Vocabularies of Silence: Follow-Up
Vocabularies of Silence: Follow-Up
A brief Q&A with Sasha Warren on psychosis and language
Sasha Durakov Warren is a writer, former psychiatric service user, and current mental health worker based in Minneapolis, USA. His first book, “Storming Bedlam: Madness, Utopia, and Revolt,” on the history of psychiatry and radical politics was released in March 2024 with Common Notions Press. He also helped to co-found a Twin Cities Hearing Voices group, and the Minnesota chapter of the International Society for Social and Psychological Approaches to Psychosis (ISPS-US). He writes about psychiatry, political economy, history, and aesthetics on his Substack “Of Unsound Mind.”
This brief Q&A is a follow-up to
Awais Aftab: Sasha, thank you for your contribution as a guest author for Psychiatry at the Margins. I also want to congratulate you on your book Storming Bedlam which is an excellent and thought-provoking work of scholarship. Since many of the issues you’ve raised in your article are somewhat abstract, I’m wondering if applying these ideas to some clinical examples may be helpful for more practically-minded readers. A focus of your discussion is on the language of psychosis and on the possibility of translation. Consider two common features of psychosis: auditory hallucinations and delusions. Say an individual is hearing voices and these voices are telling the person that her life is in danger, that the food is poisoned, that she is being followed and targeted, and that she cannot trust anyone. Let’s assume the voices are intelligible and there is no confusion regarding what the voices are saying. Take a different individual who doesn’t hear voices but holds the delusional belief that his food is poisoned and that his family is trying to kill him. He is able to express this belief and it is also evident that this belief shapes his behavior. In what sense do these psychotic phenomena constitute a “language,” especially a language that is radically different, possibly incommensurate, from our own ordinary one?
Sasha Warren: Thank you, Awais. I believe any statements made, even from someone experiencing psychosis, are language in the simple sense, i.e. that they have all the features necessary to compose language: enunciation, sense (even if inaccessible to the other), and direction. There is an implicit philosophical argument here that there need not be any true statements or statements that are immediately understandable for them to be language. True and false are not part of the definition of language and whether or not a language is incommensurate with our own has no bearing on its status as language. So I am explicitly severing the essential link between “reason” (in quotes because I am referring to an enlightenment concept of reason that assumes there is a teleological and dominant form of reason to which all either conform or fail to conform) and language that psychiatrists like Haslam insist on. A very simple way to put this is that psychosis may baffle or confuse, but, on the level of linguistic expression alone, it does not introduce any alien concepts or features: the speaker uses the same or similar sounds, signs, or movements to enunciate or express because we are all limited by the material form of the mouth for spoken speech, available letters for written language, or hands for sign language; they likely use words; and there’s very often an intended symbolic meaning.
This is recognized by most of the thinkers I discuss (Freud and Jaspers especially make it explicit), but even though language mediates so much of their work, very few up to Jaspers think much about language as such, but more often solely as a means. I think it matters because, though language and reason are inextricably bound up with one another, the total identification of reason and language can lead to the hasty conflation of “I don’t understand any of these words or their order” with “this person has no linguistic capacity,” which is overly pessimistic. So, the first and main task with this piece was to make language an explicit object of inquiry and start wondering about clinical implications.
Warren: What Benjamin and Silveira push back on, I think, is the idea that we could successfully map all the possible ways to come to meaning or understanding what another intends in advance.
What Benjamin and Silveira push back on, I think, is the idea that we could successfully map all the possible ways to come to meaning or understanding what another intends in advance. With the concept of expression, they point towards the idea that there always remain more avenues to communicate that we have yet to discover because we haven’t tried a certain combination of elements (e.g. what if we try talking outside instead of in this office? What if we draw pictures instead of trying to use words?) or because we are so intent on looking for one or another specific statement to confirm a hypothesis, we miss out on everything else happening. Jaspers’ concept of the “ununderstandable” seems at first to point to a similar phenomenon, but the emphasis and orientation is different: interpretation is a retroactive process that uses existing means of analysis to make sense of a unit of speech (an hour long session, a specific phrase, a piece of writing). If we imagine Benjamin taking part in the same conversation, his theory would orient him towards emerging properties in an evolving, dynamic process. I am ultimately pointing towards an open, flexible posture one can take with regard to language.
