Cutting Through the Jungle:
A Machete from Macmurray
By Nick Child
This paper tells the story of my searching through my Edinburgh training in medicine and psychiatry and psychotherapy to find what I was looking for in philosophy. In particular John Macmurray's reworking of the field of philosophy from the new starting point of 'Self as Agent' and 'Persons in Relation'. The paper was given twice in Scotland at meetings of the Royal College of Psychiatrists Philosophy Interest Group, this version was given in May 1994.
(In case you hadn't guessed, 'the jungle' is medicine and psychiatry; Macmurray was a philosopher. If the title reminds you of Indiana Jones or the quest for the Holy Grail, that would be appropriate!) For this brief talk, I had thought of taking the risk of making it an extemporary informal chat - like a jazz improvisation of a number I know so well that I don't need the music in front of me. But my main responsibility weighed too heavily. This afternoon is a shop window, a kind of advertisement and invitation to you, the Scottish Division of the College, from us its new Scottish Philosophy special interest group. If I am to bridge between that group and Royal College type Psychiatry, I reckoned I needed to prepare more carefully or mess up our main chance. Word processing allowed me to cut out the cutting comments that would slip in if I were improvising. That image of inner conflict between spontaneity and conformity seems to be the pattern of my personal and professional life.
My title includes a cutting comment because it was composed spontaneously without correction. It tells you about me as much as my subject. For the Machete from Macmurray is fashioned and handled by me, not him, and I choose to see the Jungle and set myself the task of Cutting through it. This half hour could anyway only be a taste or introduction to several large areas, to my view of philosophy, to my view of the Philosophy Special Interest Group, and to Macmurray. But my main point today is to include myself in the middle of it all. I hope that breaking this ground rule for academic papers is valid and ground-breaking rather than embarassing.
Philosophy, for me, means two things - 'quality thinking' and 'a way of life'. I don't know how many of you are here because you are aware that you are philosophers, but as human beings I think we all are. In a complex profession like psychiatry, it is even more unavoidable in our theory and practise - is there anyone we see in our clinics and wards who is not struggling with what are essentially philosophical problems in their lives, however helpfully we can sort things with simple pills and advice? Each of us has our own philosophy just as each has our own identity and personality, for I would suggest (as Macmurray would) that the two are intimately linked. That's why I want to link my personal and professional journey, what I needed to search for and how Macmurray fitted that need. To look at the wider personal context within which we employ the fullest logic and rationality, is not to replace logic, but to give it extra life, comprehensibility and meaning! Of course this is a much broader view of philosophy than the cold academic type. I'm not trying to persuade you through sympathy. I am inviting you to consider what the equivalent project would produce for you.
It's interesting that I feel I can talk more straightforwardly and personally here in the context of Philosophy and Psychiatry than I can in the context of another long-standing interest group of mine, Psychotherapy. Many of those who have joined the College's Philosophy Group say they previously had thought they were the only one in the land with that interest. It feels liberating to be able to "come out" and find that such a personal interest is shared and valuable in our profession. And I don't think it's a paradox that this interest is growing at a time when the government of our country and workplace is going through such a thoughtless, mindless, totalitarian revolution. People have also said that the philosophy meetings are unusual as psychiatry meetings go in that there is less gamesmanship, and more of a shared concern to listen and help each other in quality thinking. This is because philosophy is only about quality thinking, cutting across all other specialisms and sections; it has no campaign to wage for "Philosophy Therapy" or "Patients with Philosophical Derangement" or the likes.
The main College group has been going for a few years now. In Scotland we have had three meetings in just over a year. Thanks to links with professional philosophers in the Universities, our Scottish meetings have been therapeutic in another sense. Basically, the Scottish Philosophy Club is the mainstay of the group, sharing more than equally the task of organising and presenting. In recent years, some philosophers have become much more 'applied' which means they're especially expert in medical and psychiatric philosophy and ethics. So we mixed-up psychiatrists go to the meetings with our problems and practical experience, and the elegant care and thought of our philosopher colleagues helps us think through some solutions. It's like going to a psychotherapy session ourselves!
