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Book Review: 'Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry' Peter Good (2001)

Pollard, R., 2003. Book Review: 'Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry' Peter Good (2001). Reformulation, Summer, pp.40-43.

In the age of Enlightenment, according to Engels, cogitative reason became the yardstick of all that existed.

In folk grotesque, madness is a gay parody of official reason, of the narrow seriousness of official truth.1

It is rare to find a book about Bakhtin that is actually about Bakhtin and not devoted to scholarly debates and disputes over interpretation. As Charles Locke2 observes, there is no central authoritative reading of Bakhtin and therefore unlike other thinkers of comparable influence, no coherent opposition to him, but many incommensurable readings. Whilst this is all very interesting, it is purely academic and does not help us directly with problems of living. Peter Good side-steps all the various controversies and finds in Bakhtin's work a set of conceptual tools to explore hidden, surprising, even shocking aspects of what is, to the psychiatric practitioner, familiar territory.

The lack of a centralising interpretation can also be a licence to use Bakhtin imaginatively. According to his literary executor, Vadim Kozhinov3, Bakhtin thought of himself primarily as a philosopher. Peter Good makes imaginative use of Bakhtin to think psychiatry back into the realm of philosophy and ethics and away from the medical/scientific models so beloved of the NHS. Psychiatry is constituted by a rational unitary language concerned with the serious assessment and management of mental illness. Good, as a psychiatric practitioner, asks whether psychiatry has anything to learn from entering into dialogue with the irrational unserious voices from which it seeks both to silence and distance itself.

Good acknowledges the elusiveness of Bakhtin's meanings and therefore the importance of engaging with them actively and dialogically. He also embraces Bakhtin as a whole, employing all his major concepts, dialogism, polyphony, carnival and the chronotope, as well as some of the lesser known concepts such as surplus of seeing, outsidedness and great time, to illuminate the varied and often hidden spaces and time scales of the psychiatric 'landscape'.

This landscape refers to the asylum or hospital with its wards, corridors, clinics and gardens, populated by people who live and work there, patients, nurses, psychiatrists, social workers, psychologists and administrators, all of whom occupy different social standings. It is also the setting for two very different chronotopes. The care chronotope is characterised by linear, clock governed time, where spaces are filled with brisk and purposeful activities. This chronotope is filled with different, often competing voices, which are all nevertheless oriented towards a positive future. In the patient chronotope time is slower and circular, and spaces and the bodies that occupy them take on a wholly different set of meanings. The way time is structured and by whom is determined by the dominant chronotope.

Dialogism, in isolation from Bakhtin's other ideas, is often erroneously understood as a purely linguistic concept. Bakhtin's concept of the chronotope contextualises dialogue by grounding it in a temporal-spatial and therefore physical/material reality.

Without such temporal-spatial expression, even abstract thought is impossible. Consequently every entry into the sphere of meaning is accomplished only through the gates of the chronotope (Bakhtin, 1981, p258)4.

Dialogue can only occur between embodied subjects whose spatial-temporal perceptions are dependent on the senses of sight, hearing, touch, taste and smell. Our bodies define our individual chronotopes and our subjectivity. Bakhtin's allegiance to Russian Orthodox theology meant that unlike Western Christianity, he did not regard the material body as either separate from or inferior to the spiritual or the divine. The Cartesian mind/body and self/other split that is so central to Western culture with its emphasis on the private individual body, can make Bakhtin's total vision hard to grasp.

The concept of polyphony is also central to dialogism. Originally a musical concept, it is redefined by Bakhtin to refer to the existence of a plurality of independent voices and consciousnesses of equal value who are the subjects of their own directly signifying discourse (1984, p75). The equality of these voices in Dostoevsky's novels is underlined by the author's refusal to have the last word and 'finalise' his characters. Polyphony requires that all voices have the right to answer back. We all experience ourselves as 'unfinalizable' in a constant process of becoming as we interact with each other and the environment in the activity of being or living. However, we see others as 'finalised' or finished, due to the surplus of seeing that enables us to see aspects of the other's situation which they cannot see for themselves. Between equals this surplus of seeing can lead to a mutually enhanced sense of self and other. But when we come into the orbit of a unitary monological language that accords itself the authority to define and objectify others we can find ourselves arbitrarily 'finalised', with no right or a reduced capacity to answer back. Good describes the concept of surplus as useful for analysing the way others are classified and the self is affirmed. Others can be seen against a surplus of poverty, criminality or dysfunctional beliefs or simply respected for being another.