I hope it was clear in the piece that, by referring to these as language, I myself am making no claim about the value of different forms of speech or language at all. Here at least, I had no intention of judging linguistic content or saying anything about how language or speech is valued, only how it is understood as language and how the failure to recognize it as language are used as grounds for judgments about its value. In this sense, I would say that the voices the first person in your example hears do constitute language, but I won’t here speak to the second case where “belief” comes in, because that’s adding too much to the basic question I’m looking at. Something being right or wrong (e.g. whether the food was or was not actually poisoned) is a separate question, but it has no bearing on the fact that expressing it is linguistic and has the features of a language.
Aftab: When we think of language and communication, there is also the question of who is doing the communication. In some cases of psychosis at least, the unitary nature of the self can itself appear to break down, and people seem to be recipients of communication from unknown parts of their own minds (a person hearing hallucinations, for example). So when you talk about the linguistic encounter between the clinician and the psychotic patient, perhaps it oversimplifies the complexity of communication and translation involved, because there is also a linguistic encounter going on at the intra-individual level. And, relatedly, it is the case that many patients recover and look back at their states of psychosis with bafflement and mystery. So there is the additional element of a person who has recovered from a state of psychosis trying to understand (“translate”?) their own psychosis from the vantage of their current sanity.
Warren: Indeed. Just as such an encounter takes place between two individuals, several encounters are simultaneously taking place within each individual (or between different parts of them) and additionally at the extra-individual level, i.e. between them and the surrounding elements of their environments. I would argue, however, that this is always the case, even if it’s much more intense and obvious with someone experiencing psychosis. This gets at something really important: any conversation between two people is never just between those two people. One of the central arguments of the Institutional Psychotherapy school I discuss in chapter two of my book is that the moment of transference in psychoanalytic and psychiatric treatment isn’t exclusive to the clinician and patient, but occurs in a “transferential constellation.” Transference is more often used in psychoanalytic and therapeutic settings and usually refers to when the client unconsciously substitutes the therapist for a central figure in their life like their mother, for example. What the Institutional Psychotherapy group was getting at is that we invest emotion and meaning into everything around us: into trees we pass on our way to work, into the car we drive or the bus we take, or into strangers or coworkers we encounter day-to-day. A focus on “expression” and “translation” over strict interpretation takes all of these investments seriously and is open to the idea that the tree, the car, and the stranger are part of the client’s “constellation” of transference or simply of meaning.
A reasonable question here would be: what bearing does this have on the psychiatric clinical encounter? One answer might be that it denaturalizes this idea that people in psychosis are exclusively invested in the symbology of their surroundings. I don’t think that’s true. They might be unable to communicate why they are so invested in this or that object, but we are all highly invested in the objects that surround us: I expect that my car will not break down; when it does, especially if I’m far from home or on the way somewhere important, I am liable to get upset or exasperated. Additionally, there’s nothing particularly “natural” about the environment we live in, whether a rural or urban setting, or the spaces where treatment happens like the clinic. These are historically determined, not “natural.” Tomorrow, a war or climate-related catastrophe could sever all the stable connections between objects I daily assume: the highways could cease to be viable, my home might lack electricity for weeks, my money could cease to have any value. These only seem unbelievable because I happen to live in a city in the United States and not Gaza. It’s true that some instances of psychosis feature a fracturing of the unitary sense of self, as you put it, but what these extra-individual elements point to is the fact that our own sense of unitary existence is predicated on a whole number of objects outside of our direct control and is much more fragile than it appears.
