January 2009


 

Is man just a hungry animal or has the environment in which we are living conditioned us to behave in a hungry way?   Raymond Tallis, scientist, philosopher, Professor Emeritus of Geriatric Medicine at Manchester University believes we are naturally hungry.  ‘It is the human condition,’ he asserts, ‘but the way we live has exaggerated it.’ 

 

Speaking at the joint meeting of the Cafés Scientifique and Philosophique at Chapel Allerton last Tuesday,  he explained that there were more hungers than hunger for food.  There is hunger for pleasure, hunger for others (desire and attachment) and the fourth hunger, hunger for a truth for meaning, purpose in life’.  I might also add a hunger for things or consumerism and a hunger for prestige or ambition. These are of course not separate hungers; they are all connected. 

 

Tallis’ talk was like a rich meal, consisting of carefully chosen assertion and cultivated eloquence, liberally seasoned with philosophical quotation.  He served it in a cultured manner and a rapid delivery that demanded instant consumption.  It was a repast concocted by a man, hungry for attention and presented to an audience greedy for insight and knowledge.  His assertions challenged absorption and assimilation; his arguments threatened indigestion.    

 

‘Starvation preoccupies the mind,’ Tallis stated emphatically. ‘When you are hungry and starving,  it becomes the essential meaning and purpose of life.’  To support his argument, he described how the most cultivated people, doctors, judges, rabbis, were reduced to grubbing around in rubbish dumps when starving in Auschwitz.  ‘People went insane through hunger.’     

 

In his gastro-centric discourse,  Tallis appeared to express the view that hunger in all its metaphorical and philosophical connotations was the motivation for life.  ‘We are driven by our appetites. They give us life.  We suffer a kind of death if those appetites are satiated.  It is not the object of our appetite that is important,’ Tallis asserted, ‘but the process.’   

 

Eating a meal conforms to the law of diminishing returns.  The first mouthful is a relief; it assuages the tension of hunger.  The next mouthful also but less so.  The third mouthful less again.  We finish the meal although we are no longer hungry.  What stops us the uncomfortable feeling of being replete, satiated.  In a philosophical sense we might be said to be bored with the meal.  Physiologists have the concept of sensory specific satiety, meaning that we soon get tired of the same food,  but if we relieve the boredom by stimulating our taste buds and the cilia of our olfactory cells, with different ingredients, then we can maintain the ‘hunger’ and eat and prolong the meal. Gastronomy was created to relieve the mini-death of eating. 

 

Although an incredible 820 million people, an eighth of the worlds population, still exist ‘on the bread line or lower’, for people living in ‘civilised countries’ food is readily available in abundance.  They don’t need to hunt for it or gather it from forest and marsh, they collect it from the supermarkets and store it in their fridge.  The overwhelming majority of people living in the towns and cities of affluent countries do not know the physical pangs caused by lack of food,  but that does not mean they don’t feel hunger.  Instead, Tallis asserts, hunger is transferred on to other ‘objects’, material objects, thrills, excitement, sex, companionship, love,  power, prestige  meaning and  truth. Civilisation and culture followed the conquest of hunger through agriculture and farming. There is so much to be hungry for.      

 

But if human life is driven by hunger, then it must never be allowed to be satisfied.  Satisfaction inevitably leads to a state of boredom, which Tallis cleverly defined as a hunger for hunger.   When it is no longer necessary to search for food, when material objects lose their appeal, thrills cloy, love affairs become tedious and there is nothing convincing enough to believe in, then what is the purpose of life? 

 

So does the modern epidemic of depression represent a permanent state of boredom,  the near-death inertia of satiation?  Are we permanently conditioned by our success either to accept a life of diminishing returns, where food, objects, family no longer satisfy our needs and we coast gently towards death?  Or are we condemned to a neurotic search for an essential meaning in life?   Have human beings become so successful at satisfying their basic biological and psychological needs that they are sated, overweight and under-motivated?  Is that the essential precondition for a decline of civilisation?   