All unitary official languages decline to enter into dialogue with unofficial voices outside their own orbit. Peter Good takes on the mantle of a polyphonic traveller to observe the psychiatric landscape from the perspective of its different chronotopes and to get alongside its different official and unofficial voices. Polyphony requires that no voice is privileged over any other so the traveller's remit is to listen, not to judge. Polyphony has no room for hierarchies, competitive arguments or linear causal explanations. Polyphony directs psychiatry to add to or widen the circle of the perspectives it otherwise strives to distance itself from (p 17) rendering itself open to the surprising and unexpected.

But like all professions psychiatry defines itself against the unofficial voices it distances itself from. The neo-classical body of psychiatry separates the rational head from the lower material bodily strata and disdains the grotesque body of the carnival with its ambivalent laughter and its irreverent mockery of the official voice. Carnival means the inversion of hierarchies, the parodying of all that is serious and official and a celebration of the regenerative powers and sensual pleasures of the grotesque body. For Bakhtin, the grotesque body, like consciousness, is a collective not an individual phenomenon. Our bodies are part of the eternal cycles of the natural world, processes that are suppressed by the individualised neo-classical body of the Enlightenment. But the unofficial voices of the carnival are always lurking in the background and leaking into 'official' discourse.

This background noise ever ready to unsettle, invert or interfere with commonly held values, is there to remind us that life cannot be understood purely by reason alone. Its activities of laughter and low idiom capture an ancient imagination. A collective body immediately understands every one of its jokes, its crude terminologies and its lewd gestures. Occasionally the noise becomes so loud that rationality cannot ignore its presence. At these times a unitary language activates a number of tested responses - suppression, modification, or a further distancing practice. The logic of this sphere is a troublesome presence, yet in terms of its own ambivalence it is also a living thing. It grows and it contracts, and it will object noisily to being enclosed within a definition (p8.)

As a polyphonic traveller, Good's gateway into the care chronotope is the initiation of medical students into the official language of psychiatry. He situates this process in the ancient tradition of displaying madness, against which rationality defines itself, for the entertainment of the masses. It is the task of the ringmaster to ensure the ideological recruitment of the students. The composite figure of the ringmaster, or tutors, is set in the tradition of both the circus ringmaster and the keepers of the mad, whose modern day equivalent is also found in the TV host who exhibits aberrant humanity to satisfy the voyeuristic demands of a mass audience. The authority of the ringmaster lies in his skilful use of humour, using the language of the material bodily sphere, to demonstrate the superior values of rationality. That patients are frequently the objects of the ringmaster's humour both reinforces the standing of psychiatry and is an invitation to the students to take sides.

...the ringmaster has complete license to pitch malicious distortions upon the target body. He brings the mad body into focus as being gross and frightening (p66).

Dramatised to the point of caricature the body of madness was confirmed as a site of myths and images, a frame of mind, a system of management (p68)

Good demonstrates the tensions between the need to preserve the integrity of the neo classical body, and its dependency on the more enduring language of unofficial voices, by an analysis of the terminology used in the care chronotope. The position of the speaker and the addressee determine the nature of the utterance. The voices of the lower registers are only used when the addressee or the patient(s) is absent, a licence only granted to the most powerful voices. He finds that the high classical language of psychiatry cannot adequately describe mental illness, as even the most formal academic papers have to borrow from lower voices. Official terminology comes and goes as theories and practices go in and out of fashion but the terminology of the unofficial voices has endured over centuries in what Bakhtin refers to as great time. Drawing on Bakhtin's early work, Towards a Philosophy of the Act, Good draws attention to how adherence to norms of professional conduct and abstract theories can become in Bakhtinian terms alibis in being that diminish the potential for the creative understanding of the lived events of an encounter and are dangerously evasive of their rich complexities (p110).

Good's analysis of the voices of the classical and grotesque body, the official and the unofficial, the sane and the insane is an effective deconstruction of these oppositions, which the standing of psychiatry both maintains and depends on. From this perspective, it seems that modern psychiatry rests on very flimsy foundations beneath which lie ancient traditions of folk wisdom and irreverent laughter. Bakhtin's metaphor of the moving cartwheel in Rabelais and his world reconfigures the relationship between high and low or the rational head and the material bodily sphere as a revolving and dynamic process. But the fragmented body of the private individual is a negation of regenerative powers of the lower bodily strata that brings the cartwheel to a halt, thereby bringing about a separation between official and unofficial voices preventing a dialogue between them.

