[in Philosophical Psychopathology,
G. Graham and L. Stephens, eds., MIT Press (1994)]
EMOTIONAL DISORDER AND ATTENTION
San Francisco State University
I don't know where I came from,
I don't know where
I'm going, and I don't know why I do the things I do. -Evel Knievel
Beginning to think is beginning
to be undermined. -Albert
Some would say that philosophy can contribute more to the occurrence of mental disorder than to the study of it. Thinking too much does have its risks, but so do willful ignorance and selective inattention. Well, what can philosophy contribute? It is not equipped to enumerate the symptoms and varieties of disorder or to identify their diverse causes, much less offer cures (maybe it can do that-personal philosophical therapy is now available in the Netherlands). On the other hand, the scientific study of mental disorder has a long way to go. There is much disagreement and uncertainty about the nature, causes, and treatment of many specific disorders, as is evident from DSM's classification of them in predominantly symptomatic terms. And even if what is reflected in DSM were a consensus rather than a compromise, still this shifts periodically with each new edition. Moreover, it is a notorious fact that many patients who clearly have psychiatric abnormalities do not fit any of the recognized diagnostic categories.1
There are several obvious ways in which philosophy can contribute to the study of mental disorder. Questions raised in the philosophy of social science about methodology, explanation, and the fact-value distinction can be directed specifically at the theories, methods, and practices that treat of mental disorder. One noteworthy question in particular, raised not by a philosopher but by the psychiatrist Thomas Szasz (1974), concerns the very idea of psychopathology and the suitability of the medical model for purely psychological conditions (no organic disease, trauma, or lesion and no anatomical, physiological, or neuro-chemical abnormality). Underlying this question are various fact-value issues, such as whether the label "disorder" is used to imply that something doesn't work properly or that it is undesirable in some respect.2 Pertinent to these issues are various concepts that are grist for the mill of analytic philosophy, concepts such as normality and disorder, health and disease, rationality, emotion, attention, agency, control, compulsion, freedom, and self. Although I take up several of these concepts and their connections, I am primarily interested in the notion of an emotional disorder.
What makes a disorder emotional, as opposed to purely cognitive disorders like aphasias, agnosias, and attentional deficit disorder (ADD)? In most cases the disorder is specific to a particular emotion, and concerns its character, cause, or consequences. In some instances the disorder is broader in scope, and involves either enduring capacities for emotion or more transitory emotional tendencies and dispositions (moods). I will suggest that emotional disorders contain attentional and correlative motivational elements and that this is intelligible in light of the fact that emotions themselves are inherently attentional and motivational (consider such emotions as worry, fear, suspicion, resentment, guilt, shame, and confidence). Normally an emotion's strength is proportional to its attentional and motivational import, but with disorders there is a gross and chronic disparity between the amount of attention something deserves and the amount it receives; how one is motivated to act may be affected accordingly. Trivial matters can matter too much and consequential ones too little, and there may seem to be no way to rectify the disparity. A sensitive subject matter may capture one's attention to an inordinate degree and, by its persistent and often ill-timed intrusion into one's experience, impose unreasonable demands and disrupt one's activities. That may lead to a vicious cycle of anxiety, distress, irrationality, and loss of control.3 On the other extreme, a subject may be too touchy for focussed consideration or even conscious awareness, and thereby chronically escape the attention it deserves. This may yield a blind spot in one's experience, which may in turn lead to constrictions or convolutions in how one confronts recurrent situations in one's life.
Defenses appear to play a role here. Defenses may be understood as unconscious devices or strategems for managing one's attention. They can serve to keep something out of mind or, if it does come to mind, to get rid of it or at least put it in a favorable light. If, as seems plausible, some degree of defensiveness is necessary for mental health, too much or too little defensiveness can make for emotional disorder. Emotional disorders, as problems in attention management, may be regarded as emotionally-based difficulties either in bringing things to mind when need be (overdefensiveness) or in keeping unwanted intruders out of mind (underdefensiveness). I will suggest that such problems in attention management are often due either to excessive or to insufficent use of what I call exclusionary categories.
The conception of emotional disorder to be sketched
here offers a descriptive framework for identifying and connecting several
key elements of emotional disorder. To the extent that this conception
goes beyond conceptual analysis it may smack of armchair psychology, but
at least it does not speculate heavily on underlying etiological questions.4
Even so, we should note that whereas some emotional disorders may involve
problems caused by emotions, others may only be problems with
emotions, that is, emotional effects of cognitive, attentional,
or perhaps ultimately neurophysiological causes.