 

Tallis’ suspicion was that epidemic of depression exists in the minds of the media and the drug companies rather than in any real change in people’s psychology.  I question that.  The psychoanalyst in me wondered how much he was projecting his own nervous appetite for life, his fear of the depressive death of boredom on to the rest of us.  All writers and philosophers project; it allows them to stand aloof from the maelstrom of humanity and survive. 

Tallis seems a very hungry man.  Perhaps he has to be hungry to ward off the dread of meaninglessness.  His physique, slim and energetic at 62 years of age, indicates that he has solved his hunger for food,  but he certainly demonstrates a enormous hunger for ideas and meaning and a desire for recognition – as if without this essential focus in life, he would cease to exist as a hungry animal.  A recent article in The Times (September 20th , 2008) told how he depressed he became after he retired from Manchester University and lost the focus of his job. ‘I was completely taken by surprise how worthless I felt.  Suddenly I had lost the thing I valued myself for.’  So Tallis needed to be needed;  he needed to be in peoples’ minds, the object of their attention, their envy, their desire even.  In the same article, he described himself, albeit tongue in cheek, as ‘the thinking woman’s crumpet!’    

 

 

Tallis views life from the philosophical vantage of physical hunger.  It is a useful and instructive perspective.  His book bubbles and sparkles with wit and erudition.  Do buy it!   But there are as many perspectives on human life as there are metaphors.  Some are so appropriate for some observations, others may fit better for different situations.  Tallis’ metaphor has its limitations

 

His premise, I thought, broke down when applied to perhaps the most obvious manifestations of hunger – the eating disorders; the modern epidemic of obesity and the dangerous deprivation of anorexia. 

       

Why are so many people driven to eat long after they are sated with food?  Why do they eat themselves into a state of complete boredom?  Is it a death wish?  I have interviewed a few patients with morbid obesity who have told me that they are eating themselves to death, but that is not the general rule.  Most people overeat, not to satisfy their biological hunger, but to fill other gaps in their life.  Many fat people are needy, even greedy, not for food but for love.  Many have been deprived of care, love and attention when they were growing up.  Many have felt worthless.  Many have not felt listened to.  Many felt they were not wanted.  For all of them, love and security are the essential need; food is a surrogate.  They ate to fill the emotional hole inside of them.     

 

As children we were programmed to seek out not just food, but our entire life support system of shelter, security, comfort that included food, and as we grew and became increasingly separate and independent,  those essential needs became more abstract as they were sublimated into achievement, prestige, recognition and meaning. 

 

As Tallis pointed out, eating a meal is so much more than the consumption of food.  The family dinner is an occasion that affirms the essential emotional bond; it is redolent with the memory and meaning of family.  The banquet is an essential component of any congress; it brings people with disparate views together, it fuels human discourse and understanding.  The setting, the entertainment, the rituals of speeches and toasts, the presents, let alone the food, are about community, security, love and understanding among peoples. 

 

Tallis was quick to emphasise how much more meaningful and civilised his meal was compared to that of his cat.  I am sure that is true, but the point seems a hollow one.  When you examine eating behaviour among animals carefully, you see that it is part of a complex grooming sequence. Chimpanzees, glutted on a monkey they have caught and dismembered, will not only share out the food according to strict hierarchy but will also indulge in a post-prandial mutual grooming and cuddling before they fall asleep.  Cats in the wild, pack dogs, indeed any social mammal and many birds have rituals around food that serve functions of security and group cohesion as much if not more than the biological needs for nourishment. 

 

So I would contend that eating is not just about nourishment, it is part of the complex of  behaviours that make up what we call nurturing.  When a mother feeds her infant, she delivers a complete care package, shelter, warmth, safety, comfort, understanding as well as food and drink.  Which one of these takes biological precedence is not clear, but my guess is that is not food.  When Harry F. Harlow placed infant monkeys with two different surrogate mothers; one composed of a wire frame that delivered meal through a nipple and the other covered in fur that delivered no milk, they invariably went to the furry one and starved. 

