Monday, 6 July 2020

The imposter's guide to imposter syndrome

Imposter syndrome is a concept that is having its time in the sun. Although first christened almost forty years ago in a professional article, it seems positively de-rigeur. Diagnostic concepts come and go but the extent to which they take root in the popular imagination is an indication of how far they speak to broader social phenomena. This one co-exists with increasing awareness of gendered discrimination in the work place. The article linked above is about women's experience specifically, and a recent book (Valerie Young's The secret thoughts of successful women) has expanded on the theme. Perhaps imposter syndrome might be recast as a description of the way that women have been made to feel by male dominated professional spaces.

Its widespread acknowledgment means there are some self-help interventions out there for chronic self doubters, with a dedicated website (impostersyndrome.com, the companion to Young's book) leading the way. These interventions tend to focus on a version of cognitive re-structuring, with a large helping of positive self talk. We are encouraged to "learn to think like non-impostors" by engaging in self directed pep talks. Techniques like saying out loud that we are awesome, or making a list of "at least 10 things that show you are just as qualified as anyone else for the role you are seeking." This kind of approach involves entering into an argument with yourself about the reality of whether you are or are not in fact an imposter.

Having been through that self-argumentative cycle myself multiple times, it seems to me that the big problem with debating yourself out of imposter syndrome is the corrosive skeptical worry that you might be wrong. This doesn't need to feel plausible, only possible. On self examination I can easily find areas of relevant knowledge I feel I don't have, and evidence of times I failed to meet a relevant personal standard. "OK" I tell myself, "but everyone has limitations and failures." "Yes" I snap back, "but yours are worse!"

At this point it has helped me to notice what I am up to. I suspect a degree of characterological inclination toward self-sabotage; an overly aggressive super-ego. Here the ruminations on imposter syndrome become a self indulgent cocoon. A "poor me" reclusiveness, a way to hide in an endless cycle of self-abuse and avoid hard work. I have also noticed a decidedly unattractive inclination toward self deprecation in conversations - picking up on my own defects. The result is often reassurance from others, which is presumably the point.

In fact the whole concept of imposter syndrome sets up a specific question ("am I an imposter?") and invites arguments about how to best reach an answer. The dysthymic self attends to evidence that affirms the proposition ("I definitely fouled up in that meeting; "I don't know half of what I need to in order to be competent"; "I can account for all my achievement in terms of luck rather than merit"). The positive therapeutic self is supposed to weigh evidence more favourably. But this is an effortful process, and runs the risk that (without the support of an external voice) you conclude that you are an imposter after all.

I have found it more helpful to engage a gestalt shift in attention that leaves aside the question of whether I really am an imposter. It even leaves room for the possibility that I am. The focus moves instead to the facts of any given professional situation, and to considerations of what ought to be done. Instead of looking in at the person, look out at the parameters of the task, regardless of who is undertaking it.

Viewed this way, the "imposter" question evaporates. It can even be viewed as a convenient evasion.

For the real issue in most professional scenarios is not so much you as the task you confront. The question is not "do I belong?" but "what has to happen?" In work situations you have already been selected for a job. Perhaps there was someone else on the interview shortlist who would have been better at it in some sense. Too bad. It is unlikely that person (or anyone else) can replace you imminently. The ethical thing to do is to work hard and keep your end up in the now. That will probably involve hard work. You certainly cannot save the situation by appeals to the idea you "belong" after all.

Are you going to direct your attention to the job in hand, or are you going to expend energy fretting about whether you really ought to be there? Unless you're in imminent danger of harming people (say, you somehow wound up convincing people to let you perform a surgery or fly a plane without the relevant qualifications), you most likely owe it to those around you to do your job as well as you can.

I realise this approach lacks the positive validating tenor of typical imposter syndrome self help. This is not a comment on the general validity of positive-validating approaches. It is a letter to myself, and so reflects instead my personal preferences. Deliberating over whether I am an imposter has resulted in some half hearted self-praise. But seeing the ways in which that whole game is a distraction has been altogether transformative.

Monday, 6 January 2020

Neurolit




Let me not be mad - A.K. Benjamin.
Bodley Head - 2019.
212 pages.

Into the abyss - Anthony David
Oneworld - 2020.
189 pages.