Emotion and Attention
Philosophers often pretend that the only mental states recognized in folk psychology are beliefs and desires, and maybe intentions. In fact, most folks find a wide range of emotions in their own experience and cite emotions to account for the behavior of others. "Descriptions of character and temperament ╔ are frequently couched in terms of people's dominant emotions" (George Graham, personal communication), such as "hostile," "melancholic," "timorous," and "Pollyannaish" (Ekman 1992, p. 194). People recognize that they act out of anger, fear, gratitude, remorse, jubilation, jealousy, defiance, spite, etc. Yet philosophers, by ignoring emotions and by equating folk psychology with belief-desire psychology, implicitly assume that emotions are at best (if not eliminable) reducible to beliefs and desires.5 However, no has ever tried to show that each type of emotion is reducible to some belief-and-desire complex or that the explanations ostensibly provided by emotions amount to mere belief-and-desire explanations. Fortunately, there are some philosophers who do not accept such an impoverished view of folk psychology and are not embarrassed to take emotion seriously. They may disagree in their accounts of emotion, but they agree that emotion is not mere feeling. Here I will not review these many accounts,6 which emphasize judgmental and motivational features, but will focus on the attentional side of emotion.
Emotions, though sometimes still called "passions," need not be passive or irrational. Although some emotional episodes are uncontrolled reactions out of proportion to their objects, many such episodes, even if not calm and collected, are expressions of a person's considered attitude or outlook on something. Of course people often do get overwhelmed by emotion, such as by grief, frustration, or guilt, and are motivated to take action appropriate to the emotion or are moved to express it physically. Even then the emotion normally runs its course--one gains perspective and adjusts to one's situation, and the various physiological changes associated with upsurges of the emotion eventually subside for good. Sometimes, however, emotions directed at particular persons, things, or events persist indefinitely and intensify out of proportion to their objects; they can even get detached from their objects. One can become, as we say, "consumed" by guilt, "paralyzed" by fear, "stricken" with grief, or otherwise overwhelmed by an emotion. Its persistence and unwelcome recurrence can make life unmanageable and unbearable.7
Emotion and attention are interrelated: attention on something (focussing on or just noticing it) can trigger emotion, and emotion can direct attention, either toward something or away from it. When experiencing an emotion focusses attention on something, it often makes certain features salient and puts the object of the emotion in a phenomenologically special light.8 Although the onset of an emotion is typically characterized by its "unbidden occurrence" and by an "automatic appraisal" of its object (Ekman 1992), its persistence may make one preoccupied with its object and oversensitive to the actual or possible presence (or absence) of its object. Sometimes there is a vicious cycle of emotion directing thought and thought triggering emotion.9 Typical examples include negative emotions like embarrassment, alarm, worry, disgust, and envy, and positive ones like fascination, anticipation, pride, and awe. Such emotions are not unreasonable if they are commensurate with their objects, e.g., momentary fright at the sound of a loud but distant explosion or mild embarrassment at being seen in public with perspiration stains under one's arms. But if the frightening or embarrassing event becomes a preoccupation and the persistent state of fright or embarrassment leads one thereafter to avoid situations even remotely like the one in which the emotion originally occurred, surely it is irrational.10 Similarly, anger or worry become irrational if they result in excessive alertness to reasons for blaming the person one is angry with or, in the case of worry, to items to check and doublecheck. In these cases the emotion has "taken over," making something an issue of disproportionate importance at the expense of one's other concerns.11
Emotions can also have attentional effects, often lasting ones, that go beyond the direct object of the emotion. For example, disappointment at failure can lead one not only to relive the relevant events but to become preoccupied with what one would have done if one "had it to do all over again." Anger at someone may lead to fantasies about ways to "get even" and to preoccupations with the person's undeserved successes and potential misfortunes. Gloom or grief may lead one into long trains of guilty thoughts, a "barrage [of] regrets and reproaches" (Beck 1976, p. 40), about what one could and should have done when one was young or when the deceased was still alive.
Take the case of a chronic fear, say of suffocating.
