Preface to Essays on Clinical Topics
In this volume, Peter Ossorio addresses five very fundamental questions. These are the following:
(1) What is pathology (including what we traditionally have termed “psychopathology”)?
(2) How can we understand human emotions in a way that does justice to the empirical facts of those phenomena, and that clarifies how we might best address problematic emotional states in our clients?
(3) What is the central limitation that besets schizophrenic persons, and how does knowledge of this limitation render intelligible the seemingly bewildering variety of symptoms that these persons exhibit?
(4) What is a rational, sensible way to conceive the activity of using projective techniques in clinical assessment — one that alerts us both to the advantages and the pitfalls inherent in doing so?
(5) What is a cogent rationale for the apprehension and punishment of those who commit criminal acts, and how does this rationale serve as a powerful conceptual framework for designing highly effective corrections programs?
With respect to all of these questions, there is today widespread confusion and controversy. Further, with respect to all, positions have been taken by many practitioners and theoreticians that are demonstrably problematic both on conceptual–theoretical and on pragmatic grounds. That is to say, these positions are both ill–conceived and are (actually or potentially) damaging when applied in real world clinical and correctional settings. In this introduction, I shall attempt to set the stage for Dr. Ossorio’s unique and extraordinary treatments of these five topics by characterizing the contemporary scene with respect to each, and by helping the reader to anticipate how Ossorio’s treatments of them successfully address these confusions and limitations.
Pathology
The prevailing state of affairs in the mental health field is one in which we have been unable to agree on a definition of our central concept that of “psychopathology” (Comer, 1995; Rosenhan & Seligman, 1995; Wakefield, 1992).That is to say, we have not achieved consensus in the matter of what criteria constitute the necessary and sufficient conditions for correct application of this term. Factors such as maladaptiveness, deviance, functional impairment, suffering, irrationality, incomprehensibility, loss of control, statistical infrequency, and presence of underlying psychological or biological aberration have all been advanced by some proponents as relevant criteria. However, to date, none of these factors, taken individually or collectively, have commanded anything approaching a consensus as being constitutive of psychopathology.
This proliferation of claims regarding the concept of psychopathology creates numerous serious problems. For example, from a scientific standpoint, the current scene is one in which different theories of psychopathology have been constructed around different conceptions of this term. Behaviorists tend to view psychopathology as maladaptive behavior (Wilson, 1995), cognitivists as excessive emotional distress and/or maladaptive behavior (Beck & Weishaar, 1995), sociologically–oriented theorists as social deviance (Scheff, 1975; Sedgwick, 1982), medical model adherents (e.g., psychoanalysts) as an aberrant underlying condition (e.g., an intrapsychic conflict) which causes overt symptomatology (Brenner, 1974), and so forth. Thus, the overall situation is a chaotic one in which different theories purport to be providing scientific accounts of the same thing “psychopathology,” but, given their radically divergent conceptions of this phenomenon, they are in reality providing accounts of different phenomena. Further, given this radical divergence of meaning, we are given strong prima facie reason to conclude that at least some of these theories cannot be theories of psychopathology at all.
From a clinical standpoint, as practitioners we are charged with treating psychopathology. Thus, definitions of this concept become, ipso facto, specifications of what it is we are supposed to be treating. Lacking a common conception of this term, confusion is sewn in the field. Should we be reducing the incidence of maladaptive behavior? . . .. ameliorating untoward emotional pain? attempting to help our clients to behave in a manner that is less deviant from prevailing social norms? or what? Further, if we embrace certain conceptions that are proposed in the literature, might we create significant “blind spots” for ourselves and unwittingly do our clients a disservice? For example, conceiving psychopathology as social deviance, might we become inordinately preoccupied with notions like promoting “appropriate behavior” and unwittingly become, not therapists, but agents of social conformity? Or, conceiving pathology as intrapsychic conflict underlying overt symptomatology, might we, upon observing such symptomatology, assume a priori that the cause of these must be intrapsychic conflict, and thereby fail to construct our case formulations based on the empirical facts of our cases?