Good's travels take him into another part of the landscape via the moving accounts of practitioner patients, mental health workers who themselves became ill and find themselves, often suddenly, catapulted into the patient chronotope. The transition between the two chronotopes is traumatic, characterised by feelings of fear, helplessness, betrayal and abandonment. Despite working in the caring professions, these patients find little sympathy and understanding from their colleagues, find themselves discriminated against when they do return to work and are shocked to find out how different mental illness seems from this part of the landscape. They find that the fellowship and sense of shared suffering with other patients plays a far greater role in their recovery than official therapeutic interventions. When a professional from the care chronotope is perceived as helpful, it is because they have ventured outside the boundaries that define their role.

Along the way he pays tribute to R.D. Laing and the radical psychiatry movement of the 1960s which, although it was vilified by mainstream psychiatry, did lead to some liberalisation of its practices. This movement influenced a group of researchers who decided to experience psychiatry at first hand by feigning mental illness and getting themselves admitted onto psychiatric wards. They reported the same intense and fluctuating emotional reactions as did the practitioner patients in their transition to the patient chronotope. Once there they discovered a meaningful social world, unseen by the doctors and nurses who could only construe patient behaviour in individual and biographical terms. Good brings Bakhtin's description of the role of parody in the carnival to bear on the dialogues in the patient chronotope. Parody is dependent on the official voice but in ridiculing and degrading it also restores it as part of the moving cartwheel. The unofficial voice or parody of the official voice contains the wisdom of survival. Good cites an example from this research on the advice given on the best way to get discharged:

Don't tell them you're well. They won't believe you. Tell them you're sick but getting better. That's called insight and they'll discharge you!6

Good's final and most controversial destination is a clinic for the mentally ill as an apparently bone fide patient. As he remarks, to change chronotope does not merely mean adopting a different intellectual perspective, it means changing your life. Academic analysis is replaced by a painfully vivid description of his experience of patienthood; his intense levels of anxiety, fear and uncertainty and the extreme speed with which he loses his self-management skills. Social encounters of any kind are exhausting. He becomes locked into solitary inner dialogues. No criticism at all is directed at the staff in the clinic who are seen as competent and kind but also imprisoned in a different time space. He finds himself totally unable to respond to their invitations to exercise choice; - whether to have tea or coffee, whether to have a bath. This later prompts him to question the philosophy behind consent theory or the priority now accorded to patient 'entitlement' and 'choice'.

Fleeting conversations with other patients and passing physical contact, such as sharing the activity of washing dishes, are immensely comforting. Shorn of his previous status and social identity, Good finds himself in a different bodily relationship to the world and struggling to find a voice or establish a dialogue that can confirm him as a creature of social fellowship. As a patient himself he sees patienthood from a totally different perspective from his previous perspective as a practitioner.

I found this book intriguing, dense with controversial and highly original perceptions and observations. It is a compelling introduction to Bakhtin and a wide-ranging application of his ideas for anyone interested in a Bakhtinian approach to understanding the relationship between the official rational voice and mental illness. Anyone who has ever been a 'real' patient will find much to reassure in this book and anyone who hasn't may find much to learn. No doubt anyone committed to a medical model of mental illness would find much to disagree with.

The cunning and deception Good employed to get alongside the different voices in the landscape is a provocative alternative to more conventional modes of research that poses some interesting ethical questions. The imprecision of some Bakhtinian terminology can make this a difficult book to read and initially I wondered if Good is merely describing the institutional defences employed by a profession that allows little room for the expression of individual anxiety in a rather florid, even fanciful way. A second reading convinced me that Good is saying something far more important about the way mental illness is perceived in contemporary Britain, which implies that current ways of dealing with it will seem as bizarre and cruel to future generations as Bedlam seems to us today.

I felt that Good could have differentiated more between the various occupational groups in the psychiatric landscape in the way they position themselves in relation to otherness. I think there is far more variation between and within different groups than Good's analysis would suggest. A major omission is that there is no acknowledgement of the influence of gender or the complex interaction of cultural difference with the different voices on the landscape. Rationality, individual self-sufficiency and unitary authority are traditionally European male values, and, although others can be recruited into them, the principle architects of the Enlightenment as well as the founders of modern psychiatry were European men. Good, like Bakhtin, is concerned with form rather than content and so misses out some significant dimensions of meaning.