You don't have lung disease, no one has ever tied a cord around your neck,
you don't have plans to venture into a bank vault or a deep cave, and you
don't live in Los Angeles, Mexico City, or Athens. In short, you have no
reason to think that you will suffocate. Your fear is irrational not because
suffocating isn't fearful-it is-but because it is so improbable. This fear,
though unreasonable and chronic, could still be manageable. You might allay
the fear by adopting the policy of keeping a window open wherever you are
and otherwise avoiding places and situations where suffocation is even
a remote possibility. That strategy might well suffice, and the fear would
be under control. You would be like a person who manages his fear of flying
or of snakes simply by avoiding airplanes and wriggly reptiles. On the
other hand, circumstances might prevent you from executing that strategy
successfully. Resorting to far-fetched excuses, you might have to refuse
important assignments and put your job at risk or avoid normal social situations
and put your personal relationships at risk. Or, even if external circumstances
are cooperative, you might find yourself becoming subject to recurring
bouts of idle but terrifying thoughts of suffocation. On such occasions
you might worry that your air passage will contrict without warning, that
your lungs will suddenly stop working, or that the carbon dioxide in the
air will turn into carbon monoxide. At this point you are faced with a
management problem: how to rid yourself of such morbid thoughts. You might
remind yourself that the things that worry you at these moments aren't
worth worrying about (air passages don't contrict without warning, lungs
don't suddenly stop working, and carbon dioxide can't turn into carbon
monoxide). However, even if dismissing such possibilities intellectually
keeps you from taking them seriously, it might not get them out of your
Control of Attention
It is tempting to equate control over a process with determining its every phase. In the case of skilled action, like doing gymnastics or playing a violin, control may indeed be a matter of determining each phase of the action (at least up to a certain degree of specificity and temporal resolution). Being skilled at something means knowing, at each moment, what to do next or at least how to figure out quickly what to do next.12 However, if what is being controlled is not a course of action but merely an ongoing process, control involves merely regulating that process. Monitoring may be required (perhaps even vigilance), but action need be taken only to restore the controlled system to its range of normal or acceptable functioning (what counts as normal or acceptable is relative to standards, which may in turn be relative to circumstances). Intervention is needed if the process gets interrupted, goes off course, or is otherwise disrupted. Action must be taken against the cause of the disruption, which may be internal or external to the process being controlled.
In the case of attention, control is not a matter of determining its focus at every moment. Knowing what to think about next cannot require thinking what to think about next. Micro-managing attention is impossible, and you would go crazy trying obsessively to determine at every moment what comes to mind next. Exercising control over your attention just means regulating it, so that, for example, whenever you are involved in an activity and irrelevant thoughts occur (memories, desires, fantasies), you are able to restore your attention to what you are doing. If you can't divert your attention even when you desperately want to, it is no longer under your control. On the other hand, having it under control also means that matters that might become worth considering are not foreclosed from consideration.
I am not suggesting here that every loss of attentional control constitutes an emotional disorder. In some cases the disorder is not really emotional but attentional or otherwise cognitive in nature (perhaps grounded in some anatomical defect or neurophysiological deficit). And, of course, temporary losses of control due to external circumstances or even to intense but transient emotional experiences should not be counted as disorders. After all, elation, grief, lust, embarrassment, and panic wouldn't be what they are if they could be "turned off" at will, but they are not disorders. Things would be different, of course, if such an emotion lasted indefinitely or flared up periodically without external prompting, as in manic-depression or paranoia.
Unwanted thoughts aren't mere distractions or nuisances, but can be seriously disruptive. By breaking one's concentration they can interfere with what one is doing, and by becoming preoccupations they can impede the pursuit of one's goals. Indeed, they can even enter into the definition of one's goals-the contents of persistently occurring thoughts, just by virtue of their persistence, can come to matter more and more. To appreciate how this situation might arise, consider that at any given time what matters to one, at least on the very short-term basis that is that moment, is whatever one's attention is then directed at. In that narrow horizon, what matters is the matter of the moment. Moreover, the fact that this matters can, when one reflects on it, become the matter of the next moment. Then one is faced with the meta-problem of dealing with the fact that one's attention is being captured by something one deems unimportant or irrelevant. This meta-problem is the problem of regaining control of one's thought, feeling, and will; one needs to be able to attend to and act on what matters, and what matters is, in the longer term, generally not what one is attending to at the moment. Successful attention control, to the extent that it is possible, harmonizes one's short-term foci of attention with one's longer-term concerns.13
Whereas with emotional disorders there is a disparity
between the amount of attention something receives and the amount it deserves,
when one's attention is under control one is able to keep them commensurate.14
But what does this ability involve? We must largely avoid considering what
is not worth considering, and obviously we cannot spend time and effort
on everything that might come to mind just to determine that it is not
worth considering. Indeed, at every moment we implicitly judge things not
worth considering by not considering them at all, or at least not for long.
In this respect the process of attention management is analogous to default
reasoning. Just as effective reasoning, given our limited cognitive capacities
and resources, requires the ability not to consider matters not worth considering
while being sensitive to the presence of matters that are (Bach 1984),
so it is with effective attention management. Given that we have limited
control over what attracts, maintains, or diverts our attention and over
what reminds us of what, irrelevant thoughts will occur, but normally (see
note 10) we can focus our attention on things that matter and disregard
things that do not. Yet we must also be sensitive to the possible pertinence
of things not currently considered or not currently considered pertinent.