In his seminal paper, “Pathology,” Ossorio offers a new defining formula that is unlike any other in the mental health field: “When a person is in a pathological state there is a significant restriction on his ability (a) to participate in deliberate action and, equivalently, (b) to participate in the social practices of the community.” The predictable and quite understandable reaction on the part of many readers of this definition is likely to be that it represents “just one more guy’s idea about what abnormal means,” and thus not deserving of any special credence. However, a careful reading of Ossorio’s treatment will reveal that his conception conveys the following very considerable advantages over current alternatives. (a) It serves far better than any other extant definition to distinguish consensus cases of psychopathology (e.g., obsessive–compulsive disorder, anorexia, schizophrenia) from consensus non–cases (e.g., eccentricity, deliberate malingering, or circumstantially imposed limitations on persons) (Bergner, in press). (b) It makes the identification of pathology a matter of observation, not of inference (in contrast with definitions that equate pathology with unobservable “inner” conditions). (c) It distinguishes what pathology is from what causes it, leaving the identification of pathology a separate matter from its explanation, and leaving the latter a matter for open empirical assessment (in contrast with definitions with built–in etiological commitments). (d) It successfully addresses the notorious problem of psychopathology’s relativity to time, culture, and situation. (e) Ossorio’s conception, when viewed in connection with his further discussion of explanations of pathology, illustrates how forms of explanation generally thought to be incompatible (e.g., cognitive deficit, skill deficit, biological deficit) are conceptually coherent and compatible in practice, thus providing the conceptual basis for an integration of existing theoretical approaches (Bergner, 1991). (f) Finally, Ossorio’s treatment clarifies the ways in which pathology is a matter of social concern, while clarifying and warning against the specific ways in which the concept could be misapplied in socially dangerous ways.
The widespread adoption of Ossorio’s deficit model of pathology would, I believe, provide a centerpiece that would go far to remove the theoretical and practical chaos that characterizes the fields of psychopathology and psychotherapy today.
Three Minute Lectures on Emotion
The traditional and still quite dominant conception of human emotions is that they are certain sorts of feelings or experiences (Leventhal, 1980; Mischel, 1993 pp. 440-442). Terms such as “fear,” “anger,” “guilt,” and “joy” stand for relatively unique, discriminable, subjective human experiences, each of which is associated with a state of bodily arousal. These experiences are inherently private, and are known to their possessors through observation. They are causally linked as the middle term in a chain that begins with a perception and/or thought and ends in many instances with a behavior (“The thought of my wife leaving me created unbearable anxiety, which in turn led to the anxiety reducing behavior of consuming excess quantities of alcohol.) Finally, since emotions are a kind of experience or feeling, the solution to emotional problems lies in the elimination or diminution of the feeling state. Thus, such solutions as their reduction through psychotropic medications, relaxation training, meditation, and/or cathartic release are all widely practiced on the contemporary therapeutic scene.
Despite its widespread acceptance by the general public, by psychological and medical researchers, and by clinicians, there are strong reasons for concluding that this traditional view is seriously flawed in many respects. While an extended discussion of this contention is beyond the scope of this introduction, let me briefly cite two important reasons for making it.
First, according the famous “private language argument” (Wittgenstein, 1953, nos. 243-305), no word could be the name of something observable only by introspection, and be connected with publicly observable phenomena only causally and contingently. The reason why this is so is that language is essentially public and shareable. If the name of anything, then, acquired its meaning by a private naming event from which every other person was necessarily excluded, nobody would have any idea what anyone else meant by this word. (Compare: I use the word “turquoise” and you wonder if we mean the same thing by this term; to determine this, we both produce paint chips illustrating our intended color and see if they match. But now, I use the word “fear” and you wonder if we mean the same thing by this term; if the term designates a private feeling, what could we possibly produce to establish that we meant the same thing?) According to this argument, then, emotion concepts could not possibly refer exclusively to sensations observable only through introspection, for if this were the case, they could never have come to have any place at all in our public language. Nor, it follows, could they ever be the appropriate subject of scientific investigation.
One more point, this time a pragmatic one: As noted above, the equation of emotions with feeling states leads logically to the equation of emotional problems with problematic feeling states. This in turn leads logically to conceiving the solution to such problems as lying preeminently in the reduction or elimination of such feeling states. The use of psychotropic medicines, arguably the most common way that contemporary Americans deal with emotional problems, thus represents a sort of paradigmatic treatment on the traditional view (especially if one further equates emotional states with physiological states of affairs). However, emotions have a reality basis. Paradigmatically, anxious persons are confronted with threatening circumstances in their lives, angry persons with provocative circumstances, sad and despairing persons with irreparable losses, and so forth. Thus, to equate therapy with the removal of these person’s feeling states by chemical means is in many contexts to do them a vast disservice. It is to eliminate their pain without helping them to address and to change the genuinely problematic life circumstances (the increasingly unstable marriage, the unresolved loss of a loved one, etc.) that constitute the reality basis of the emotion.
In “Three minute lectures on emotion” and “More three minute lectures on emotion,” Ossorio offers a radically different conception of emotional phenomena than that found in the traditional view. In doing so, he provides us with a far more adequate basis to do conceptual justice to many obvious facts about emotion, to study the phenomenon scientifically, and to engage in sound and truly helpful therapeutic interventions when our clients are beset with emotional problems. It is a view that does not run afoul of the private language argument, but beautifully accommodates it. It is a view that acknowledges the fundamental importance of helping psychotherapy clients to deal with the reality basis of their emotions, while also preserving and clarifying a valuable place for the use of psychotropic medications in certain circumstances.