 

Nutrition could be compared to a hijacker on a pleasure cruise.  The consumption of food stimulates the pleasure centres of the brain. Experiments carried out in rats have demonstrated that when the putative pleasure centre, the nucleus accumbens, is stimulated directly by electrodes inserted through the skull and attached to a lever which the animals can operate, they do not bother to eat; they just press the lever repeatedly to give themselves a buzz of satisfaction. There is evidence that certain addictive drugs may work on the same centre.           

 

Indeed, if hunger were the primary drive, then why are so many young girls anorexic?  It seems that for them, the desire for the security of childhood outweighs the drive for food. 

 

So is it food that is the essential need, as Tallis has suggested, or is it attachment, as the psychoanalyst, John Bowlby has asserted?  Are we not so much the hungry animal as an insecure animal?  We need the company of others, in reality or in our imagination.  If that is not there, we will crave a surrogate: food, thrills, possessions and sex. 

 

We are also a perverse animal. As much as we crave security, when we have it, we want to get away.  The anxious drive for freedom and change can be as strong as the yearning for security.  That is when ambivalent illnesses, such as anorexia, can supervene to sort out the dilemma.  Human beings would not have been so successful if civilisation had not conspired to make them so neurotic.    

 

So are we, as Tallis seems to suggest, living in a permanent state of anxiety, preoccupied with the lack of what we feel we need to support our lives?  Are we all like Sisyphus, condemned to roll the boulder up the hill, obtaining a grim kind of satisfaction in the effort?  Or does that only apply to the neurotic majority?   If Tallis is right, he presents a very bleak view of human life; permanently driven, never satisfied, constantly striving to avoid boredom and depression. 

 

Are our notions of peace and contentment just goads to drive us on in an ever futile quest for an illusory satisfaction?   And if we see through it all and lose the illusion and see our striving as merely the way we are programmed to avoid entropy, do we just succumb to a loss of meaning? 

 

I retain the touching belief that humans are capable of blissful states of peace and contentment, conditions of being without striving, the freedom from all needs and desires that the Buddhists call nirvana.  Babies are probably in that state for much of the time.  But for the rest of us, we have to find it in nature, the companionship of others, music, poetry, reading in front of the fire, listening to the radio and paradoxically, rhythmic exercise like running.  

 

I think both states of being exist and alternate within us like yin and yang.  They are  expressed in the body via activity in the sympathetic and parasympathetic nervous systems.  The sympathetic creates the tension for change to endeavour to satisfy our needs, while the parasympathetic conserves energy by promoting rest, companionship, digestion, growth and sleep.  For a complete life the two must be in balance.  The problem is that the way we lead our lives these days is destabilising and encouraging us to strive for illusory goals more than is healthy.   

 

Advertisements

In 325 AD, the Emperor Constantine convened the First Ecumenical Council at Nicaea in Bithynia (present day Iznik in Turkey).  It brought together a remarkable array of charismatic bishops and priests, each representing a different interpretation of the Christian scriptures.  There were the three patriarchs, Alexander of Alexandria, Eustathius of Antioch, and Macarius of Jerusalem, the confessors, Paphnutius of Thebes, Potamon of Heraclea and Paul of Neocaesarea, who came to the council with the marks of persecution on their faces.  Other remarkable attendees were Aristakes of Armenia (son of Saint Gregory the Illuminator);a former hermit, Hypatius of Gangra; and Spyridion of Trimythous, who, while a bishop, still made his living as a shepherd.  There were bishops from as far away as Persia, Egrisi in the Caucasus, the Gothic lands to the north, Dijon in Gaul, Cordoba in Hispania, Carthage in North Africa, and the provinces of the Danube.  They had all travelled to come to resolve certain fundamental differences in the belief and  practice of Christianity, in particular whether Jesus was God or just similar to God and the date on which to celebrate the resurrection.  While they were there, they also established twenty new canons or laws, which included the prohibition of self castration, the setting of a minimum time of instruction before baptism, the prohibition of the presence of a young woman in the house of a cleric, the provision of provincial synods, rules concerning ordination of bishops, prohibiting usury among the clergy and kneeling during the liturgy.  This was the first time that an attempt had been made to establish concensus among the diverse beliefs and practices which constituted the broad church of Christianity.  Seventeen centuries and scores more councils later, divisions still exist but they are not as serious or as profound as they were and for the most part there is a peaceful coexistance among Christian beliefs.      