Effective attention management requires habits, skills, and strategies
that enable one to get things done and to further one's aims without being
blind to new considerations and possibilities. But, as we will see, these
devices (so-called defenses) are not always effective, for they can be
used to excess and keep worthy things from coming to mind, or they can
be inadequate and fail to prevent distressing or disruptive matters from
dominating one's attention.15
Attention and Defense
Although having your attention under control does not require determining its focus from one moment to the next, this does require being able to keep or at least get out of mind matters that you do not need or want to attend to. On occasion, however, an emotion that leads you to dwell on something can become so intense and involving as to be unmanageable.16 For example, it could cause you to be haunted by fantasies or hallucinations that don't go away no matter how hard you try to get rid of them. You might become preoccupied with humiliating episodes, terrifying situations, imagined misfortunes, unrequited love objects, and lost love ones. You might dwell on how horrible you are and on all the rotten things you've done. You might even fear that if you fall asleep you won't wake up. Most of us, most of the time, are lucky enough not to haunted by such thoughts and without conscious effort we generally avoid dwelling on them. This is fortunate, for if eternal vigilance were required, we'd go out of our minds trying to keep them from persisting or recurring.17 Still, we can't always rely on touchy subjects to stay out of mind spontaneously. When they don't, we can often distract our attention from them by focussing on what we are doing or, if we are not doing anything, by immersing ourselves in a good book or movie, some exercise, a chore, or some other diversion. Sometimes, however, keeping such thoughts out of mind requires special devices, commonly (and aptly) called defenses.18
There are various views of what psychic defenses are and of what they are defenses against. Freud thought they protect the ego from instinctual demands, and they have since been viewed as protections from such things as pain, stress, anxiety, insecurity, low self-esteem, and other people. Considered from the standpoint of attention management, a defense may be defined as any device for preventing the occurrence of an intolerable or unmanageable state or at least for neutralizing or forestalling its effect. This conception is broad enough to include self-deception and selective inattention as well as such classic defenses as rationalization, denial, repression, displacement, and projection. There are several sorts of evidence for the existence of defenses. For example, repressed traumatic experiences, such as of being abused as a child, can eventually reveal themselves, whether spontaneously or as the result of psychotherapy, and that they are not fantasies but genuine memories may be corroborated by such evidence as that their subject matter is specific to the issue in question, thereby suggesting that their not having been recalled is not a problem in memory. Also, people's resistance to a touchy subject can become evident if, whenever the subject is brought up, they resort to implausible rationalizations or engage in evasive tactics to get on to something else. An ever handy ploy is procrastination: one not only avoids doing something about an issue but avoids even thinking about it, on the grounds that it can always be addressed later.
Philosophers sometimes wonder how processes like defenses can be purposeful yet unconscious. This is one facet of a broader question about unconscious motivation: how can a desire (or other motivational state, like a state of fear or jealousy) motivate one to act if one is not only unaware of being in that state but unable to be aware of being in it? The answer to this question (unless the real philosophical worry here is how desires and other states can be unconscious at all) is straightforward. An unconscious state motivates in just the way that a conscious state does: by virtue of being in that state, one represents the desired outcome as to-be-achieved; one represents a way of achieving that outcome; and one acts in that way. Just as one can draw a conclusion from something one believes without being aware of believing it or thinking that one believes it (only a diehard Cartesian would insist that being conscious of a belief is necessary for making an inference from it), so one can act on a desire (or other motivational state) without being aware of it or representing oneself as having it. And action itself does not have to be conscious, much less intentional, and this includes the mental acts involved in defenses. One can be motivated to do something and act purposefully from that motive even if one is not acting consciously. Indeed, as Mark Johnston (1988) has suggested, "mental tropisms," or purpose-serving but subintentional mental mechanisms, are quite common.
The idea of unconscious defense, though not this way of describing it, is prominent in post-Freudian folk (some would call it "pop") psychology. It is widely accepted nowadays that people often engage in motivated, though unintentional, avoidance of painful or anxious thoughts. Popular discussions of such topics as death and terminal disease, rape and incest, and POWs and torture reflect the view that people sometimes "lie to themselves" and deny or perhaps even repress an extremely painful experience or fearful prospect because they cannot "deal with" or "face up to" it-they cannot "bear the thought" of it. People even acknowledge this in themselves, at least retrospectively.