In addition to the foregoing, Ossorio’s position accomplishes a great deal more. For example, it explains the familiar phenomena of displacement, and does so in a remarkably simple and straightforward way that does not involve the postulation of strange and unobservable “inner” processes. Further, it accommodates the observational commonplace that persons often have two, possibly conflicting, emotions at the same time (“I love her but I’m angry with her”; “I’m calm about my upcoming exams but anxious about the prospect of finding a decent job”); on the traditional view, as exemplified by Wolpe’s (1958) notion of “reciprocal inhibition,” such coexistence should be impossible. Finally, unlike the traditional view that emotions are inherently irrational phenomena, Ossorio’s formulation makes sense of the easily observable fact that emotional behavior (e.g., jumping to dodge an oncoming car) is, far more often than not, rational behavior.
Thus, in sum, in these two essays, Ossorio provides us with a far more adequate basis to do conceptual justice to many obvious facts about emotion, to study the phenomenon scientifically, and to engage in sound and truly helpful therapeutic interventions when our clients are beset with emotional problems.
Cognitive Deficits in Schizophrenia
If one surveys the contemporary scene with respect to our view of schizophrenia, the following general picture emerges: Schizophrenia is a mental disorder (or possibly group of disorders) that is characterized by symptoms such as hallucinations, delusions, inappropriate affect, bizarre behavior, and more. Empirical evidence suggests that this disorder is caused by biological and psychological factors that interact in some fashion. On the biological front, these would include genetic factors (Gottesman, 1991), excessive amounts of the neurotransmitter dopamine at critical brain sites (Snyder, 1976; Strange, 1992), and abnormalities of brain structure such as enlarged ventricles (Cannon & Marco, 1994). On the psychological front, these would include factors such as the presence of significant life stressors (Ventura, Neuchterlein, Lukoff, & Hardesty, 1989); being a member of the lower class residing in large city (Saugstad, 1989); and coming from a “schizophrenogenic” family characterized by interactive processes such as “expressed emotion” (Mavreas, Tomaras, Karydi, & Economou, 1992), family conflict (Miklowitz, 1994), and double bind communication (Bateson, Jackson, Haley, & Weakland, 1956).
While the foregoing view is not without empirical foundation or pragmatic value, what it most importantly fails to provide is any account of the intelligibility of schizophrenia. That is to say, it portrays schizophrenia as a more or less mysterious phenomenon which just happens to be characterized by a set of seemingly unrelated symptoms. Furthermore, the view leaves many important questions for the most part unanswered. Is there a central limitation or deficit that we can identify in schizophrenia? How do we account for the fact that the individual loses reality contact? Why does the individual have just these symptoms and not others (e.g., why hallucinations and delusions, and not obsessions or panic attacks)? Do these symptoms have some relationship (aside from mere empirical co–occurrence) to one another or to the individual’s central limitation? In the end, especially in recent times with the ever increasing focus on physiological factors, these questions are not only left unanswered but are largely ignored.
In his report on “Cognitive deficits in schizophrenia,” Ossorio presents an account of the intelligibility of schizophrenic phenomena. Explicitly characterizing his position as an hypothesis, he sets forth an account of the central limitation in schizophrenia as lying in an inability to appreciate higher levels of significance. Having shown how this hypothesis accords with a longstanding body of empirical evidence on schizophrenic thinking, Ossorio proceeds to give rigorous accounts of (a) just why certain sorts of stressful events and states of affairs, specifically, those whose significance was unthinkable, would cause persons to lose contact with reality; (b) why these persons’ symptoms might assume just the forms that they do (e.g., delusions and hallucinations); (c) why schizophrenic affect is often incommensurate with the person’s circumstances; and (d) why certain anomalies would be exhibited with respect to the schizophrenic individual’s behavioral productions. What emerges from this account is a picture of schizophrenia as a coherent, intelligible entity — a radical departure from and improvement upon the present consensus view in the mental health field.
Projective Techniques
Where projective techniques such as the Rorschach and Thematic Apperception Test (TAT) are concerned, the contemporary scene within psychology is characterized by controversy. Two distinct camps have been established. The first of these consists of supporters of the clinical utility of projectives. These persons, many of whom are theoretically grounded in analytic schools of thought, attest that responses gleaned from projectives frequently serve as valuable and accurate hypotheses regarding their clients’ conflicts, preoccupations, motivations, and more. The second, and by all accounts currently dominant camp, consists of persons of a scientific bent who contend that projectives are invalid test instruments. These persons note the rather tenuous data base (e.g., “It looks like a butterfly”) upon which clinical inferences are made in projective situations. Further, and more decisively, they cite a body of empirical evidence that has failed to support the validity of projective instruments.