 

Psychotherapy is also a broad church.  There are psychoanalytical psychotherapists,  cognitive behaviour therapists, Gestalt therapists, humanists, existentialists, couple therapists and family therapists.  And within the psychoanalytical subdivision, there are Freudians, Jungians, Kleinians and even Rogerians.  In the past, too much effort has been spent in arguing which is the true path to understanding and salvation.  Psychotherapists, experts in helping others resolve their personal conflicts, have themselves been split, even splintered, by their extraordinary capacity for internecine warfare, for division and entrenched non communication. 

 

The organizations that represent them, as many as the early Christian sects, are now in crisis as they struggle to hold the tension between the interests of public and private practitioners, between cognitive behavioural and psychoanalytic modalities, between psychodynamic and psychoanalytic practice and  between Jungian and Freudian.  Although diversity is professed to be the strength of psychotherapy, and eclecticism a virtue, unless the profession can attain a clear concensus of core values and practice,  it is in risk of being shunted into the sidings of everlasting analysis.

 

 

It doesn’t. The goals of therapy can appear too abstract, the principles of practice as diverse as complementary therapies, the profession fragmented, the public confused and the government frustrated.  With depression the most common illness in the UK and antidepressants not really the answer, psychotherapy should be accessible, brief and effective.

 

In order to establish consistency of practice and improve accessibility to psychotherapy, the British Government has proposed that regulation of the psychotherapies should be  removed from the professions concerned and placed in the hands of public servants who are unfamiliar with the nature of the clinical work. The Health Professions Council (HPC) has been given the task of regulating talking therapies through the establishment of clear criteria for accreditation, approved training courses and strict codes of ethics. Skills for Health (S4H) has been charged with developing National Occupational Standards for psychotherapy.  More than 450 rules have been listed for psychodynamic and psychoanalytic therapy. They dictate every aspect of how therapists should organise their sessions, how they should ‘monitor’ themselves and how they should carry out their work. They go into minute detail about the timing of interventions, the setting of the therapy, its aims – and even the expression of appropriate ‘feelings’.

 

Psychotherapy is therefore in danger of being forced into the current culture of outcomes, where everything can be predicted in advance, and evaluated in relation to the expected results.  It will increasingly become an intervention to be applied to patients, rather than the long and painstaking change achieved by patients under the guidance of the therapist. Only those professionals who practice (or appear to practice) an approved form of intervention will be allowed to remain in business.      

 

But what is likely to be the approved intervention?  The government’s watchdog on medical treatments,  The National Institute of Clinical Excellence (NICE) recommends cognitive behavioural therapy (CBT) as the approved treatment for most mental illnesses.  CBT works on the principle that people get ill because of the way they think about things.  Thus, if they can be instructed to change they way they think, they will return rapidly to health. 

 

CBT has a clear protocol and programme, which can be conducted over a few weeks.  The required change in thinking and behaviour can be clearly defined and what’s more importance for an evidence based culture, the achievement of those goals can be assessed by questionnaire. But response to questionnaires is subjective, people often provide the answers they have been trained to provide and make responses that will please the therapist.  It is hardly surprising that CBT gets the results it intends, the relief of specific symptoms.  But critics point out that although it conforms to a medical model and, as such, is just what the doctors and their employers order, it does not achieve a lasting change in attitude nor even a return to health. 

 

If CBT is adopted as the true religion, then more psychoanalytical sects will need to adapt and conform or risk excommunication.  