By the time Oliver Sacks died in 2015 he had become something of an untouchable. Not exactly a "national treasure" - but whatever the transatlantic equivalent of that might be. It seems strange to remember that, although he had attained sage-like status at his death (see Vaughan Bell's obituary post for a lovely example of the justified affection Sacks' inspired), he attracted controversy earlier in his career. The ethical worry about Sacks was that he was "the man who mistook his patients for a literary career;" writing for the "voyeuristic cognoscenti."

Whatever other legacies Sacks may have left, he arguably created more or less an entirely new literary genre ("neurolit" perhaps?), and every publisher of popular neurological case studies since has been keen to get "Oliver Sacks" onto the cover in some form, to provide the requisite signal to browsers.

I could read Sacks endlessly. After he died I ploughed through many of the ones I hadn't yet got to. I also worked through some of the expanding shelf of his literary progeny: Paul Broks, Suzanne O Sullivan, Jules Montague, the list goes on. As a psychologist this is all work related, but it is also a guilty pleasure - like detective fiction or spy thrillers.

Two recent books in the Sacks tradition have revealed some of the different things it can offer. A.K. Benjamin is the pseudonym for a mysterious clinical neuropsychologist who writes in the idiom of a world weary psychoanalyst. Anthony David is an academic psychiatrist and giant of his field whose first foray into popular writing is a spare but immaculate primer on psychiatry.

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Benjamin's book comes with something of a "twist," for we learn by the end that some of the clinical vignettes within pertain to his own mental health problems. This device is personally revealing, but the use of pseudonym necessarily takes some of the edge off. In the end it is far from the most interesting part of the book.

I wasn't taking notes as I read Let me not be made, but so vivid and honest is the writing that much of it has implanted itself in my mind. Healthcare often involves an element of facade; of adopting a confident professional position and sticking by decisions despite the knowledge they could be wrong. Benjamin sees and - you sense - detests this facade.

In an extraordinary passage he writes of the emotional work that patients (sometimes) do to protect clinicians from the worst of their experiences. Our patients do us a service, Benjamin points out, by dying well. Most of us want a social encounter to feel comfortable and will collude with people, including clinicians to make it so. This is a form of protection, but it is coursing in the wrong direction. The person receiving the salary ought to the be the one doing the protecting. Benjamin invites us to recognise that it is often the other way round. That this is so brings into relief the importance of discomfort. If someone can make you feel uncomfortable, and you can sit with that discomfort and bear it, you might really be doing something for them.



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The title of David's book seems to conjure something rather vague and mystical, but it in fact denotes a precise idea. Karl Jaspers once posited an "abyss" between the mechanistic and hermeneutic forms of understanding people. David sees the psychiatrist's task as bridging this abyss, to provide a working understanding of people that draws on both. Much has been made in mental health of the biopsychosocial model. David points out that in offering an apparent theory of everything, this idea threatens to explain nothing. Here he is on the way psychiatrists ought to related to the three strands, bio, psycho and social: "Every time we meet a new patient, we must decide which of the three, if any, is most important." (p.2) This is a punchy and pragmatic version of sense making that I recognise in the referral questions to a neuropsychology department, and it seems potentially at odds with my own profession's sometimes broadly inclusive formulations.

Each case study here seems carefully sculpted to reveal something important about the discipline of psychiatry - there is a patient with Capgras and Cotard's, who allows David to illustrate the meaning of the two-factor theory of delusions; another who illustrates the paradoxical neuropharmacological connection between psychosis and parkinsonism. Unusually for neurolit - David also includes a case that illuminates the issue of race and psychosis - allowing him to weave in some reflections on Frantz Fanon.

My own route into neuropsychology has felt weird to me - like many I was inspired by the intrigue of astonishing neurological phenomena and a desire to understand them. But I came into the field via an interest in psychoanalysis, phenomenology and mental health. What is the appeal of these books to this jobbing clinician? As a psychologist, working in neuropsychology, I realise I read them as something like a form of supervision. Academic texts give you statistical generalities, but there is nothing like a vivid account of the minutiae of clinical work and some startling clinical advice (at one point he abruptly announces to a family affected by head injury that they "will never be the same again") to help you really learn something.

A book like Abyss then is something like a series of lessons - archetypal illustrations of how people can be distressed. It expands ones clinical repertoire, opening up new possibilities for formulating complex situations. This is more or less what you would expect from a prominent expert in psychiatry. The cases are well worked through and served up with aplomb. But they are also like events from a distant past. As a clinician I envied David the unruffled clarity he brings to bear on each situation. A patient appears to recover from a crippling depressive guilt, only to throw himself under a lorry within moments of being discharged. David is unsettled, but seeks solace in Durkeim's writing on anomic suicide and emerges a wiser clinician with what reads like relative ease.