I think we as individuals are far more determined at the extra-individual level—or much of our personality and sense of self depends on things external to us—than we like to believe. On the practical level, since anything can function as an emotional or intellectual substitute, all objects and environmental conditions are part and parcel of the experience of communicating. This is relatively easy to prove. All you’d need to do to see a massive shift in how a psychiatrist and patient interact would be to move them from an office park or hospital to, say, a forest and put them both in hiking gear. I’m choosing a silly example to make a point, but I can guarantee this would shift the way they talk to one another and yet all that’s happening is a shift in surroundings and clothing. Institutional Psychotherapy felt that clinical environments had become so rigid and predictable that both clinicians and patients were liable to fall into unconscious roleplay, to perform habitually, and that therapeutic breakthroughs would be foreclosed, so they made conscious decisions to change those environments to try and stimulate new thoughts, new forms of communicating, or new desires (all of which, I’ll add, occur simultaneously in their line of thinking). Changes might include: moving objects around, moving to a new environment, making use of other senses to try and stimulate new responses, or participating in an artistic practice. Perhaps nothing but silence will come of it, but one can never predict what will spark a connection or more meaningful communication.
As for the relation of the post-psychosis individual to their former psychosis, I would add that they will never again be “pre-psychotic.” They went through psychosis, so even if it feels like a binary switch has been flipped and those ideas or modes of communicating are utterly foreign to them, temporally speaking, they still passed through it and their language is “post-psychotic language.” Whatever vantage point of reason or sanity they now think and speak from will necessarily exist in relation to that psychosis. I don’t think that experience is entirely unique. I might sound somewhat pessimistic when I say this, but I think we are always mysteries to ourselves, at least in part. I don’t believe it’s possible to really know what we meant to communicate in the past. I can hardly relate to my own language when I was a kid, when I’m dreaming, when I accidentally drank too much, or certainly when I experienced psychosis in my 20s. In those cases, even when I have a clear record of exactly what I said, I can’t say for sure what I meant. I can only interpret or translate. We are always reinventing the self through narratives about these periods, and these narratives are constructed after the fact. Psychosis can make that process all the more agonizing, but it is not structurally different from the perspective of translation.
Aftab: You say in your guest post that the healer must “relinquish the presumption of linguistic and rational superiority.” What sort of superiority do you have in mind? In what ways can we recognize the profound disruption in shared reality (for lack of a better term) and the fragmentation of experiences and thoughts that a person with psychosis experiences without an attitude of superiority? And on following on a theme from my previous question, if a recovered person with psychosis looks back to their psychotic state and exclaims, “What possessed me to believe all those crazy things!” are they adopting an attitude of linguistic and rational superiority towards their own psychotic self too?
Warren: Admittedly, “superiority” may not have been the best word, but there are cases where it is a clear matter of superiority. For one, in the early examples in my piece, psychiatrists imagined their patients to be hardly more capable than animals. No real conversation is going to happen with someone you treat as subhuman. And that relation of supremacy is certainly not limited to the 17th and 18th centuries. When Frantz Fanon attempted to introduce social psychiatry to his Arabic-speaking patients at the Blida-Joinville hospital in occupied Algeria in the mid-20th century, he found that his speaking French was associated by the patients with the occupation, and his experiment failed spectacularly. In this case, the physician does need to “relinquish the presumption of superiority,” because the physician was speaking a language associated locally with violence and occupation, i.e. of colonial supremacy. It was totally reasonable for patients to remain silent, since they feared (correctly) that French psychiatrists were passing on information to the state. Were he to simply start interpreting his patients’ lack of responses in his French dialogues, all knowledge gained in this way would be tainted by association with the colonial regime and would express a relation of occupation much more than objective fact about their linguistic capacities. A lesser doctor would have done so without recognizing any issue. And they did: the dominant colonial school of psychiatry in Algeria landed on the idea that Africans are generally incapable of developing their communicative and cognitive capacities beyond the level of a European child or lobotomized adult.