 

 

Psychoanalytical psychotherapies in the UK are cuirrently regulated by two main bodies, the United Kingdom Council for Psychotherapy (UKCP) and the British Psychoanalytical Congress (BPC). Practitioners belong  to a variety of member organizations, some geographically based, some modality based.  Each has strict codes of ethics, practice and complaints procedures, and is inspected periodically by the regulatory body. The new developments threaten to render the existing regulatory structures obsolete.

 

It is not surprising therefore that psychoanalytically based psychotherapists feel under pressure to get their house in order, to clear out the box room of ancient couches and dusty books and to convert the basement into a new purpose built mental health centre. 

 

The Alliance for Counselling and Psychotherapy, which represents the views of many psychonalytically oriented psychotherapists, is opposed to state regulation.  In a recent statement,  they point out that most forms of psychotherapy do not focus exclusively on the relief of symptoms.  ‘The goal is more an improvement in general quality of life.  Moreover, psychotherapy is a contract between responsible adults, not a health intervention regulated by the state.  The client should have freedom of choice for the kind of therapy they need.  Many practitioners see their work as an art rather than a science,  a series of skilled improvisations within the context of a relationship where each client offers unique issues and demands unique responses.  Such activity cannot be captured by a list of competencies. Diversity and flexibility are important.  By privileging cognitive behavioural therapy because it appears to be evidence based, the proposal for state regulation will reduce access to long-term, rationally-oriented therapies, to reduce client choice and to medicalise the field, to rigidify training and inflate its cost and hence the cost of therapy, making access more difficult to the disadvantaged.’ 

 

Thousands of therapists have been writing to MPs and politicians, seeking a recognition of the fact that analytic work cannot be reduced to a set of rules to be mechanistically applied to a patient with predictable outcomes, but involves an exploration of the meaning of an individual’s history.

 

To head off the threat of statutory regulation, the UKCP has organised numerous meetings on how it might restructure itself to satisfy the regulatory zeal of the state without losing its psychoanalytic soul.  This exercise is known as SHAPES and might be compared, by the cynical, to arranging the next day’s onboard activities on the Titanic.  The latest creation, SHAPE 6, proposes a Psychotherapy Council that includes representatives from each of the major divisions as well as from regional member organisations.  The Council would advise the Board of Trustees, which under the by laws of its charitable status, oversees the work of the executive.  The next tier of organisation would include new colleges for the major modalities of practice.   It would be the colleges that would organise their own trainings, criteria for accreditation and models of  ethical and clinical practice, but under guidelines and supervision and approval of the Board of Trustees of the UKCP.  Overlapping with the colleges would be the faculties, multidisciplinary groups, that support an integrated form of practice for special interests, such as eating disorders, trauma and mind-body illness.  The diverse collection of regional and modality based member organisations would align themselves with the faculties and colleges according to their specific practices and interests. 

 

James Antrican, the current Chair of UKCP, has asserted that the member organisations   are the life blood of the profession.  If the member organisations withdrew their support,  then the UKCP, a charity totally funded by subscriptions and a few donations, would not exist and many psychotherapists would lose any influence they might have on government policy.  The hope is that although psychotherapists would need to register with HPC in order to practice, registration would be subject to controls and criteria set out by the professional organisations working as agencies for the HPC.  But the UKCP are needs confidence and support of government if it is to function as its agent for regulation of the psychotherapies.  This fear is that this might mean that it would restrict support for psychoanalytical psychotherapists. 

 

Since the colleges have not yet formed, psychoanalytical psychotherapists are organised under a section of the UKCP, known as the Council for Psychoanalysis and Jungian Analysis (CPJA).  The panic felt by UKCP has been passed down to CPJA, who are rapidly attempting to rebrand themselves with mission statements and clear descriptions in order to be appear less abstract and more accessible. 

 

But why are the professions not talking directly with HPC?  I have an impression of HPC smiling benignly and just allowing the psychoanalytical professions to demonstrate that they cannot organise themselves and the money is better placed elsewhere.   