Preparing this paper, I enjoyed collating my life and works so far, but I'll keep that to a minimum. The reference list includes Macmurray's main books and some of the places where my thinking got published. First, a little about:
John Macmurray was born in 1891 and died in 1976 in Edinburgh having invited the wrong curly haired psychiatrist to dinner just before he did. Macmurray saw philosophy as a grounded universal matter akin to everyone's struggle to find their 'way of life'. Making 'philosophy' mean: 'a way of life' is an example of how he aimed to use ordinary language, but brought new and deeper meaning to the words. This is at odds with much of philosophy which remains a much narrower academic pursuit. Macmurray's project was (modestly!) to rethink the whole field of philosophy from a new starting point. Instead of the implicit assumption of humans as 'thinkers' first and 'agents' a problematical second, his thesis is of "The Self as Agent" and (sine qua non) "Persons in Relation" - which are the names of two books of Gifford lectures in the 1950s published by Faber.
As you can imagine, Macmurray's cutting through his jungle meant that he has been rather "neglected" (Conford 1977) in the established field of philosophy. Outside it, many have valued his contribution immensely - in our field, Kelly, Guntrip (and surely Fairbairn), Laing and the original family therapist, John Bell. He gave a famous series of radio talks in the 1930s. Published as "Freedom in the Modern World", and followed up by "Reason and Emotion", this is the best place to start. Still sounding extraordinarily relevant today, all four books have been reissued recently by Humanities Press with new introductions by experts on him.
It's not surprising that philosophers, being armchair thinkers, start from the static and essentially divided view of '(wo)man the thinker' thinking about 'the world out there'. From this divided view, dichotomies are inevitably generated - mind/body, idea/behaviour, subject/object, imaginary/real - which will be inherently difficult to resolve because they are built on that divided basic assumption. Yet we all live and act as if the world is an integrated whole, not fundamentally divided. In contrast, Macmurray creates a more integrated picture of the interdependent relationship between the realms of matter, organisms and persons, and an understanding of those definitively human enterprises: science, art and religion. Verbs take over from nouns, 'ideas and thoughts' (for example) transform into 'a person thinking or reflecting', with 'reflection' being a secondary form of human action. Along with interpersonal relationship, 'feeling' and therefore 'feelings' too, take a more important and integral place where they are problematic for most philosophies. New dichotomies arise, but they are familiar human and moral ones: doing/undergoing, passive/active, self/not self, good/bad (that is valuing), authentic/inauthentic, and so on. He gives an account of child development within this framework. His rational and pacifist approach seems not to do justice to the rough and tumble of the world we and our clients inhabit, with its conflict, hate and even more "animal" aspects of human existence. But I think the personal life line is a better guide through that than the many impersonal alternatives available.
OK, so where does my need to cut through jungles come from that drove my search that led to Macmurray? (It is that 'search for humanity and honesty/ authenticity' that made medicine and psychiatry seem 'a jungle' - if you aren't looking for that, you won't find a jungle. But if you don't expect to find humanity and honesty in psychiatry, I wonder why not?) I was born the eldest of four in India. My father was a minister in the united Church of South India. As good secular minded Christians, my parents loved us from behind a gentle intrusively prohibitive emotional distance and sent us off for our own good at 5 years old to colonial type boarding schools in India. Seeing us every 3 months was more progressive than the pre-war pattern of every 3 years as a result of being sent to England to relatives and boarding school there. Continuing from this kind of family and school institution, in England by now, at 13 I had to choose without further advice which subjects to specialise in for a two-years-in-one rush to O-levels. With a vague idea that I wanted to help people, I could think only of medicine or the ministry like my father. If I had been better looked after, I think I should have chosen the arts, journalism, creative writing, even philosophy perhaps.
In such uncontrollable subjects at that time, I felt inept. (By the way, I think it's partly because I shouldn't have become a medic that I make rather a good one!!) Pathologically pushed to sciences, I chose medicine and (with noone to tell me about the London medical schools which were not then on the UCCA form) a pin and Edinburgh chose me without an interview. Having lived in 18 places in my 18 years, I was determined to stay in one place in order to belong somewhere. I loved the sharp edges of Scottish life and land that cut through the gentle imperialism and the numbing cotton wool of my English background. By managing to keep nearly all my training in Edinburgh, and then by commuting to Lanarkshire (when the training centre rightly saw me as too unconventional to have one of their jobs), I have managed to remain an adoptive Scot and resident of Edinburgh's fringe at Portobello. We've been there so long that we have finished paying our mortgage and have contributed to a community newspaper and other organisations to the point where we can leave them to other people and enjoy just living there. The Glasgow-Edinburgh conundrum still fascinates me in my daily commute.