But what I’m generally getting at is closer to “pre-determined.” Franco Basaglia once developed a notion of “bracketing illness,” which is not the same as “erase” or “pay no attention to.” He wrote: “It is not that we put the illness aside, but rather that we believe that in order to have a relationship with an individual, it is necessary to establish it independent of the label by which the person has been defined. I have a relationship with someone not because of the diagnosis, but because of who she is. In the moment that I say, ‘this person is a schizophrenic’ (with all that this implies for cultural reasons) I will begin to behave toward her in a unique way, that is, knowing full well that schizophrenia implies an illness for which nothing can be done. My relationship will be that of someone who only expects “schizophrenicity” from the individual. We can see how, in this way, the old psychiatry discarded, imprisoned, and excluded the sick person for whom it was believed there existed no recourse, no tools for treatment. This is why it is so very necessary to draw closer to her, bracketing the illness, because the diagnostic label has taken on the weight of a moral judgment that passes for the reality of the illness itself.” When I wrote that the clinician should “relinquish their presumption,” I basically mean that these sorts of pre-determinations (e.g. expecting “schizophrenicity”) foreclose the emergent properties that might (or might not) arise from an open-ended conversation or activity. I see that as a missed opportunity.
Being free of moral judgements passing for reality is extremely difficult, but I think that’s more likely when we center a mode of expression and the dynamics of translation as opposed to interpretation, especially when getting to know someone. I singled out the clinician because they are more likely trained on interpretive models that may work to predetermine the meaning of words or phrases. Imagine the client says “I have always been smart. Now I’m so stupid.” An interpretive model would first look to slot that statement into known categories: he is self-deprecating as people with depression are, his cognitive capacities have diminished in this or that quantified way, etc. Those may or may not be true, but someone attentive to expression and translation might wonder why that came up when it did, how he expressed it, or what was said immediately before and after. Instead of immediately trying to figure out what the statement “means” beyond the encounter, one might linger a while longer in the conversation.
Warren: My ethical argument is that space ought to be made for open-ended encounters and not just for a special designated professional, but at every level… Abstractly put, the “linguistic encounter” is to prioritize the commonalities that emerge from a grounded dynamic over the successful identification of static properties.
My ethical argument is that space ought to be made for open-ended encounters and not just for a special designated professional, but at every level. As Basaglia says, it is about “drawing closer to” someone, rather than “putting the individual first,” because the latter is yet another way of centering a concept of someone in the form of a list of properties (e.g. tall, long-haired, funny, sad woman) over the actual encounter. Abstractly put, the “linguistic encounter” is to prioritize the commonalities that emerge from a grounded dynamic over the successful identification of static properties. Translation is always a collaborative process, whereas an interpretation can be made on observation alone. It’s certainly not always the time for slow collaboration. If someone is at imminent risk of losing their apartment, it’s not a great time to sit and talk until some connection is made. But therein lies the problem I ended the piece with: hasty simplistic interpretations are favored because of the necessary speed of appointments and processing. Establishing a deep connection with someone might take years, but that’s not viable if that person is facing the risk of losing access to food or shelter. I should underscore though that translation and interpretation are not actually in conflict with one another, even though the format of my piece might suggest that. It’s only presented that way because the interpretive moment has historically taken precedence over translation.
In Nise da Silveira’s art therapy practice, it’s important to note that she was working with people who in many cases hadn’t had an effective back-and-forth conversation with people in years, even decades. In some cases, they were entirely silent, or they spoke using very limited sets of words that seemed to be entirely specific to their own thoughts. To hearken back to the notion that people get stuck in rigid roles and patterns, her first act was to create an environment where the medium of communication was no longer solely and exclusively sitting in an office and talking face-to-face with a professional. The patients were totally unresponsive. Perhaps they associated that form with the violent hospital regime that was in place during the dictatorship. Whatever the case may be, she first introduced them to the arts as an alternative medium for communicating one's thoughts to other people. When you paint or sculpt, you aren’t just externalizing your inner thoughts or emotions, you’re also embedding them in an object that’s available to others to see, touch, smell, etc. In other words, you are producing something that exists in a common space. At first, she just worked patiently alongside the patients and with great attention to what they created and what they did while they created. Only after a great deal of time had passed and she felt she understood the way a patient was communicating using paints, for example, did she attempt to interpret the work. This could mean looking at hundreds of paintings, discerning common icons or formal elements, and holding long conversations, for years if necessary. If verbal conversation was not possible, she might paint alongside them, walk with them and pay close attention to the surroundings to see what if anything appeared in the art at a later time. At that point, she would attempt an interpretation of a piece. You can distinguish three moments here: altering the institutional or environmental conditions to provide the widest possible means for communicative strategies or modes to emerge, embedding oneself in a shared experience or world until some type of effective bond emerges, and, finally, the act of interpretation.
