Book Review: The I of the Other: Mindfulness-Based Diagnosis and the Question of Sanity

The I of the Other: Mindfulness-Based Diagnosis and the Question of Sanity

G. Kenneth Bradford (2013). St. Paul, Minnesota, USA: Paragon House.

For those of a phenomenological leaning who are critical of the pathologising of psychological distress, and for whom mindfulness is important, this book is a must.

Amid the debate on the future direction of counselling and psychotherapy there is a great deal of criticism of the DSM from many sources – not least existential therapists, and this book critiques the epistemological (as well as ethical) foundations of it. However, it goes further and Bradford proposes an alternative way of diagnosis, a phenomenological-mindfulness contemplative approach, based on an understanding of sanity that recognises psychological distress as existential rather than pathological and madness as being often primarily a social construct.

While neither DSM nor the criticism of it is new, there is a contemporary relevance to the debate, given the questions about the role of counselling and psychotherapy, potential regulation of the profession, NICE guidelines and preferential treatment for certain modalities, the government's policies regarding mental health provision, the wellbeing agenda and the deeper philosophical implications of the medical model and 'economicisation' (not a term used in the book but one that I believe conveys his point) i.e. a reductionist commodification of everyone and everything. It is a significant political issue for counsellors and psychotherapists to engage with, not just to criticise but to propose viable alternatives. Therefore The I of the Other is a timely book.

In his introduction Bradford starts by setting the scene, which includes a foretaste of his critique of the supposedly empirical basis of the DSM. As he puts it on page 4, psychology's 'empiricist framing of psychopathology' is no more solid than sand at the ocean's edge'. He also gives a historical introduction to ideas of madness in Europe and how they have changed significantly through history, from the Medieval period, through to the present day. Reading this, I can only think woe betide anyone considered mad during some periods of history: it must have been a terrifying experience to be subjected to how the so-called mad were treated in Europe through most of that time. Now the picture may in some ways be different, with the focus more on economics and economic productivity, but still there is the stigma associated with a label of madness or insanity, and Bradford notes that the transition from 'mental illness' into 'disorder' in this age of techno-mechanisation only increases the sense of some faultiness in the individual, and he argues that the disorders listed in the DSM are still a social construct. One is left wondering who decides what is insanity and what is sanity. Reference to R.D. Laing's views of madness as a product of society itself would not be amiss here. The introduction then lays the groundwork for the author's phenomenological-contemplative approach to diagnosis and his understanding of sanity discussed in later chapters.

Chapter 1 critiques the DSM model, especially its supposedly empirical basis, pointing out not only that the translation of the empirical method from areas like physics to the area of psychology is inappropriate – as it completely ignores the subjective experience of individuals, but also that it is unsound methodologically, since neither of the criteria for the empirical method – validity and reliability – hold. He argues that the very fact that there have been so many re-writings and even re-conceptualisations of DSM undermines any claims to scientific validity, and the huge variation in diagnoses even for the same patients after a period of years leaves in tatters any notion of reliability. In the latter case (pp 24-25) he gives the very compelling example of diagnoses of hospital admissions in New York and London, there being a sharp contrast of diagnosis between the two, and also a huge contrast with the diagnoses in a subsequent re-evaluation. Bradford's use of figures demonstrates that his critique of the supposedly scientific basis of the DSM does itself have scientific validity.

In chapter 2 Bradford explores a completely different foundation for diagnosis, one that is mindfulness-based and phenomenological, which he refers to as a contemplative approach. He sets out a range of criteria. Firstly, his focus is on process rather than content; in this he draws from existential-phenomenological ontology and Buddhist psychology. Secondly, his approach emphasises spontaneity and freedom rather than prediction, control and rigid fixed categories. It is inter-subjective rather than objective and moreover it is contextual, recognising that 'one is always a being in the world, inextricable from the social and natural contexts in which he or she is embedded' (p 46). I might also think of the gestalt field here. His other two criteria are that the diagnosis is intuitive and empathic rather than based on causality and that it is participatory. All of this would appear to be eminently in line with the stance of existential therapy whilst at the same time also being informed by Buddhist principles.