But I'm ahead of the story. While I struggled at university to find something ordinarily human in my personal life, I was expecting something human in medicine. I wore flowery shirts and long hair and felt uncomfortable with myself and with medicine and medics, but I was still a long way from having the capacity to feel free of institutions that weren't caring for me. It was clear that medicine was about bodies not human beings. I went straight into psychiatry to find that it too was even more surprisingly not to do with human beings but about first scanning people's thoughts and behaviour for signs of syndromes or psychodynamic complexes, rather than listening to them as themselves. (I hasten to add that part of our job does indeed require us to scan for syndromes and complexes.) Psychotherapy was some solace, and I set my sails for adolescent and child psychiatry. But both of these, in their taught academic form anyway, still seemed to miss the person.
Throughout all this, I could never accept foggy or dishonest words or thinking - I knew too much about good intentions and caring words unwittingly masking deprivation, treachery and institutionalisation. Leaving aside the mindlessness of organic and behaviourist psychiatry, I even despaired of psychotherapy. How on earth, I wondered, could people who supposed themselves to be experts on humans and communication choose such precisely wrong terminology - 'object' relations (an object being the one thing a person isn't) for 'human or personal' relations? On top of that they were surprised that outsiders weren't more understanding about them?! And for me the word 'therapy' is second only to 'depression' in the so-broad-as-to-be-useless league. Or turn to Thomas Szasz on the Myth of Mental Illness, where you discover that it should have been called the Myth of Hysteria as Illness. Under that title, if he had been serious about contributing to psychiatry as opposed to populism, he would have aligned himself with the very psychiatrists who have maligned him over the years and not read the book. Really it was all too familiarly exasperating!
With the help of a home life, and of non-medical colleagues at work in the peripheries of excellence, and with help from one final facilitating institution - an analysis and half an analytical psychotherapy training - I found liberation by therapeutically acting out and giving up institutions to become myself, a free(-er) agent roaming enjoyably around the peripheries of many fields and organisations.
But the key intellectual influence goes back to Macmurray. Twenty years ago, my wife was doing a PhD on Interaction in Nursery School Children at the University Department of Psychology at the same time as I was trying to wring something good out of my psychiatry training. The Clinical Psychologists were all rats-in-a-maze behaviourists, while the academic psychologists were nearly all into much more human ideas like intention and intersubjectivity even if they were studying animals! Colwyn Trevarthen convened a regular Intersubjectivity Seminar across many disciplines and departments. It began with someone presenting on Macmurray's philosophy. I didn't really follow it at first, but I feasted on it and knew that this was what I was looking for. Something human about human beings. Of course it was still something intellectual about them, but it provided a vital logic and structure to my thinking and practice. It was a kind of blueprint for life and work and thinking and teams and training, an intellectual blueprint (which normal well brought up human beings may not need) and which can be discarded once the building is built. I should say, however, that in 20 years, I've hardly read or preached Macmurray at all - it's felt more like an inner comfort and guide.
From 1976, we had a philosophy interest group amongst trainees at the Royal Ed(inburgh Hospital), which led into a successful weekly Psychodynamics Forum. I gave wonderful papers on Action, Apperception and so on, developed from Macmurray that noone understood, so I set about making it simpler. It became an overall simple 'systems' conceptual framework about people with tasks and problems, helped by one or more other people with solutions, and "inner" persons, all of whom may get into inter-and intra-personal conflict which can then become a different category of problem itself. Such conflict can present in direct or disguised forms, requiring methods of inter- and intra- personal conflict resolution. Three characteristic patterns occur: abling, enabling, or disabling. Abling occurs when one person takes the problem away from another; an enabling process helps the person to cope with their own problem; a disabling process occurs when the right one hasn't been found or worked through properly. The medical model is based on the abling pattern; counselling and psychotherapy in the enabling pattern. Psychiatry needs to be eclectic, but not all at once since that is likely to be a recipe for the disabling pattern. Leading off from this conceptual motorway are all kinds of by-ways around our territory. I have presented the machete in various guises and settings. I use it regularly in subversively teaching Strathclyde's Child Psychiatry Registrars every six months about philosophy while looking at Conduct Disorders in terms of what conceptual framework is more suitable for that kind of 'problem of living'. I'm pleased to see more intelligent awareness in psychiatry of different conceptual frameworks (Taylor 1982; Tyrer and Steinberg 1987), of more flexible crossing of boundaries (for example, articles in the Yellow/Blue Journal even (Alanen et al 1994) about psychotherapy and family therapy for people with schizophrenia), and of action philosophy applied, (for example, in Fulford's (1989) meticulous demonstration of 'mental illness' as 'action failure'). The press also shows occasional signs of intelligent thinking about psychiatry. The modern development of audit is welcome because it is basically a method for encouraging quality thinking where it is missing.
