual can take responsibility her or himself for this.
The houses are not set up to manage serious crises, although back in the day some people came in quite acute psychotic states and lots of those involved in the PA and the psychotherapy training would spend time, sometimes many hours, in the house with the person in crisis, to try and see them through without psychiatric intervention. It is fair to say this did not always work, although for others this was enough to allow them to manage their own journey. One example, the person concerned has written about this, was a young man who spent two years in his room, almost never coming out, at one point almost starving himself to death. There was huge concern in those around him about leaving him. Most psychiatric doctors, nurses and others would think this terrible neglect. Nevertheless, and while the PA would eschew measuring success as a return to social conformity, this young man did subsequently go to University and complete a higher degree.
The houses are therapeutic communities, in perhaps a minimalistic sense. There is no daily programme of activities, no occupational therapy, no particular routine other than the house meetings. The houses provide a safe living space, a community of others who have their own often difficult life journey, and there is no pressure to stay a quick few weeks or even few months and then leave and move on. The houses are a limited resource, as people may sometimes stay for 2-3 years, and movement from the house would be considered slow by other services. That said the houses tend to have vacancies. It is not always easy to find people who want to live in these interesting and quite difficult places. Because of the unstructured ‘referral’ process, and the PA houses being unorthodox and relatively unknown, there is not always a steady stream of applicants to live in them.
Some research has been done on outcomes, but the PA has not been good at organising research, nor has it wanted to particularly. The PA’s philosophical position is to eschew ascientific, objectifying approach, although there are good examples elsewhere of phenomenological research into other approaches to ‘mental illness’, in Europe and in Australia. The PA does not claim to be treating people’s ‘mental illnesses’, nor does it claim anything special, rather emphasising ordinary living. People may choose to come to the houses, live there for a while, and perhaps find a different direction for themselves in their life. Nothing is promised, nor could it be.
The same is true of the psychotherapy the PA tries to show a way towards. Therapy in our privileged society (for many but certainly not for all, and maybe for a lot less now) is often seen as a treatment for ‘mental illness’. With mental illness destigmatised especially for young people, many embrace a diagnosis - bipolar disorder is popular - as some sort of indication of self-awareness. We now expect solutions to life problems, happiness is a commodity we must have, CBT or mindfulness supposedly reshape our minds or thoughts so we are no longer anxious, depressed or in despair. There is perhaps a sense in our society, although this is not unique, that it is your social duty to get ‘sorted’ so you are not a burden – read cost – to others, and you can take your place in a commodity and consumer driven neo-liberal capitalist society, without worrying too much about the climate emergency or even Covid-19. Medication is a huge part of this as we know, many people expect targeted drugs, perhaps tailored to genetic or immunological differences, to rapidly rebalance their neurotransmitters and endorphins.
The PA takes a sceptical view towards theory and practice in psychotherapy. One of the main thinkers behind this scepticism was John Heaton. Heaton was for a long time, from an early member in 1965, until his death in 2017, one of the main intellectual figures in the PA. He was also one of the founders of the Guild of Psychotherapists, with Ben Churchill and Peter Lomas, who also took a critical view of psychoanalytic theory and practice. Laing, although radically criticising the psychiatry of his early years when heavy use of ECT and lobotomy were common, and patients often spent years incarcerated in psychiatric ‘bins’, was not so clear in his critique. Laing brought together the philosophy of Sartre and the existentialists, with psychoanalytic ideas, notably from Winnicott and the “Middle Group” at the Institute of Psychoanalysis. Heaton in contrast took psychoanalysis to task for reification and objectification of ideas such as the unconscious, projection, transference, but vitally our more general ideas about the ‘mind’, the nature of thinking or feeling, and what might count as psychotherapy and training in psychotherapy.
Heaton was a member of the British Phenomenology Society, and a regular attender and contributor to the annual Wittgenstein conference in Austria. He published several books including Wittgenstein and psychotherapy: From paradox to wonder and The talking cure, which explicate his thinking in relation to how we conceptualise and practice psychotherapy, very much influenced by the ‘therapeutic’ move in understanding Wittgenstein’s philosophy. Heaton comes to see therapy not as a rule based activity (not that anything goes) but a relationship in which someone is helped to make sense of her life in new ways perhaps freeing herself from a weight of fixed ideas and ways of perceiving things. Psychotherapy is not a technical process, but an exploration, and language, however at times difficult to find, is ordinary.
Importantly, especially in finding other ways of thinking about symptoms or the ‘unconscious’, Heaton emphasised, following Wittgenstein, that while psychoanalysts as well as neuroscientists might insist that ‘experience’ is private and mediated in the brain, many questions can be asked here. When it comes to making sense of ‘experience’ we depend on language which cannot sensibly be private, or just ‘in my head’. Wittgenstein, well before developments such as systemic family therapy or attachment theory, suggests that we learn to speak of our pain as children surrounded by adults who give us the words to use. Words at first are part of the expression of pain, and not a description, and replace crying or screaming, unless we are in extremis.