Benjamin's book offers something more emotional, and counterintuitively more reassuring. Here is an author who portrays the startling and graphic events that bring people into contact and inevitable emotional entanglement with neuropsychologists. He is vividly impacted by his patients and has gone searching in some unusual places (tibet, his own dreams; psychoanalytic theory) to try and make sense of them. But as he shows in a remarkably drawn scene of an NHS team meeting ("the decision is made, the knife is readied, and nobody who was there can quite say what just happened" - p.67), there is never really anything like a complete sense to be made. The best we can hope for is to figure things out a little better and a little more usefully. The note of horror, the terrible senseless randomness in the world that lets brains grow tumours and collide with skulls at high velocity, haunts the pages relentlessly.

Friday, 3 May 2019

Therapy for therapists?

We see periodic flare ups - among psychologists and psychotherapists - of a debate about the importance of personal therapy for therapists. If you want to work in this business providing it to others, the central question goes, is it imperative that you undergo your own? The debate usually gets hot headed, perhaps because it is actually a form of culture clash between very different types of professional psychology. Across the spectrum of the "psy professions," the requirements vary. Many (most?) psychotherapy training courses mandate it. Others don't. It is constitutive of what it means to a psychoanalyst that you are someone who has been psychoanalysed. Meanwhile, most courses in clinical psychology will not insist that their trainees receive any sort of therapy.

It seems easy to argue that personal therapy has value for several rather banal reasons: the experience of being in the “hot seat” (being encouraged to divulge personal details, opening up about your insecurities) can give you a sense of what you are asking people to do. The opportunity to discuss feelings about the ways your work affects you personally is also a way to ward off professional fatigue and "burn out." The privacy of the whole situation (it's hard to see what a therapy session is like without actually sitting in one) also makes personal therapy seem an attractive introduction to how the process ought to look - a sort of apprenticeship. 

There are also arguments that the case in favour of personal therapy is overdone. It is a very resource intensive requirement, hitching entry to the profession to a large financial outlay that some more "hard headed" clinicians argue is simply unnecessary. I sought therapy when I was training to be a therapist, but whatever value it had for me as a person, it was not the only (and maybe even not the best) source of insight about the intersection of my personal and professional development. Intensive supervision on the other hand was profoundly helpful. I had the fortune to meet with supervisors who took a granular interest in the blow to blow of the sessions, and who were not afraid to tell me when they thought I was avoiding material from my own anxieties, or getting wrapped up in a response that was more aimed at gratifying me than helping the person I was meeting. 

Looking at my colleagues I hesitate to suggest personal therapy is essential. Some of them were the most gifted and emotionally insightful people I have met, but I suspect this was principally a result of their temperament, interests and life experiences. Many psychologists seem conscientious and rather neurotic, making them good candidates for extensive self-examination in or out of therapy. Others I have met seem somewhat emotionally unaware despite years of personal therapy. Hardly a convincing advert. 

It may be that this is a case (one of many in my view) in which the psychoanalysts have made an accurate diagnosis of a problem (therapists without personal insight are a bad thing!), but don’t have a monopoly on the remedy. Much as “mindfulness” is actually a description of a wide ranging mental state, which can be facilitated in many ways other than those that have been made popular since the advent of professional meditation training, so "emotional insight" does not only need to arise from a particular form of two way conversation that became popular in the 20th Century. The flip side of this is that therapy is not a precise science and has no guaranteed outcomes anyway. It would seem weird therefore to put too much store by it as some sort of royal road to clinical wisdom. 

How could we settle the question? Apart from examining the efficacy of therapist therapy on outcomes (those who worry about the value of personal therapy for trainees often ask to see the evidence that it "works"), the most interesting way of looking at the problem would be a straightforward “taste test”. You could (for instance) take a panel of senior psychotherapy teachers who run therapy courses mandating personal therapy and have them interview a sample of psychotherapy trainees, some of whom have had at least a year of therapy and some of whom have had none. Would the trainers be able to discern the “analysed” from the “unanalysed” cases? If the trainers’ judgments about who had had therapy were no better than chance then that would seem a significant challenge to the dogma that personal therapy is doing something clinically relevant.