Finally, in my view, when the post-psychotic person in your example says “what possessed me to believe all those crazy things!”, there’s no need to appeal to the notion of superiority, nor is there any pre-determination, since they are actively involved in translating their experience after the fact. They moved past an experience that was difficult and confusing and now take an active role in translating and judging it from a new perspective gained by traveling through it. Psychosis does not define that person; nor does sanity. The subject is in constant mutation, and language is one of the mediums in which that dynamic subject reconstitutes itself over time. What’s important from the perspective of expression and translation is that they are an active, reflective subject in the communicative process. How they judge their own experience of psychosis is their own prerogative and has no bearing on the concept of the “linguistic encounter.” If expressing wholly negative views about that experience means they communicate more effectively and form a stronger bond with those around them, then that doesn’t contradict the basic ethical argument at the core of my piece that we should always seek to engage each party as an active participant in communication whether in psychosis or after it, that we should remain attentive to linguistic features as they actually emerge and not as we expect or desire them to, and that one should therefore adopt a patient and open posture to others, especially in the early stage of a relationship.
Aftab: Thank you!
See also:
A spectacular dialogue.
Aftab writes: “In some cases of psychosis at least, the unitary nature of the self can itself appear to break down, and people seem to be recipients of communication from unknown parts of their own minds (a person hearing hallucinations, for example).”
This is a vital insight. Without understanding that we have parts and that these parts communicate with each other we can’t even begin to understand any mental condition whatsoever. Our parts communicate via hallucinations in psychosis, via emotions in depression and anxiety, via paranoia in anyone who has been hurt by the people who are supposed to love and support them, via obsessive actions and so forth.
I would add that the “unitary nature of the self” is an illusion, but perhaps that is understood. It’s an illusion, but it can be devastating if it seems to be breaking down.
Warren responds: “Indeed. Just as such an encounter takes place between two individuals, several encounters are simultaneously taking place within each individual (or between different parts of them) and additionally at the extra-individual level, i.e. between them and the surrounding elements of their environments. I would argue, however, that this is always the case, even if it’s much more intense and obvious with someone experiencing psychosis.”
Yes, this is always the case. And these parts come into therapy and if the therapist doesn’t know they are there, therapy fails.
Wow, this is so interesting.
One of many thoughts: It can often be difficult, even impossible, to really remember what it was like to be in a completely different state of mind. That goes for remembering events from your childhood, it goes for remembering a night out when you were really drunk, it goes for remembering psychotic experiences. All this is true enough.
However, I also think people can feel an implicit - and yet intense - social pressure to talk about their past psychosis as completely incomprehensible to them now. Because psychosis is so stigmatized, there's pressure to sharply separate your "mentally healthy self" from the psychosis. I know that in the past, I really used to stress to everyone who heard about my condition that I OBVIOUSLY KNOW WHAT'S REAL and what's not!!!
No, I don't. No, not really. No, not a lot of the time. I'm pretty much fully out of the closet now and I've published about this matter both on my own and co-authored with fellow mad philosopher Paul Lodge ... But for a long time, I insisted both to other people and tried to trick myself into believing that I OBVIOUSLY KNOW WHAT'S REAL!!!!
In hindsight, this was clearly due to social pressure and stigma - this pressure to construe a "sane self" and present madness as this thing that sometimes fall over me but is ultimately quite separate from that sane self.
For some people, this may be an accurate picture, but for others, it's something we're pressured into pretending.