There seems to be a certain conception of mental
health that underlies this view: one deals with something one cannot face
up to by not facing up to it. Defenses are the means to that end. A defense
is a routine for nullifying, neutralizing, or at least forestalling the
damaging or debilitating effect of facing up to a certain subject matter
or acting on a "dangerous" impulse. Different defenses offer
different ways for one to respond to the problem posed by the dangerous
or threatening subject. One can repress the thought of it, deny that there
is a problem, put it off, immerse oneself in other things,19
or just trivialize it. That is, different defenses serve, as the case may
be, to get rid of the threatening thought (or dangerous impulse), help
one to ignore the touchy subject for the time being, enable one to work
around it, or make it seem innocuous.20
There is one particular kind of defense which, so far as I know, has not been explicitly identified. It is a form of rationalization that involves the use of what may be called exclusionary categories. An exclusionary category is a way of classifying an actual or potential object of attention in a way that ostensibly justifies not attending to it or, if one is already attending to it, not attending to it any further. These categories come in a variety of types which, whether or not they are applied for good epistemic reasons, serve the practical purpose of keeping one's experience manageable. They fall into several broad, overlapping classes, as illustrated by the following examples (they apply, depending on the case, to propositions, ideas, actions, or persons):
epistemic: absurd, baseless, hopeless, impossible, incoherent, insignificant, irrational, ridiculous, risky, superstitious, unreal
ideological: blasphemous, communist, diabolical, extremist, fascist, irreligious,
out-moded, racist, sexist, sinful, subversive, un-American
social: embarrassing, forbidden, offensive, outrageous, taboo, unspeakable
evaluative: dangerous, filthy, hostile, incompetent, inferior, intolerable, obscene, onerous, overwhelming, perverted, selfish, shameful, stupid, unhealthy, unimportant, wicked, worthless
psychological: bigoted, crackpot, crazy, hateful, imaginary, inconceivable, misguided, selfish, unthinkable
I am not suggesting that using an exclusionary category is inherently irrational or defensive. Many of these categories have perfectly legitimate applications quite apart from their role in attention management, although some are merely pejorative and cannot provide an objectively valid reason for excluding something from consideration.21 But even the legitimate ones can be applied hastily, carelessly, indiscriminately, or zealously. On the other hand, even when a legitimate one is applied for epistemically valid reasons, using it may also serve a collateral managerial purpose. This purpose could be cognitive, say to keep one's mind from getting too cluttered or changing too easily, or emotional, to shield one from pain or anxiety.
Worth special mention is the use of exclusionary categories to sustain acceptance of what might be termed a psychologically basic proposition. It seems that most people have a fundamental need to believe such things as that one is competent, important, attractive, and well-liked, that one's projects and goals are worthwhile, and that the world is safe and hospitable. The inability to sustain such "existential a priori" propositions (Needleman 1968) may lead to chronic and debilitating feelings of inadequacy, inferiority, insecurity, precariousness, rejection, or worthlessness. On the other hand, there are certain propositions whose acceptance leads to such effects. Many people irrationally accept negative propositions about themselves, such as that they are helpless, worthless, repulsive, mad, or otherwise "different," and that others must inevitably despise, ignore, or mistreat them. They perpetuate such negative thoughts by perversely using exclusionary categories to keep from thinking anything positive about themselves.
Generally speaking, the use of exclusionary categories is continuous with the use of other categories for classifying and evaluating things (people, objects, events, possibilities, and courses of action) and play key roles in the system that makes up one's overall theoretical and practical view of the world. When an item does not fit into the system, either the item must be excluded or the system must be adjusted. Insofar as something that does or threatens to come to mind fits the system, one knows what to think of it and what to do about it; or at least one knows how to go about figuring out what to think of it and what to do about it. One thereby knows what to do next with respect to that object of attention. Unfortunately, not everything fits the system. Those that do not pose a paradoxical question: how to deal with what one can't deal with?
A person's basic repertoire of exclusionary categories provides a practical answer to that question. One deals with a recalcitrant item by classifying it as something that does not have to be dealt with. One can do this directly, by means of an exclusionary category like absurd or impossible, or by means of one, like blasphemous or obscene, whose application implies that the item does not deserve to be dealt with. Applying an exclusionary category plays the role of getting something out of mind in much the way that in the context of solving a problem one summarily rules a bad idea out of consideration. Indeed, prior application of an exclusionary category to an object or type of object may keep it (and things saliently like it or related to it) from coming to mind at all. Prior application may even produce an attentional aversion to the touchy subject, whereby one recognizes when the dangerous object even threatens to come to mind altogether. The thought (or mention) of something distantly related to it may be enough to divert one's attention to something else.