This distinction between language as expression, and language as description is missed in psychiatry, leading to deep confusion about the nature of so called ‘mental states’. Psychiatrists tend to assume there is some mental object, a mood, an hallucination, that must be accurately described, although mainly for diagnostic purposes. Currently in psychiatry, there is little attempt to understand what drives the torments, whether thoughts, voices, moods, although psychoanalysis, as well as Jaspers, traditionally has wanted and attempted to do just this. Psychiatry still distinguishes between the form and content of psychiatric symptoms for nosological purposes and orthodox psychiatrists are often very suspicious of the search for meaning in the terrifying experiences of those they are confronted by.
While Jaspers and Freud both set a limit on trying to understand psychosis, a phenomenological approach is exploratory but not dogmatic about what might be found. Interestingly, Roger Boyes, a Times journalist who experienced hallucinations after coming out of intensive care for Covid-19 (see article), apparently a common experience, talked of these as ‘his brain’ trying to make sense of what happens when you are so ill and in an induced coma for some time. Working with young people I have seen, sometimes at least, hallucinations disappear, not when made sense of directly, but when the young person makes sense of their often traumatic or abusive experiences in other ways. Hallucinations may be experienced when things don’t make sense; when language in some way reaches into someone’s experience, the hallucinations might fade away.
We can ask therefore, what could psychiatry be like if it was recognised that there was no such thing as a ‘mental state’, certainly not the reified object it is taken to be, and that what patients need is to be able to express themselves, in whatever way comes to them? Art and music are vital ways of expression, whether or not they are part of a therapeutic method. Recognising this is important as children who were abused are often not given words by concerned adults to express their pain. The abusing adult more often insists on secrecy and silence. Hence the inchoate nature of someone’s pain that may end up being expressed through illness, of whatever kind. We now know that trauma is non-specific in its effects and can be part of ‘mental illnesses’, ‘physical illnesses’, the rather horribly named ‘medically unexplained symptoms', as well as for some a push to do extraordinary things. Finding expression through speech or in any other way is not necessarily a cure, there is no cure, but may allow some form of liberation.
Wittgenstein said the philosopher seeks to find the liberating word. Liberation itself is a word that leads to many domains, not least questions of race, gender and class. This is the subject for another blog, but having recently, in spite of ‘knowing’ about it before, woken up to the hidden ways racism works even when the protagonists are not overtly or deliberately racist, it needs acknowledgement. It is common knowledge that poverty is linked with poor health outcomes in all domains, it is also common knowledge that BAME people have more mental illness than white people and are imprisoned and hospitalised using the MHA more. That BAME people die more from Covid-19 is also linked. How do we talk about this knowing how painful it is, how difficult it is for BAME people to be constantly the whistleblower (whistleblowers are still more likely to be discriminated against, sacked from their jobs, and further persecuted in some way), how difficult for white people to acknowledge that even without intention our actions, social structures, regulations, stop and search or policing of social distancing can be racist?
Intersectionality3 is a broader way of thinking about people’s position than existentialism, which claims universality from a European context, showing that non-European value systems are equally valid, and making explicit how race, gender, class and sexuality interrelate in the subjectivity and position of people of colour. However the idea of situation in existentialism still has a lot to offer to psychiatry and psychotherapy in thinking about meaning, value and position. Sonia Kruks in Situation and human existence discusses the social aspects of situation, mutuality and freedom. Alfred Kraus’ idea of a phenomenological-anthropological approach in psychiatry covering all aspects of the personal, social, cultural, meaning world of the subject derives in part from this idea of situation.4 We are not determined by our situation, freedom is fundamental, situation is however our starting point. Situation, and the meanings attached, move between or beyond notions of the inner world and particularly horrible, ‘external reality’. External to what? Another question is whether we can ‘transcend’ our situation by our own efforts, or do we require a revolution, a social movement, politics? Can psychotherapy address all of this? Whether we have the potential for change in relation to the areas considered by intersectionality, whether racism, sexism, ableism, class, not to mention the climate emergency, is at the heart of our current dilemmas.
The PA tries – what does this mean exactly? – to put all this in question: theory, position, situation, subjectivity, power structures. But there is a limit. And we are bodies, as Merleau-Ponty lets us know, and merely human. If we ‘meet’ in some sense, see each other, experience through our limited speech something of the terror we face, the hurt, the loss, our ‘thrownness’ into this world, our despair, our futility, our ravenous desires and destructiveness, our rage at the world and at death … is all this universal, cross cultural, beyond intersectionality? Doubtless not, but there is the necessity that we meet, and find ourselves not in isolation but in the face of, in the presence of the other.
1 Karl Jaspers quoted in Thomas Fuchs, Brain mythologies; Fuchs, Breyer and Mundt (eds) Karl Jaspers’ philosophy and psychopathology, Springer, 2014.
2 Maurice Merleau-Ponty, The Visible and the Invisible, Chapter 4 The Intertwining, the Chiasm. Northwestern University Press, 1968.
3 Patricia Hill Collins Intersectionality as critical social theory. Duke University Press, 2019
4 Alfred Kraus. How can the phenomenological-anthropological approach contribute to diagnosis and classification in psychiatry. Chapter 13 in Nature and narrative, eds Fulford, Morris, Sadler and Stangellini. OUP 2003