I was disappointed with Good's overcautious conclusions that the insights gained from polyphony give no brief for reform or revolution and that it is an error to derive any overt political conclusions from Bakhtin. Instead he ascribes a mystical significance to polyphony, suggesting that, as for Bakhtin, God was the supreme polyphonic author, we must abide with the foolishness of the world. It does seem that politically, polyphony has never been more relevant and that together with the concept of the chronotope it can help towards an understanding and acceptance of the radically different perceptions and interests of different groups and populations. But polyphony on its own is not enough. It can help us to see what is there but does not tell us what to do about it. As Natalia Reed wryly observes, the characters in Dostoevsky's polyphonic novels may have had equally signifying voices but it did not stop them killing each other or committing suicide.7

Nevertheless this is still a thought provoking book, not just for psychiatry but for all mental health workers, particularly therapists wedded to a 'finalising' theoretical framework for their conceptualisation of mental distress. Good draws attention to other, often unacknowledged, processes that accompany and are, perhaps, inseparable from, the activities of caring and to how insignificant our interventions really are. Whilst this has all been said before in other ways, Good's Bakhtinian perspective is both highly original and of particular relevance for cognitive analytic therapists.

As therapists, whether in the NHS or not, we are all part of a wider care chronotope. We all have our alibis in our theories, professional identities and codes of conduct and, in the NHS, an increasingly complex burden of administrative and accountability procedures. Therapeutic practice in the NHS is becoming so regulated that it can seem as if there is little room left for the exercise of individual moral responsibility. Peter Good's travels through the psychiatric landscape took him into areas that meant he had to give up the certainties and security of the neo-classical body, live without alibis and experience psychiatry from the perspective of those who have nothing or in Bakhtinian terms no alibis in being: an experience that fundamentally changed the way he views mental illness.

Cognitive analytic theory has not eluded the 'official' language of the medical model and has its own therapist and managerially defined chronotopes. A patient's need for therapy may be experienced as intermittent according to the ebb and flow of circumstances, something to drop in and out of, rather than the therapist prescribed 16 hour long sessions of 'treatment' in a clinical setting. CAT is also a surplus of seeing site where clients risk being 'finalised' in terms of dysfunctional or restricted RRPs or seen as narcissistic or borderline. As CAT expands and extends its influence both inside and outside the NHS, it is becoming increasingly monological in its training and regulatory practices. Perhaps this process is inevitable but it is as well to be aware of its limitations.

It is not surprising therefore that CAT seems ambivalent about Bakhtin. Despite the work of Mikael Leiman and Anthony Ryle, the two most recent books give relatively little space to Bakhtinian contributions to practice. A practice informed by Bakhtin cannot afford to retreat into a unitary monologic discourse without becoming embroiled in impossible contradictions. But at the same time, it seems that any school of therapy wishing to gain credibility in the NHS has to conform to commercially influenced managerial demands for quantifiable evidence, which inevitably means a capitulation to theory driven 'scientific' models of practice and research in which patients are measured and assessed rather than invited to enter into a dialogue in which they can speak for themselves.

References

“Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry”
Peter Good (2001)
Kluwer Academic/Plenum Publishers, New York.
ISBN: 0-306-46502-7
£59.95

Reviewer: Rachel Pollard

Bakhtin, M,(1984), Rabelais and His World, Indiana University Press.

1991, Carnival and Incarnation: Bakhtin and Orthodox Theology, Journal of Literature and Theology, 5 (1) 68-82. Reprinted in C. Emerson, ed. (1999) Critical Essays on Mikhail Bakhtin

Rzhevsky, N. (1994), Kozhinov on Bakhtin, New Literary History, 25 (2), 433-37. Reprinted in C.Emerson, ed. (1999) Critical Essays on Mikhail Bakhtin

Forms of time and of the chronotope in the novel, in The Dialogical Imagination, University of Texas Press.

Problems of Dostoevsky's Poetics, University of Minnesota Press.

Rosenhan, D.L.(1975) The contextual nature of psychiatric diagnosis, Journal of Abnormal Psychology, 84, 5, 462-4.

Reed, N. (1984), Reading Lermontev's 'Geroj nasego vremeni: Problems of Poetics and reception, unpublished PhD, Harvard University.

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Full Reference

Pollard, R., 2003. Book Review: 'Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry' Peter Good (2001). Reformulation, Summer, pp.40-43.

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Book Review: 'Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry' Peter Good (2001)

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