There is no guarantee that a given exclusionary ploy will work. One may be unable to get or keep something out of mind even if one does subsume it under an exclusionary category. When that happens, either one bears the consequences or, to try further to exclude the recalcitrant item from consideration, one engages in a more elaborate scheme, which may invoke other exclusionary categories. The more elaborate scheme may have unpleasant or otherwise unfortunate side effects, producing irrational attitudes or behavior patterns like those delineated in the clinical literature. In particular, the use of one or more exclusionary category to avoid confrontation with a touchy subject may lead to excluding too much and disable one in some way. For example, categorizing sex as wicked might cause a person not only to avoid all thoughts about sex but to be frightened away from any social encounters.
Different types of ineffective or even self-defeating policies or strategies of attention management are epitomized by certain chronic attitudes towards problems that arise in everyday life:
1+: There always is or may be a problem. (chronic anxiety or worry).
1-: There is no problem. (denial)
2+: The first candidate is the solution. (impulsiveness)
2-: No solution is adequate. (perfectionism)
3+: The problem must be solved now. (obsessive-compulsiveness)
3-: The problem will be solved later or by someone else. (evasiveness)
4+: I can always deal with it. (overconfidence)
4-: I can't deal with this. (panic, depression)
5+: It's always my fault. (guilt)
5-: It's always someone else's fault. (passive-aggressiveness)
In each pair the first attitude is symptomatic of insufficent use of some exclusionary category(-ies),22 and the second involves excessive use. So, for example, the chronic worrier (1+) fails to exclude from consideration possibilities that are not worth taking seriously, whereas someone in denial (1-) always thinks of reasons (impossible, ridiculous) for not taking real possibilities seriously. Similarly, an impulsive person (2+) is satisfied with the first solution that comes to mind and acts accordingly, failing think of why it might be dangerous or stupid; whereas a perfectionist (2-) never fails to find reasons for not being satisfied with a solution.23
It is beyond the scope of this paper and its author to classify in detail the multitude of emotional disorders. However, it does seem to me that a great many involve the ineffective use of exclusionary categories. In impulsive disorders they are not used enough,24 but with phobias and in paranoia they are used to excess. Mood disorders seem to involve a generally excessive use of exclusionary categories, except with respect to the emotion, such as anxiety, despair, or excitement, specifically associated with the disorder, where exclusion fails.25 Obsessive-compulsive disorders involve not only the inability to get something (represented as needing to be done) out of one's mind, but also the inability to neutralize the occurrence of the obsessive desire except by acting on it.26 On the other hand, there are disorders that result from the repression of certain states (desires, memories, or emotions). They may involve the inability to address certain problems or to bring oneself to do certain things, and may even lead to a blind spot in one's experience which one can't even see as a blind spot. In inhibitions one shies away from doing a perfectly normal thing and maybe even from thinking about doing it. The extreme compartmentalization of experience in multiple personality disorder seems to be the result of massive repression, which perhaps involves the application of exclusionary categories to major chunks of one's personal history.
* * * * * *
Our original question was "what makes a disorder emotional?" I raised it in order to focus on specific relations between emotions and disorder. Interestingly, there seems to be an intuitive sense of these relations in folk psychology, including an inchoate recognition of the role of attention. Partly by building on what is implicit in folk psychology, I have tried to make explicit certain attentional aspects of emotional disorder. From a descriptive point of view (I have not speculated on underlying etiological issues or on therapeutic methods27), they may be regarded as extreme versions of normal relations between emotion and attention. In the simplest cases they involve devoting either too much or too little attention to the object of emotion. In other cases an emotion or a mood (an impermanent emotional disposition) produces attentional and evidential biases by heightening one's attention to certain considerations and possibilities and diverting one's attention from others. It is normal, at least to some extent, to deal with things one cannot face up to by not facing up to them. Given our cognitive as well as emotional limitations, some degree of defensiveness is inevitable. This includes the use of exclusionary categories in order to avoid facing up to something and to do so with at least some semblance of justification. I have suggested that different types of emotional disorder can be characterized in terms of loss of attention control through over- or under-defensiveness, and that this may involve excessive, insufficient, or otherwise ineffective use of exclusionary categories.
All in all, it appears that attention plays a
key role in emotion and emotional disorder. Unfortunately, we will never
fully understand how that role is played until we find out far more than
we know now about why things come to mind when they do and what constrains
transitions in mental state from one moment to the next. Equally unfortunately,
these questions are, for the foreseeable future, hopelessly beyond reach.
So perhaps we should turn our attention to something else.
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Solomon, Robert C. 1976. The Passions: The Myth and Nature of Human Emotions. New York: Doubleday.
Szasz, Thomas S. 1974. The Myth of Mental Illness (revised ed.). New York: Harper & Row.
Wakefield, Jerome C. 1992. "The Concept of Mental Disorder." American Psychologist 47:373-388.
Wing,. J.K. 1978. Reasoning
about Madness. Oxford: Oxford University Press.