My simple version of Macmurray was what I first thought of as my Machete. Where is it published you ask? Well, my few attempts have been unsuccessful. I don't think this is because it is a bad piece, but because it is (correctly, I think) seen as so obvious as to be common sense, and also because journals are always specialist and this is certainly not a specialist paper. As philosophy it is of course too inferior for a philosophy journal, though perhaps my earlier unsimplified efforts would pass muster there! The reference list includes some cuttings from my machete that have got published. The most cutting version was an unpublished talk at a medical school reunion, entitled The Trick-cyclist - an Honest Con.
And what about the jungle? I spent
some weeks jotting down bits of what I mean by the psychiatric
jungle - or at least as I have come across them over 20 years
- I fondly hope much of it is now removed from modern psychiatric
practice and training. Certainly there are signs of new psychiatric
thoughtfulness in the literature. I have already slipped in a
few examples of the jungle - being trained to invalidate people,
exactly wrong terminology as in 'object relations', and specialist
journals that systematically exclude common sense. My still accumulating
list is huge. Many of my bits of jungle are more within the field
of psychotherapy and counselling. Some of them are just bad or
thoughtless organisation rather than about bad thinking or philosophy
per se. But I think that quality organisation comes from quality
communication and planning, and that comes from quality thinking
which I say is akin to philosophy. We would be here all day if
I tried to go through my list now. I'll pick out a few more examples
· The new SHO thrown into the dreaded ward meeting armed only with vague mythical rules like "psychiatrists mustn't speak first" - imagining this is psychotherapy (though nothing could be further from it), no wonder juniors head for the organic approach!
· Utterly predictable case conference debates arising from the assumption that certain diagnoses inseparably require certain kinds of treatment; in psychiatry, the ideal of confidence in aetiology predicating reliable skilled treatment may always remain less tidy than in physical medicine.
· How come, many scientific organicist psychiatrists recognise the power of the psychological in controlling for that plainly psychological matter, the placebo effect, in every proper drug trial, yet scorn it at all other times?
· Can you believe there's a paper in the Yellow Journal illogically to the point of being ungrammatically entitled 'Visual Interaction in Psychiatric Patients'?
· Why is the myth so strong that to work in the periphery is akin to being banished to the saltmines of old Soviet Siberia?
· And so on, and so on.
Before I finish, here's a taste of Macmurray himself (from Reason and Emotion) to give you the sweepingly confident yet simple style and logic that I still find exhilirating: [There wasn't time for this - but please open any of his books and give him a go!]
To conclude: I think our patients, our colleagues in the rest of medicine and other professions, and the public at large find Psychiatry obscure partly because of the nature of the subject, but partly because Psychiatrists obscure themselves as human beings. They have to read our minds because we keep in the shadow of our mystique. It is sometimes only informally at conferences like this that we ourselves find out about each other as people. I suggest that the enterprise called Psychiatry, like any other particularly challenging enterprise, would be better if we Psychiatrists 'came out' and declared what sort of people we are, what our 'philosophies' are (that is, what we are doing) in this unusual business. Then we'd be better able to integrate our various contributions to it. That is my appeal to you today. I think that is the appeal of philosophy. And I think that is part of the appeal of the Philosophy Special Interest Group.
Conford, P (1977) John Macmurray: a neglected philosopher. Radical Philosophy, 16: 16-20
Macmurray, J (1932) Freedom in the Modern World. Faber
Macmurray, J (1935) Reason and Emotion Faber
Macmurray, J (1957) The Self as Agent. Faber
Macmurray, J (1961) Persons in Relation Faber
All four books have been reissued
in 1992 by Humanities
Press with new introductions by experts in Macmurray's
ideas. They include full lists of other writings by and about
Child, N (1989) The myth of hysteria as illness. Letter in British Journal of Psychiatry, 155, 865-866.
Child, N (1989) Family therapy: the rest of the picture. Journal of Family Therapy, 11, 281-296
Child, N (1991) Quality thinking and a formula they [managers] can't refuse. Psychiatric Bulletin of Royal College of Psychiatrists, 15, 476-477.
Child (1992) Finding a philosophy that fits. Letter in Journal of Family Therapy, 14, 225-7
Fulford, K.W.M (1989) Moral Theory and Medical Practice. Cambridge University Press [Non-philosophiles should read the Clinical Preface, and chapters 11 and 12!]
Taylor, D C (1982) The components of sickness: diseases, illnesses and predicaments. In One Child (eds Apley and Ounsted) pp 1-13. London: Heineman.
20th May 1994