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We have all seen some people make movements that seem to be non-voluntary, awkward or impolite. The difference between those and the full blown disease, Tourette syndrome, is a matter of degree. The chief symptoms are precisely the lack of control of some subset of movements (changes in gait, sudden upper torso jerks) and some parts of the linguistic repertoire (involuntary mimicking of ones own or others sentences, violent cursing, and so forth, together with more peculiar fixations on some particular number, or some set symmetry between ones nose and spectacles, and so forth.) Kushner does a superb job in first telling a medical story, a story of the way a set of phenomena is categorized as a disease. After all, barring thoroughly degenerative cases, something like Tourette syndrome can be lived with, and, given some degree of social tolerance, could even be categorized as something eccentric rather than as a pathology.
The plot thickens when Kushner faces the scientific conflict between the two main approaches to treatment. The psychoanalytic tradition (stronger in the U.S. after Hitler managed to exile all analysts from their European homelands, and even stronger in France after the war) stuck to the idea that the tics symptomatic of Tourette syndrome are of psychogenic origin. For example some psychoanalysts postulated that the tics represent some fight against or some replacement of masturbation. Others in the clinical communities saw that there could very well be purely organic causes, e.g. malfunctioning of neurotransmitters, giving rise to forms of behavior that do not, strictly speaking, even qualify as intentional actions.
What is interesting in Kushners story is that the battle between the two schools was won largely because of the organizing of patients, who simply refused to swallow whole the "witchcraft" of psychoanalysis -- to use the phrasing of a young patient fed up with being told he was sexually this and that and all his conflicts were to be found in his family environment. Patients looked for help where they could find it and found it largely by means of Haloperidol, a symptom-suppressing drug, not devoid of side effects either. This was a battle won also, strangely, in the mass media with direct intervention of patients groups buying advertisement spaces to pressure doctors to recognize what they did not want to recognize.
So Kushner tells a story of triumph of human suffering over the dogmatism of received opinion. It is also a story, alas, of the extreme conservatism of the medical establishments in several countries, suspicious not only of being told what to do by the suffering patients, but also suspicious of anything that could put in doubt some obscure opinion based on deductions from Sigmund Freuds work. Kushner acutely notes that Freud himself did not see tics as psychogenic; it was his Hungarian follower, Ferenczi, in a sort of imperialistic worry, thought it better to give a psychoanalytic interpretation of tics and did so without examining anybody.) This is largely the story Kushner calls the French resistance, since it was in France that the chemical treatment of Tourettism had to fight the hardest battle, and which even today is not completely won, by the way. The worst traits of the arrogance of the medical authorities, mixed with nationalistic rhetoric, are on display in this history.
Thus the author presents his work both as the story of the birth of a particular syndrome, classified and recognized as a disease, and the story of the politics involved in reaching some degree of consensus about its treatment. To this day, in France, influential figure insist on the "unconscious" source of the disease and support psychodrama, family treatment, and in general "talking" approaches intended to reveal the hidden sexual conflicts of the patients. What emerges, from a non psychological point of view, is the sheer weirdness of the linkage between sex and absolutely everything else the psychoanalytic movements state with a strange degree of dogmatic assurance.
Being a philosopher, I cant help adding some remarks about the conceptualization of Tourettism, since it sheds some light on truly tough questions. Deciding whether or not a movement counts as an action is a difficult choice in borderline cases where no self-evident answer is available. The tics and vocalizations of Tourette patients are triggered by nothing clear: the actions are not intentional in any straightforward way. Virtually nobody chooses to scream fuck you at bosses at work, or teacher at school, -- unless directly engaged in insulting. And yet the Tourette patient is typically acting (acting? Is that the right word?) like that. It would seem that the very notions of will and the related voluntary action is misplaced and that the tic has to be considered as physical movements of the same kind as blinking eyes, reflexes, and so forth. One of the results of the scientific work on this syndrome is that indeed there are chemical suppressant of the unwanted bits of behavior, but there is at least a prima facie piece of evidence for still seeing tics as actions. To some extent (the range of variation appears to be enormous) patients can control their tics, they can refrain from cursing. In some cases the focus of attention appears to be doing the trick. Oliver Sacks in one case history describes a Tourettic surgeon ticcing all the time except when he operates or flies his plane. [An Anthropologist on Mars, reviewed in Metapsychology July 1998.] In some cases environmental triggers are needed (it is only seeing certain objects in motions that tics are acted out.) Tourettic patients remind us in a poignant way of how little we understand of what it is to be a voluntary action.
The existing philosophical literature on the metaphysics of the will is of very little help. At best the counterfactual analysis is the only one which is somewhat illuminating: this says that we ought to call an action voluntary if there is a possible world which is a clone of the actual one save for the doing of this very action; intuitively if I could do otherwise than F, and F is enacted, F is voluntary. I fear that the very existence of something like Tourette syndrome hints at how deep is our ignorance of what the mechanisms of intention are, showing our feelings of "being in control" to be nothing but a thin veil of epiphenomenal certainty over vastly unknown real mechanisms. One influential current in philosophy views all actions as tics, in the sense here at stake, as bits of motion put in existence by neurological mechanisms, however complex. Intuition tells us against this, since our whole psychology bets directly on the causal influence of the mental; for example, I drink coffee because of my desires for coffee. Phenomena like Tourette's may not be the end of folk-psychology, but they point to the fragility of our ordinary psychological understanding.
Adrian Palma was educated in the UK, Italy, Germany and France before doing his Ph.D. in philosophy at Indiana University. He is currently a researcher at the Center for Research in Applied Epistemology (CREA) in the École Polytechnique, Paris, and is also at the University of Technology in Compiegne, France. His main interests lie in the intersection between philosophy of language and the philosophy of mind.
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