1. "In most hospitals, about one-fifth," according to Goodwin and Guze in their treatise on psychiatric diagnosis. They add, "The suitable label for these people is undiagnosed. One advantage of this term is that physicians who deal with the patient will not be biased by having a poorly grounded diagnosis in the chart. Another advantage is the sense of modesty it correctly implies" (1989, p. 299).
2, Jerome Wakefield (1992) argues, after disposing of six other theories, that a disorder is a "harmful dysfunction." Although I am concerned with what makes a disorder emotional rather than with the notion of disorder as such, my later suggestions-that in disorder emotion is not commensurate with one's values and that disorder involves a problem in attention management-are consonant with the harmful dysfunction view.
3. A classic example is Freud's Rat Man, whose "obsessions are recurrent persistent ideas (e.g., that something terrible will happen to his sweetheart), impulses (e.g., to cut his throat), and images (e.g., that a rat is boring into the anus of his father). He experiences them as alien and senseless (ego-dystonic) and evolves complicated formulas to ward them off. ╔ As with the obsessions, he recognizes that the [compulsive] behavior is senseless and derives no pleasure from carrying it out, other than the release of tension" (DSM-III Casebook, p. 338).
4. Indeed, as Goodwin and Guze acknowledge in their treatise on psychiatric diagnosis, "╔ for most psychiatric conditions there are no explanations. 'Etiology unknown' is the hallmark of psychiatry as well as its bane. Historially, once etiology is known, a disease stops being 'psychiatric'" (1989, p. xiii).
5. Psychologists do not suppose this. See, for example, Arnold 1960 and Ekman 1992.
6. Recent book-length accounts include Solomon 1976, Lyons 1980, and Gordon 1987.
7. This does not entail that the emotion is unreasonable. For example, chronic gloom can be justified by hopeless life circumstances (Graham 1990).
8. Solomon 1976 and de Sousa 1987, as well as personal experience, provide numerous examples of this phenomenon.
9. Although I am emphasizing the relation between emotion and attention, I should note that emotions can be triggered by subliminal or what Aaron Beck (1976, pp. 29-37) calls "automatic thoughts."
10. Beck describes the "spiraling of fear and anxiety" (1976, p. 149) , with its exaggeration of dire consequences and their probabilities, as indicative of an "overactive 'alarm system'" (p. 156), sensitive to idle as well as to realistic possibilities.
11. The topic of rationality of emotions is far too complex to take up in any detail here (see de Sousa 1987 and Greenspan 1988). Nowadays philosophers of emotion reject the traditional view that emotions are inherently irrational and the Humean view that they are nonrational. Above I have indicated several ways in which they can be justified or unjustified, and undoubtedly there are many more. Also, emotions are sometimes said to be unjustified when they are based on unwarranted beliefs.
12. Knowing how to figure out or how to go about figuring out what to do next is itself, strictly speaking, knowing what to do next.
13. The notion of attention control is central to George Ainslie's (1992) intrapersonal game-theoretic account of impulse management.
14. What counts as commensurate is a matter of opinion, not necessarily the opinion of the person at the moment. Some people suffering from attentional problems like those described here will acknowledge the disparity between their opinion of the moment and their considered opinion. Some, on the other hand, may be so absorbed in an obsessive concern that they find their excessive attention on something to be perfectly reasonable. Still, they suffer from the consequences of this "opinion," which they eventually acknowledge should they ever seek therapy. What counts as one's "considered" opinion-and exactly why it should override one's opinion of the moment-is not as straightforward as it might seem.
15. After drafting this paper I discovered the following apt passages in Beck 1976: "The patient has to grapple to retain voluntary control over concentration, attention, and focusing" (p. 78); the "disruption of voluntary control over focusing attention" is indicated either by the "mercurial nature of attention" or by a "involuntary fixation of attention" (p. 152), i.e., "attention-binding," in which the patient is "overly attentive to certain cues ╔ and oblivious to others" (p. 79).
16. By "unmanageable" I mean more or less what J.K. Wing has in mind when describing "pathological" anxiety: "The main question is whether the condition has gone 'out of control', producing symptoms that cannot be dealt with by consciously turning the attention to other matters, or withdrawing from the anxiety-provoking situation in good order, or simply exercising the will. The symptoms that result can be very severe: palpitations, muscular tremors, 'butterflies' in the stomach, giddiness, sickness, breathlessness, muscular tension, and faintness. In a total panic, there may even be loss of control over bowels or bladder" (1978, p. 60).
17, David Shapiro (1965) describes the "continuous state of volitional tension" (p. 36) in the obsessive-compulsive, whose attention is "markedly limited in both mobility and range, ╔sharply focused and concentrated" (p. 27).
