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As I started to read Donna Orange's book an email came round on a nursing forum asking us to support a petition to do away with the concept of schizophrenia. The basic idea behind this movement is that the concept "schizophrenia" does no more than describe a cluster of symptoms (with a definite negative bias) which means that the individual is overlooked in favor of a medical diagnosis. So, runs the argument, we risk focusing on treating the symptoms whilst ignoring the person experiencing the symptoms. This is an argument that would find favor with Orange whose book sits in the tradition of those analysts who accuse traditional psychiatrists, analysts et al as holding to the idea of the "isolated mind". This view "... claims foundational reality for the single individual" (p.124) and stands against an intersubjective view "...that claims that all experience originates, is maintained, and may be transformed within the field or system formed by two or more personal subjective worlds of experience." Put simplistically, John Donne's line that "No man is an island" is at the heart of Orange's thinking. The paradigm of the "isolated mind" would be the imagined philosopher sitting on desert island thinking. And forming a view of himself and his world solely on the basis of his own experience of this phenomenon. And without recourse to any one or anything to challenge his world view. For the intersubjectivists, life is always to be understood in terms of relationships with others. As Orange writes "We believe that our involvement in humankind means that all human experience is in principle understandable through empathic dialogue, including its nonverbal or embodied forms. This means that although you or I may not be able to understand every patient, no patient, no psychosis, no cultural difference, no form of otherness lies outside the possibility of understanding by someone." (p.9) (Which reads almost as though it were a manifesto statement!)
The subtitle of "Thinking for Clinicians" is "Philosophical resources for contemporary psychoanalysis and the humanistic psychotherapies". "I have wanted to introduce my philosopher friends to my clinical colleagues" she writes. And, one might add, my clinical colleagues to my philosopher friends. The book comprises six chapters, five of which examine the clinical implications of the work of a particular philosopher. These five philosophers are Martin Buber -- The dialogic we; Ludwig Wittgenstein- Nothing is Hidden; Maurice Merleau-Ponty -- Embodied Intersubjectivity; Emmanuel Levinas -- Trauma and the Face of the Other and Hans-Georg Gadamer -- Undergoing the Situation with the Other. I confess to being ignorant of many of these writers-which probably confirms Orange's view of the need for a book like this!
Her key argument is that "mind" is always embodied and thus always in a relationship with somebody else-which accords with the current view of illness as having a bio-psycho-social etiology. And, equally, that health is bio-psycho-social. (A colleague at work always used to ask our potential psychiatric nursing students to define mental health. After five or six false attempts to define "mental illness" some of them would reach the conclusion that Health was about relationships. Orange would have approved of both the question and the answer.)
The first chapter is on the work of Martin Buber, focusing on "I and Thou". This chapter, as with all the others, opens with a quote or two from the philosopher in question. In Buber's case she has "A soul is never sick alone" which sets the tone for the chapter. She writes "If I reduce the other through diagnosis or by any other form of experience-distant description-whether from psychology, sociology or, or neuroscience- I have missed the encounter and objectified the other." (P.31)
She again quotes Buber "Only in partnership can my being be perceived as an existing whole."
Chapter 2 is a brief introduction to Wittgenstein and is headed with three quotes from him of which my own favorite is "What we cannot speak about we must pass over in silence." That seems like sound advice for any of us involved, directly, in the "people business"-nurses; teachers; counselors; therapists etc. An acknowledgement of the limitations of our knowledge; wisdom, experience etc. should be our starting point. Orange gives a brief summary of some of Wittgenstein's key ideas-notably the concept of "I" and definitions of "self" The arguments about what constitute "self" are important-particularly in the realm of such things as psychosis where it can be very hard to find the individual hidden within a mass of symptoms which seem to serve to hide the person's "true" self. They are, however, complex and abstruse-and thankfully outside the remit of this particular book review! However, Orange takes his ideas and links them to concepts of pathology. She writes
"Concepts of pathology, considered as an individual's property, give way to those of suffering, intersubjctively generated, maintained, and possibly transformed. Shame, no matter how isolating it feels, reappears as intrinsically social experience, usually resulting from humiliation and contemptuous, demeaning treatment (Orange,2008c)" (p.47)
Thus once more Orange restates her view that "self" is social-as are pathology and healing.
The next philosopher is Maurice Merleau-Ponty and this chapter has as one its headlines, Merleau-Ponty quoting Saint-Expuery's comment that "Man is but a network of relationships, and these alone matter to him". From here Orange leads into her theme of embodied-ness and cites Merleau-Ponty's observation that "The perceiving mind is an incarnated mind." (p.62). From here she talks about some of her own clinical work in a way that I found moving. Clearly she is a compassionate analyst as well as an erudite one! She speaks of a female patient who in the past has been diagnosed as Borderline. Orange talks of the girl's fear that Orange, too, will so define her.