In chapter 3 Bradford explains further the differences between the contrast in approach between the DSM and his contemplative approach. Here the explicitly existential references become more numerous, including in his critique of calculative thinking, the type of thinking involved in empirical assessment with its rigid categories and fixed views, and contrasts it with the meditative thinking which underlies his mindfulness-based phenomenological approach to diagnosis, with its 'openness to the mystery' (p 63, an existential reference) and which 'allows unmediated awareness (gnosis, prajna) to function spontaneously' (p 63).

He acknowledges the variations on the DSM approach in which there has been a laudable attempt to introduce positive qualities and spirituality by transpersonal therapists but which are still (even if unwittingly) derived from a dualistic empirical methodology. He exemplifies this contrast through the case study of a client whom he calls Beatrice, who was originally diagnosed according to DSM criteria as suffering from panic disorder and clinical depression and then was prescribed medication and attended counselling for a short time, all of which left her feeling even more depressed for twenty years. She subsequently went to a psychospiritual organisation (which strictly speaking was not for therapy but for education), where she was diagnosed according to an apparently more spiritually informed approach but was deemed unsuitable for it, which reinforced the message that she had received from her previous diagnosis. Then she went to Bradford, who diagnosed her according to the phenomenological contemplative approach, and though it took time for her to build trust in him, positive results emerged. He actually refers to two diagnoses of her from this approach, which I take to be based on the stages that she was at in therapy.

The next chapter looks at sanity and insanity, in which Bradford highlights the question raised by Laing and Thomas Szasz many years earlier. He interprets ideas of sanity in terms of conditional and basic sanity. Conditional sanity as social adaptation, an idea which I am sure would be agreed upon not only by existential therapists but also by Rogerian and gestalt therapists. In existential terms this is inauthenticity. I would at this point mention the Japanese Zen master Kosho Uchiyama (2004, pp 143, 186), who commented on the phenomenon of group stupidity, which is an obstacle to awareness, but itself a form of social adaptation.

In relation to Bradford's discussion of sanity, it might be worth noting here the discussion by Erich Fromm (1950/1978, pp 65-98) on the function of psychoanalysis (we could extend this to psychotherapy more generally), whether it is for the purpose of social adjustment or for one's growth as an individual. In the former case, therapy would be about the client adopting conditional sanity and therefore inauthenticity in the existential sense, conforming to the 'They' in the face of the existential givens, while in the latter case – which is very much the existential way – psychotherapy is seen as concerned with being in touch with who one is, one's authenticity and one's growth as an individual. In the latter case, Bradford takes this further, even beyond what existential therapists might countenance (given the very reasonable wish not to kid themselves that they know more than they do), moving towards what he refers to as basic sanity, which is based on a Buddhist idea of open space awareness (particularly the Dzogchen teachings found in Tibetan Buddhism), this awareness being primordial and an unconditional non-dual presence, free from the mental constructs that the mind builds, and in touch with reality.

Chapter 5 is a creative reworking in psychotherapeutic terms of a seminal Buddhist text, the Heart Sutra, which is a condensed summary of the philosophical principle of emptiness in the Buddhist sense (empty of separate identity as all things are interdependent). For some of those unfamiliar with the Heart Sutra, this chapter may not appear to add much to the content of the previous chapters, though Bradford does provide a commentary of his version of the sutra. However, I think that those familiar with the original Heart Sutra will likely appreciate his reworking, precisely because of their familiarity with the latter, both due to the context and also due to the style of how it is written. Some readers may wish to ignore or gloss over this chapter, while others (like myself) enjoy and appreciate it for its creativity and its poetic adaptation of the original text to Bradford's phenomenological-contemplative vision of psychotherapy as described earlier in the book.

I thoroughly enjoyed this book. I suspect that those who are less interested in Buddhism may wish to gloss over the Buddhist elements and miss out chapter 5 altogether, but I still feel that they would gain a great deal from the rest of the book. However, for those open to Buddhist understanding, I would heartily recommend the whole book, which I feel integrates existential-phenomenological and Buddhist understandings of the problems of diagnosis and proposes a contemplative-phenomenological approach very effectively and in a compelling and readable way.

Charles Gordon-Graham

References

Fromm, E. (1950/1978). Psychoanalysis and Religion. New Haven and London: Yale University Press.

Uchiyama, K. (2004). Opening the Hand of Thought. Somerville, Massachusetts, USA: Wisdom.