18. There are also teachable techniques, such as "thought-stopping." As Rimm and Masters describe it, "The client is asked to concentrate on the anxiety-inducing thoughts, and, after a short period of time, the therapist suddenly and emphatically says 'stop' (and loud noise or even painful electric shock may also suffice), the locus of control is shifted from the therapist to the client. Specifically, the client is taught to emit a subvocal 'stop' whenever he begins to engage in a self-defeating rumination" (1974, p. 430). This technique would seem to be particularly effective when what makes the thought unmanagable is not so much its content as its uncontrollable recurrence.
19. Immersion can be in attention-engaging activity or simply in fantasy. As John Neale remarks, "Frequent use of pleasant fantasies to distract oneself from unpleasant events or cognitions may make the fantasies more accessible and may heighten their reality" (1988, p. 146). Indeed, activity and fantasy can be combined, as in grandiose delusions. Neale suggests that "by distracting the person, guiding information processing, or occupying the limited processing capacity of conscious awareness, the grandiose delusion may function as an avoidance response, reinforced by the reduction of distress. ╔ [Indeed,] grandiose delusions may have yet another function in that they produce the elated mood of the manic. Elated mood could make it less likely that the manic will access distressing cognitions from memory, an effect similar to the one discussed [in Bower 1981] for alcohol" (1988, p. 148).
20. Such ploys and strategems are central to my account of self-deception (Bach 1981 and 1992).
21. There are some postive categories, such as attractive, friendly, pleasurable, productive, and sensible, which some people perversely use for exclusionary purposes. Perhaps this use of such categories partly explains the self-defeating character of certain disorders.
22. In some cases, such as obsessive-compulsiveness (3+) and paranoia, an extreme version of 1+, "inclusionary" categores, like urgent or menacing, seem to be at work, categories which chronically provide reasons for considering certain sorts of things and whose persistent use repeatedly gets them and keeps them in mind.
23. Both insufficient and excessive use of exclusionary categories can aid and abet the reliance on false assumptions, massive overgeneralizations, and rigid rules, three culprits identified by the cognitive therapist Aaron Beck, and help further what Karen Horney, as cited by Beck (1976, p. 257), called the "tyranny of the shoulds." David Shapiro describes how obsessive-compulsives experience these "shoulds" as "quasi-external ╔requirements of objective necessity" (1965, p. 39), whose observance leads to "overcontrol" and flatness of affect. Ainslie explains how compulsiveness can be "a side effect of personal rules" (1992, pp. 205-227).
24. Shapiro, though aptly describing impulsive persons as "unmindful of consequences" (1965, p. 143), suggests that their "lack of planning is only one feature of a style of cognition and thinking in which active concentration, capacity for abstraction and generalization, and reflectiveness in general are all impaired" (p. 147). From the standpoint of Ainslie's intrapersonal game-theoretic account of impulse control, impulsive persons lack the techniques normally used to "precommit future behaviors" (1992, pp. 130-144)
25. For example, "Thoughts of escape and avoidance are particularly prominent in the ideation of anxious and depressed patients" (Beck 1976, p. 39).
26. It is often supposed that what drives obsessive-compulsives is anxiety-reduction. However, there may be, as Baer and Minichiello suggest, "two classes of obsessional behavior: one anxiety-increasing, and another anxiety-decreasing. Anxiety-increasing obsessions occur automatically in response to anxiety-provoking stimulation. Anxiety-reducing compulsions occur as a reaction to the anxiety, and their performance temporarily decreases anxiety" (1986, p. 53). It is easy to see how the second phase can involve the use, often desperate, of exclusionary categories
27. George Graham, whom I wish to
thank for his valuable comments and references, suggests that the method
of treatment most consonant with my approach is cognitive therapy, with
its emphasis on "control through reason and reasoning" (personal
communication). However, I should note that control over thought and thought
processes is also part of the cognitive approach, as Beck implies when
he speaks of "breaking cognitive habits" (1976, p. 217) and "alleviat[ing]
psychological distress [by] correcting faulty conceptions and self-signals"
(p. 214). It would take research on the effects of clinical practice to
ascertain to what extent, and in which conditions and circumstances, improved
reason and reasoning are enough to correct a psychological disorder. Insight
might not be enough. Harrow, Rattenbury, and Stoll, in their discussion
of schizophrenic delusions, distinguish three "important dimensions
of patients' delusional ideation ╔: (1) patients' belief-conviction about
the delusion, (2) their perspective on the delusion, and (3) their emotional
commitment to the delusion" (1988, p. 185), and suggest that these
do not always correlate. In particular, then, "perspective on the
delusion" (2) may not help to get rid of it or its effects.