"'What do you think they (the hospital social workers) meant by that?' I asked. 'I don't know' she said, ' but I think it's something really bad and I want to know if you think I have it, and if it's something that can get better' A phenomenologist would instead have responded to her embodied suffering in a world of misunderstanding and humiliation." (p.63)
As a psychiatric nurse of some years, I found myself in two minds about this particular "reminder". Having worked with patients with a diagnosis of Borderline Personality Disorder, I am well aware of the stigma that is attached to this label, the mores o since it is all too often used with an expletive in front of it. Yet surely our task as clinicians is to meet our patients as people-not as a diagnosis? (Certainly that is what I tell my students!) So why does Orange need to remind us once more of this central tenet? Bur before my own prejudices take central stage, there is one more idea in this chapter that caught my attention. It is that of "advent" a phrase taken by Merleau-Ponty from Paul Ricoeur. This is the notion that every cultural expression has the capacity to exceed itself, "to inaugurate a meaning" (p.67)"Merleau-Ponty thus reminds us clinicians" writes Orange, "that development may be understood not only as past-loaded, but also as forward-pointing."(P.67)
And Advent, in terms of the Christian calendar is also a time of cold and darkness; of a waiting in hope that something new will begin- a difficult time in therapeutic terms as well.
Chapter 6 deals with Emmanuel Levinas and this chapter is headed "Trauma and the Face of the Other". The quotes which open this résumé are from Levinas himself- the most notable of which seems to me to be "If one could possess, grasp, and know the other, it would not be other. Possessing, knowing, and grasping are synonyms of power". Helpfully, Orange takes us quickly to Levinas' "Big Idea", namely that "... the ethical relationship is not grafted on to an antecedent relation of cognition: it is a foundation and not a superstructure."(p.79)
Levinas' seminal experience seems to have been to witness, first hand, the persecution of the Jews under Hitler. He was himself imprisoned in a Nazi camp-although he did mange to survive physically. From this experience came what could be termed his" philosophy of trauma". Levinas values trauma not for its own sake but because it offers us the chance to respond to Another in an empathic response. As Orange comments "For Levinas, trauma is the experience of responsibility for the destitute neighbor, for his or her suffering.(Chanter:1997). The suffering other holds me hostage." (p.85). This suffering is linked to clinical work by Orange by reflecting on the trauma we are sometimes asked to share with and bear with our patients.
It is noteworthy that the root of our word "martyr" is "one who bears witness". Thus there is a cost for us as clinicians in bearing witness to the suffering of our patient. Yet this cost is part of what Orange and others argue makes the difference between embodied and disembodied suffering. The writer of the New Testament Epistle to the Hebrews, talking of Christ, commented that "We have not an high Priest who cannot be touched with the feeling of our infirmities..." (Heb.4:15) This seems to be the model that Levinas uses as representing our work.
The final chapter is devoted to Hans Georg-Gadamer who follows on from Levinas both chronologically and ideologically This chapter is sub headed "Undergoing the Situation with the Other" Orange summarizes Gadamer's work under three main headings.
1. The Gadmerian refusal of all forms of authoritarian communication.
2. An unmasking of the pretensions of interpretive expertise.
3. A theory of emergent and self correcting understanding.
The "Big Idea" for Gadamer is that life is about Conversation-and "conversation" having its original sense of "living with; sharing and associating with". Thus we come back to Orange's central idea that mind is not disembodied but enfleshed and incarnated. (It is hard to picture two disembodied minds meeting for coffee and conversation!) As Gadamer puts it "What distinguishes our humanity is not any rational capacity that would catapult us into a divine world of pure ideas, but rather only the ability to go beyond our particularity, to take into account the heritage that can help us grow above our limited selves." (p.118)
I came to the end of this book with a mixture of feelings. Some envy of Orange's breadth of reading. An appreciation of her compassion. And a renewed wish to read some of her favorite philosophers for myself.
© 2010 Terry Burridge
Terry Burridge is a Senior Lecturer in Mental Health Nursing at Buckinghamshire New University. He has spent most of his professional life as a psychiatric nurse and now spends considerable time and energy trying to inspire future psychiatric nurses to be the best kinds of nurses that they can be! He is very much influenced by psychoanalytic thinking and sees analytic theory as offering a valuable critique to many other areas of human activity. He can be contacted at Terry@dancingbears.co.uk