This controversy serves as a context that highlights the radically different approach to projective techniques that Ossorio takes. This approach starts from a radically different point of departure from both of the contending camps characterized above. This starting point is that it is plainly and straightforwardly the case that projectives are not tests at all! Ossorio proceeds to demonstrate why they do not qualify as tests, why they should not be subjected to the sorts of standards that tests are rightly held to, how (unlike tests) they involve observation and not inference, and what considerable good can come from thinking of them in an entirely new way.
Ossorio asks us in this article to recall an extremely commonplace human activity: assessing other persons or, to use a popular term, “sizing them up.” One comes to this activity from the outset, not as a tabula rasa, but with vast personal knowledge about such matters as what sorts of persons there are, what social practices exist in a community, what would represent standard and nonstandard variations in the enactment of these practices, what various situations conventionally call for, and how a “Standard Normal Person” in some community would behave. When one encounters a new person, then, and sets forth to ascertain what sort of person this is, what one does essentially is to observe how this person deviates from the Standard Normal Person in a community, and to continually adjust one’s picture in light of these observations. This activity is straightforwardly observational and not inferential.
Ossorio proposes that giving a Rorschach or a TAT is essentially a special, if sociologically queer, version of this common human activity, and not a version of the technical practice of giving a test. Like the broader activity of observing and assessing other persons, it is not a foolproof activity that comes with built–in guarantees of success but is subject to all of the limitations that beset observation in everyday life. However, on the positive side of the ledger, some persons, those whose background knowledge and expertise about persons and social practices is considerable, may be quite good at it and able to yield highly valuable hypotheses about their clients.
In the end, what Ossorio provides for us is a rationale for using projective techniques in clinical practice. It is a rationale that involves neither the postulation of questionable metaphysical entities (e.g., energy systems) nor the making of logical inferences. It says to us in effect: “Here is a rational, sensible way to assess persons if you are so inclined. It is based on observation; it is not mysterious; it can often yield valuable information to persons who are gifted at it; but it does not conform to the Platonic ideal of the “Test” as a foolproof, 100% always–and–everywhere–valid mechanical procedure.”
Status Management: A Theory of Punishment and Rehabilitation
Traditionally, three major theories have been advanced in the field of criminal justice to provide a rationale regarding why those who commit crimes should be apprehended and punished. These are the Deterrence, Rehabilitation, and Retribution theories. They hold that those who commit criminal acts should be punished because, respectively, (a) it will deter them and others from future criminal activity, (b) it will enable them to change their behavior and become law–abiding citizens, and (c) it will exact the retribution owed them by society for their antisocial acts.
Unfortunately, all three of these theories are at present in some disfavor. In the case of the Deterrence and Rehabilitation theories, a good deal of empirical evidence has been accumulated to the effect that punishment neither deters crime nor rehabilitates those who commit it. Thus, the force of these theories as justifications for practices such as incarceration has been radically undermined. In the case of Retribution Theory, which affirms in essence that society should wreak revenge on those who commit crimes by causing them to suffer pain and deprivation, this view has never been a generally acceptable rationale due to its inhumane character. The upshot of these states of affairs is, in Ossorio’s words, that “At the present time there is no generally accepted theory of punishment in this country and there is no general confidence that our correctional institutions have either a rational basis or a sufficient social value to warrant their continuance, except that no acceptable alternatives are to be found, either” (p xx).
In “Status management: A theory of punishment and rehabilitation,” Ossorio presents both a critique of the current corrections system and a positive rationale for punishment that is highly useful for designing far more effective corrections programs. At the heart of such alternative programs would be something that the current system does not provide, namely a way back for criminals — a way that they would be enabled, if they so chose, to regain full membership in their communities. In creating this framework, Ossorio in collaboration with Bente Sternberg draws upon (and elucidates) many Descriptive concepts such as those of Status, Degradation, Accreditation, full vs. limited membership in a community, and more. Finally, he describes a highly effective program, designed and carried out by Sternberg, built around the Status Management model which, over a five year period, achieved the astounding recidivism rate of 1.5 percent with 765 offenders.
Conclusion
For those persons who are not familiar with Ossorio’s work, the present volume will almost certainly provide a new, decidedly different way of looking at things. It is my belief that the reader who seriously studies the essays contained herein will find them, not only startlingly unique, but breathtaking in their conceptual clarity and coherence, and in their elucidation of countless ways that as professionals they may behave more effectively in their clinical or correctional endeavors.
Raymond M. Bergner, Bloomington, Illinois June, 1997