Ultimately the dispute is so intractable because what is at stake is two conflicting visions of the ways that it is possible for us to deceive ourselves. For the cognitively minded, a salient sort of self deception might arise from the various self-justifying biases that are tied up with the insistence upon personal therapy: that it may seduce you into thinking that you’ve got (that it is possible to get) your own psychological house in order; that it bestows an unchallengable authority on the figure of the "well analysed" therapist ("I have the requisite sort of insight - you do not"), and that it is an arrangement principally suited to keeping psychotherapists in business through a steady flow of trainees who need to sit on the couch.

For the psychoanalytically inclined, the relevant self deception is tied up in the hubris of embarking on "the work" without sufficient knowledge of what lurks in your own unconscious. Enter the room as a psychoanalytic naïf and you will be hit by a storm of transferential and counter-transferential responses that you can’t make sense of. You will likely be pulled into a range of potentially harmful enactments with the people you’re trying to help. You'll be lucky to avoid causing harm to the client and to yourself, let alone providing help. I find this way of thinking fairly compelling. The rampant abuse of patients by mental-healthcare professionals (who didn’t – I assume – enter their field as aspirant sadists) looks like striking evidence of how harmful and surprising our unconscious motivations can be. Personal therapy - under the psychodynamic conception - is a way to start looking at the darkness that lies within you so you can stop it from wreaking havoc on those you work with.

The point of raising these two types of consideration is not to try and arbitrate between them, but to diagnose the whole problem with the debate as it is currently constituted. Both sorts of concern seem valid to me. I am convinced of the fact that therapists bring things into therapy that will impact on the work in potentially profound ways. I am also convinced that therapists are motivated to preserve their professional identity by appeal to the special significance of their hard-won clinical insight, and that this can often be overblown. If different sides can retreat from their favoured assumptions, a new way of asking the question might emerge.  

Thursday, 31 January 2019

Psychoanalysis' unlikely innovator

There is a popular narrative about the history of psychoanalysis and schizophrenia; that it involved little more than the invocation of schizophrenogenic parents and equated to victim blaming. This version of history is sometimes raised to engender doubts about any psychological theorizing in this area and shut it down.  It’s intellectually healthy to raise such doubts. Contemporary psychoanalysts - worried about repeating historical mistakes - have grappled with them too. Here is an excellent essay, by a psychoanalyst warning his colleagues to heed the "cautionary tale" of the schizophrenogenic mother theory.  

But historical reality is more nuanced than the narrative that runs "psychoanalytic theory bad; biomedical revolution good": Frieda Fromm-Reichmann’s “schizophrenogenic mother” idea has come to symbolise the theoretical chauvinism of the age, but her legacy is more complex. She didn’t focus on aetiology as much as on therapy. Her heroic efforts are documented in Gail Hornstein’s fantastic biography.

More overtly anti-mother was the work of Theodore Lidz, who devoted a large part of his career to studying the dynamics of families of those diagnosed with schizophrenia. His descriptions of two schizophrenia-creating family patterns (skewed families locate all of the power in one parent while schismatic families split it between them in a perplexing civil war) contain toe-curlingly misogynistic descriptions of mothers. These ideas stuck around a long time. As late as 1994 the notion of schizophrenogenic parenting was still doggedly advocated by some authors, with no attention to the idea’s serious evidential shortcomings.

But there was a more subtle and integrative idea at large during the psychoanalytic heydey of American Psychiatry. Sandor Rado was a peculiar figure in American psychoanalysis. Although an elder statesman of the field (he had known Freud well and was selected by him to edit two early psychoanalytic journals), he was cast out from the orthodox New York Psychoanalytic Society for his belief that psychoanalytic knowledge could not be separated from a sound understanding of neurology and genetics. “I believe that the influence of genetics, especially biochemical genetics, is going to be so enormous that it would be bootless to try to outline it.” Rado once said (see page 141 in this)

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Rado coined a term that has become ubiquitous in modern academic psychiatry: schizotype. This portmanteau (a collapsing of “schizophrenic genotype”) was used to designate an individual genetically vulnerable to a psychotic decompensation. For Rado (who outlined his ideas in a 1953 paper) a psychotic breakdown represented a combination of this genetic predisposition and the very human process of adapting to the world in light of that predisposition. Although highly speculative and somewhat vaguely couched, Rado’s paper on schizotypy is notable for its almost Laingian level of phenomenological detail. His ideas about the relationship between the constitutional factor (an “integrative pleasure deficit”) and the dynamic contents of the mind were supposed to be the start of a serious mind-body theory of psychosis. But it wasn’t to be.