 

It probably doesn’t help to be defensive.  Change is going to happen.  It is easier for government to work with professions than against them so it will listen if the message is clear and sensible.

 

Indeed, what is happening is the evolution of psychoanalysis.  Initially a dangerous doctrine with a certain cult status, it grew throughout the thirties, forties and fifties to be the dominant force in medicine.  Many professors of medicine in the nineteen fifties were psychoanalytically trained.  Then disillusion set in.  There were some spectacular failures, important diagnoses were missed, the treatments were too long, too expensive, the method too abstract and erudite,  Freudian philosophy was seen as antithetical to feminism.  Psychoanalysis became restricted to private practice available largely to those rich enough to afford it. 

 

In the meantime however, the philosophy of psychoanalysis had invaded the culture.  Film, plays, poetry and novels took up the baton and the precepts of psychoanalysis became an accepted part of human discourse. 

 

So instead of seeing state regulation as a threat and cognitive behavioural therapy as the enemy, I wonder if there is sufficient scope and enthusiasm for adaptation and flexibility.  Cognitive analytic therapy (CAT) and ‘mentalisation therapies’ are hybrids that enrich the strain of CBT with a psychoanalytical culture of meaning while maintaining treatment goals. 

 

    

Like the early religions, psychoanalysis is not an immutable dogma but more a process.  It will not disappear but it will change and merge with other methods to become more relevant to the requirements of a changing culture.  It seems that instead of mounting a defensive rearguard action against change, we should be seeking ways of working with the powers enforcing change to ensure that optimal understanding and help for the ever increasing numbers of people suffering from unexplained mental and physical illness. 

Clags of mud clung to the feet

that slipped on the greasy stones

while folds of mist

obscured an expectant sun. 

 

With all the tolerance of obligation,

a grey-nosed spaniel

shuffled its muddy flanks and allowed

its ears to be pulled.

 

Four cows, large and black, stood

in the deep mire of an open barn.

answering my comments  

with long, low groans.

 

As gloom gathered, grey on grey,

in the valley by the silent ford,  

tandem swans on siren wings flew in

from older, colder climes. 

 

The ocean was on the wind

and seabirds trod the meadow  

by the grey river, thread

through iron crag

and melancholy forest.

 

Twelve young stags sheltered

under the thought of a tree, then rose,

crossed the path, their brushes

already dipped in the dark,

dangerous musk of spring. 

 

Tip toe,

among the stunted oaks

of a secret slope, 

the dappled girls

stopped, 

sniffed

……. and shivered.   

 

Bright green shoots of winter wheat, low

sun reflecting white under a peewits wing,

mellow from the abbey tower

as I leave

for the funeral

of my friend. 

 

Whiter on white;

colder than before;  

Trees like stately wedding guests,

Georgiana’s ghosts.

The paler disc of the sun

evanescent through frosted air.

 

No dancing deer. 

And the offer of nuts

on a wayside stone is

unnoticed by the squirrel

that balances with swinging tail   

on the trapeze.  

 

Despite scolding rooks,

mocking daws and

the hollow rattle of an expectant woodpecker,

they have cut away the willows by the bridge

and placed the russet twigs

to smoulder in the ash.

 

It had rained all day, steady, inclining on a warm southwesterly breeze. 

 

Wisps of smoke, like Japanese brushwork, drifted through the trees and up the hillside.  A narcosis of roasted leaves, dilute but still potent at no more than five parts in every million. 

 

Jackdaws and rooks circled against the darkening grey clouds, calling light and dark, gathering more in the gloom, drifting north by east, searching for a roost.

 

A buzzard settled nearby on the low branch of an ancient oak; both of  us reluctant to take off. 

 

The rowdy boys met by the path for another stag night were spooked by my splashes and danced away on legs as spring laden as Nureyev, while their fairy girls on the hill trod a dainty arabesque between the trees.       

 

Then the lights came on in the big square house and it grew darker.  

Next Page »