Although some theorists took note (Paul Meehl brought the concept to academic clinical psychology where it slowly began to gain traction), American psychoanalysis at the time - which is virtually to say American psychiatry at the time - entirely ignored Rado’s idea. In fact “ignored” might be too suggestive of indifference.Some have gone so far as to suggest that Rado’s influence on psychiatry was repressed: “Rado and his collaborators were shunted out of the mainstream psychoanalytic journals and largely vanished from even their references and citations” (p.975 here). Instead American psychoanalysis became committed to ever more dogmatic assertions of the role of parenting in the development of schizophrenia. It's tantalizing to imagine how different it could have been.

Saturday, 24 November 2018

Matthew Parris misses the point

Matthew Paris has written an essay in The Times arguing against increased mental health funding. This issue is a sacred cow for politicians and the media so I have some respect for Parris for going against the grain. Mental health is too important to be untouchable. Unfortunately the article is based on a series of misconceptions that undermine its argument.

Here is how the substantive line of reasoning gets going. Treatment should be based on science, Parris is going to say, and psychiatry isn't scientific:


This is a ludicrously limited understanding of science. There is virtually no area of medicine where patients behave like the billiard balls of Parris' schoolboy physics. Medical science is generally probabilistic; surgeries tend to have a particular outcome, babies tend to emerge in particular ways. Psychiatry is more probabilistic than most, dealing as it does with cognitions and affects rather than hearts and livers, but the empirical principles are the same. To try and reign in the uncertainty, patients are grouped together by diagnoses and provided with treatments. What works best is what gets recommended for the NHS. That formula doesn't always get implemented properly, and we can argue about ways to change it, but it's misleading to ignore the fact that it exists as an ideal.

To bolster his case about the unscientific foundations of therapy, Parris makes reference to psychoanalysis:


Parris is talking here about psychoanalytic therapists (the majority of whom are paid privately) as a way of arguing for reduced NHS spending. It's a spurious connection. We can get up a whole separate debate about the merits of Freud, Adler and Jung, but in this context they are a distraction. 

When he does turn to the dominant mode of NHS therapy, Parris' ignorance is astounding. First he paints a picture on which the only sort of research conducted into therapy's effectiveness is from the most casual inquiry on the part of the therapist:


Then, with the sort of comic assuredness that can only come from profound ignorance of the literature, he cooks up a scheme for how such research might be better conducted:


These passages suggest that Parris cannot have read -- nor read about -- a single randomly controlled trial of psychotherapy in preparation for his essay on psychotherapy. Only someone in such a state of epistemic innocence could suggest with a straight face that, hey, psychiatrists might like to conduct a systematic test of their treatments one of these days. The problem he thinks he as identified was foundational for the project of psychotherapy research, well over 50 years ago. The broad consensus of that literature is that psychotherapy is helpful. Parris could take issue with those results but instead he doesn't acknowledge they exist. 

There follow some rather waffly personal reflections on the ascendancy of therapy as a culturally available means of dealing with distress, and the vagaries of psychopharmacology. With regard to the first Parris says that he was averse to seeking therapy on the two occasions it was offered to him. This tells us little about the value of therapy per se and only about Parris' attitude toward it. Fair enough - psychotherapy should always be an informed choice. 

On the latter issue he makes some concerned noises, but may as well have pasted in the shrug emoji:


There follow some half baked worries about Ritalin use in schools and the rising demand for antidepressants, but without any solid idea of what impact these things are having Parris just sounds like Robert Whitaker without the conviction or the reference list.

All of this is building up to what amounts to a tepid call for hesitation about funding:
This is infuriatingly facile. It's just the old Cameron idea of the Big Society, warmed over. Moreover, however shaky the ground he has trodden to get to this conclusion, the things he has left out are even more damning. Everyone can surely agree that kindness is essential in mental health. What is so frequently missing, and what drives people to campaign for increased funding in the sector, is the means to implement that kindness.

Parris tries (unconvincingly) to debunk therapy and medication, but he doesn't even touch on the most important parts of mental health. Put aside therapy, put aside medications, a huge amount of mental health care consists of things that are far more basic and important and done by people who aren't particularly interested in Freud, CBT or Ritalin. It can be found in practical support with daily tasks, in messy intervention at times of crisis, in advocacy, in needs and risk assessments, and in simple human contact.

The contemporary mental health crisis emerges not in the consulting room, but in A&E departments, job centres and community mental health teams. It arises because people in intense distress are showing up in all sorts of places that have neither time nor resources to help them. The political push for more mental health funding is not some rarefied thing that can be separated from the kindly pastoral figures that inhabit the conservative imagination. There can be no kindness where there are no people available to offer it. 

Wednesday, 17 October 2018

Making Up Symptoms

I have a short article in Psychiatric Bulletin about the question of historical variation in psychiatric symptoms. It's brief and rather speculative, but I hope fun and interesting.

The essentially private nature of subjective experience means that its occasional misdescription by mental health professionals is virtually guaranteed. Given the centrality of subjective symptoms in assessing psychiatric disorder, such misdescription could have important ramifications.

Here are two anecdotes about language:

During the morning handover meetings in an inpatient unit I once worked on, the shift manager would read a thumbnail description of each resident’s behavior over the last twelve hours. The phrase “responding to internal stimuli” recurred over and again, far more frequently than seemed plausible if you knew the people on the unit at any given time and their propensity to attest to hallucinatory experiences. What was going on here, I suggest, is that in some percentage of these instances, staff were witnessing a set of objectively describable behaviors (speaking aloud to oneself, laughing, ignoring others) and attributing them to inner events that are unobservable from without. The use of the right sounding psychiatric language (“internal stimuli”) was reassuring to staff, who felt they had something professional to say. Unfortunately it also contributed to the elision of the messier and more complex reality. 

In another setting I noticed I heard the use of the Bleulerian notion of “blocking” more than I had ever heard it elsewhere. You could see, in some staff meetings with patients, how the word was applied. It seemed to me that whenever a patient paused, struggled to find the words, or remained silent for any socially awkward period of time, this was apt to be described later as blocking. Thought blocking is often defined with reference to behavior (see the Wikipedia article here), but it is something that can only be identified by reference to subjectivity. Feeling that your thoughts have been blocked is not the same as simply stopping speaking. Additionally, verbalizations such as “he’s blocking,” (blocking as a verb) imply something quite different from the passive concept (your thoughts being blocked) that Bleuler initially described. This shifting use of words changes our understanding of what people are experiencing.

It seems likely to me that this process of misdescription takes place frequently; it may be impossible to avoid. Mental health professionals receive, through their training and through clinical lore and fashion, a sort of rubric for how to make sense out of people who are behaving in ways that are hard to understand. Through such misdescription entire swathes of symptomatic experience may be getting essentially overwritten.

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But this all still amounts to a fairly basic misapprehension, by one person, of the subjective experience of another. Such misapprehension is in principle rectifiable. But what if the confusion runs deeper? What if the interaction between experience and language through time has wrought a more pervasive form of overwriting? This is the subject of the Bulletin article. I suggest that changes in psychiatric terminology over time (namely the shift toward more homogenous descriptions of psychotic symptoms) have potentially had an impact on the very experiences that terminology tries to describe. This is a simple extension of an argument by Ian Hacking, who claims that new diagnostic categories actually bring new ways of being into existence (read this essay in the LRB for a brief overview of this idea, and to see from where I stole my title).

Unlike Hacking though, I think we need more conceptual resources to understand such change. I draw on the work of philosopher Eric Schwitzgebel (check out his excellent blog here), who has written interestingly about the indeterminacy of psychic experience. I am convinced by Schwitzgebel's argument that, far more than we habitually think, there is no fact of the matter about what many aspects of our experience are like. If that sounds extraordinary to you then I recommend you read his book Perplexities of Consciousness. If it doesn't, then you are some of the way to being persuaded by what I am suggesting. If consciousness is indeterminate to some degree then asking people questions like "do you hear the voice inside your head our outside it?" or "is it a male voice or a female voice" is likely, in some cases, to introduce more confusion than clarity to our understanding what an experience is like. Every time we do that, and every time we defer to official definitions of delusions as "beliefs" or hallucinations as "perception like experiences," we are potentially nudging people toward those definitions rather than nudging our definitions toward them.

Monday, 10 September 2018

So long, psychiatric New York

Islands are attractive to the builders of asylums. The seclusion of large bodies of water lends itself well to the defacto banishment of those people deemed easier not to engage with. New York is a city of islands that have functioned to keep certain people out of sight.  Rikers Island can be instantly recognised as a notorious prison. Hart Island is less well known but has long served as a burial site for vast numbers of the forgotten residents of New York. The awkward confluence of large seething rivers makes parts of the waterways surprisingly treacherous.

This city has been my home for five of the last six years and I am two days away from the flight that will take me out of it indefinitely. It seems like a good moment to explore parts of the city that I never got to before. A friend has just become licensed as a city tour guide and is piloting his tour of Yorkville. It's a secluded and often overlooked neighbourhood. I join him for a stroll through the drizzle, past Gracie mansion and the apartment building that once housed the Nazi party of America. At the start of the tour a building across the East River catches my eye.

Toward the northern end of Roosevelt Island stands a striking little segment of asylum architecture: The Octagon.


The Octagon is now the entrance to a well appointed apartment building, but it used to be the centrepiece of the New York City Lunatic Asylum. According to my tour guide friend wealthy people in need of psychiatric care were more likely to end up at the West Side's long-gone Bloomingdale Asylum. The last remaining building from that institution -- Buell Hall -- now sits incongrously on Columbia university's Morningside campus housing several academic departments. New York City Lunatic Asylum was state run, and this was the place that you got incarcerated if you were poor and insane in New York. 

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Long before David Rosenhan sent his students off to pose as psychiatric patients, the pioneering journalist Elizabeth Seaman (an amazing character in her own right -- I strongly recommend the linked page) went undercover at the asylum to expose conditions. She gained admittance by feigning a pervasive and global amnesia, causing a mini media sensation in the process with her youth and striking looks. The book she wrote (Ten Days in a Madhouse, written under the non de plume Nellie Bly) detailed sadism by asylum staff, disgustingly unsanitary conditions, and inedible food. At one point Seaman found a spider baked into her bread. The book's publication led directly to an increase in funds to the asylum and became part of a much broader movement in which the working practices of insane asylums were exposed and reformed. 

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Benign neglect: The Octagon in 1970

The asylum was closed at the beginning of the 20th Century and the buildings taken over by the Metropolitan Hospital. The latter moved off Roosevelt Island in 1955, and the building fell into the kind of neglect that was widespread in parts of New York right through the 1950s, 60s and 70s. This still seems so astonishing in the contemporary New York of unceasing development and barely affordable rent. In 1972 (two years after the photo above) the last remaining part of the building -- the Octagon -- was put on the natonal register of historic places.

A stepped pathway of care

It's a cold and drizzly day when I take the elevated tramway over to Roosevelt. This island has always felt ahistorical to me. It's a warren of newly built apartment buildings with a Starbucks and a Duane Reade. Unless you have access to the gyms or swimming pools dotted around, or want to look at Manhattan from an unusual perspective, there are few reasons to visit.

You have to walk through all that to get to the Octagon complex. Moving north you start to pass tennis courts and coniferous trees. The whole place has the air of a country retreat, and feels about as far away from New York as it is possible to be while still technically within the borough of Manhattan.

I walk in past the concierge and am immediately confronted by the smartly renovated spiral staircase. This takes you up past a billiard room, a gym, and a play area for young children. Somewhere I have read that you aren't supposed to take photos, but no-one is around to care. All is serene. When I reach the top I feel like I could be in a lighthouse. Looking down the centre of the spiral staircase gives you a sense of space that few modern residential buildings manage to achieve.


It's fun to imagine that you are in some way communing with history in these buildings, and the Octagon shines a light on its own past. Prints of historical images from the building's asylum days are framed on the walls as you make your way up the stairs. Apart from these there is little to see. The refurbished interior is tasteful in its simplicity. As I leave I can see another of New York's island institutions from the northern tip of Roosevelt: the modernist concrete bulk of the Manhattan Psychiatric Center -- a state-run inpatient facility on Randall's Island -- looming out of the grey sky.


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More links:

Ten Days in a Madhouse full text here

Ten Days in a Madhouse as a free audiobook download.

This page at The Ruin has some good photos of the abandoned asylum buildings. 

Asylum projects has a good page on the New York City asylum that skips some of the more lurid and sensationalist nonsense you find elsewhere.