John Heaton is, amongst others, a practising psychiatrist and psychotherapist, a regular lecturer on the Advanced Diploma in Existential Psychotherapy programme at Regent’s College, London, and a long- and some-time editor of the Journal for Existential Analysis.

This is Heaton’s third book with Wittgenstein in its title. In it, he applies the great philosopher’s insights to the psychotherapeutic process in all its forms. Heaton’s principle thesis is that many of our deepest and most intractable problems find their roots in linguistic confusions and limitations, and are resolved not by the search for causes inherent in the various pseudo-scientific doctrines and theories of the mind (such as those of Freud and Klein), but by careful attention to the use of language. This is particularly true in neurosis and psychosis in which language is used not so much to clarify and to communicate as to deceive and to obfuscate.

Like all the best things, the talking cure has its roots in ancient Greece with such luminaries as Socrates and Diogenes the Cynic (see my post on Diogenes here). Upon being asked to name the most beautiful of all things, Diogenes replied ‘parrhesia’ (free speech, full expression), and his intransigently courageous and sometimes delightfully shocking behaviour consistently accorded with this, his, truth. The self-understanding that underlies parrhesia is revealed not in reductionist propositions based on questionable pictures of the mind, but in the singular use of language – both by the expression and by its truthfulness. In short, it is revealed not in causes, but in reasons, with all their multiplicities and particularities.

For Wittgenstein as for Heaton, the talking cure is, like philosophy itself, a battle against the bewitchment of intelligence by means of language, for it is not knowledge but understanding that is needed to live an integrated, productive, and, dare I say it, happy, life. To date, this important, indeed, devastating, critique has had little or no impact on psychotherapeutic practices, and Heaton’s revolutionary book requires and deserves to be read not only by psychotherapists and psychiatrists but by every mental health professional. Although the book is not difficult to leaf through, she with little more than a scientific background may find it difficult to understand, accept, or come to terms with certain concepts. As Lichtenberg tells us, ‘A book is like a mirror: if an ape looks into it an apostle is hardly likely to look out … he who understands the wise is wise already.’

Neel Burton

NB: This review has also been published in the September issue of the British Journal of Psychiatry.

According to Aristotle, the young have strong but changeable passions. They are quick tempered and lacking in self-control, and this makes them all the more likely to yield to their passions. They are eager for superiority and easily feel slighted. They love honour and victory more than money, and would rather do noble deeds than useful ones. As the greater part of their life lies before them, they live more in expectation than in memory; and as they are lacking in experience, they have exalted notions and tend to see the good rather than the bad. Although they are confident and courageous, they are still accepting of the rules of their society; and although they like spending their days with others, they have not yet learned to value their friends for their usefulness. They are quick to pity because they think that everyone is honest. If they wrong others, this is more to insult than to do real harm. As they are fond of fun, they are witty – wit being nothing other than well-bred insolence. They think they know everything and so they overdo everything. This is the source of all their mistakes.

In contrast to the young, the elderly live by memory rather than by hope. As they have a lot of experience, they are sure about nothing and under-do everything. They are small-minded because they have been humbled by life. As a result, they are driven too much by the useful and not enough by the noble. They are cynical and distrustful and neither love warmly nor hate bitterly. They are not shy but rather shameless, and feel only contempt for people’s opinion of them. As that which is desired most strongly is that which is needed most urgently, they love life, and all the more when their last day has arrived.

The body is in its prime from thirty to thirty-five; the mind at about forty-nine. The character of people in their prime is between that of the young and that of the elderly. Thus, people in their prime are neither overly confident nor overly timid, neither trustful nor mistrustful, and driven both by what is noble and by what is useful. ‘To put it generally, all the valuable qualities that youth and age divide between them are united in the prime of life, while all their excesses or defects are replaced by moderation and fitness.’

Source: Rhetoric, Book II, Chapters 12-14

Motivational interviewing (MI) is a powerful technique used by psychiatrists and other healthcare professionals, often in the context of encouraging a person to recognise his alcohol or drug problem and of ‘motivating’ him to reduce his substance use. However, the technique has very broad applications. In our private life, we often feel compelled to offer advice to our near and dear, but the better the advice, the more likely it is to be ignored, resisted, or opposed. This can have unfortunate consequences, not only for the problem in hand but also for the warmth or quality of the relationship. Such problems can be avoided by using the principles and techniques of MI. In short, MI involves a sort of empathetic Socratic questioning aimed at determining a person’s readiness for change and, if possible, at encouraging him to recognise the full import of the problem and then at guiding his reasoning so that he appears to come to a solution all by himself. This not only lends him a sense of ownership and empowerment, but also strengthens the relationship or, in the professional setting, the ‘therapeutic alliance’ – as illustrated below.

Scenario A (without using motivational interviewing)
Doctor: According to your blood tests, you’re drinking too much alcohol.
Patient: I suppose I do enjoy the odd drink.
Doctor: You’re probably having far more than just the odd drink. Alcohol is very bad for you, you need to stop drinking.
Patient: You sound like my wife.
Doctor: Well, she’s right you know. Alcohol can cause liver and heart problems and many other things besides. So you really need to stop drinking, OK?
Patient: Yes, doctor, thank you. (Patient never returns.)

Scenario B (using motivational interviewing)
Doctor: We all enjoy a drink now and then, but sometimes alcohol can do us a lot of harm. What do you know about the harmful effects of alcohol?
Patient: Quite a bit, I’m afraid. My best friend, well he used to drink a lot. Last year he spent three months in hospital. I visited him often, but most of the time he wasn’t with it. Then he died from internal bleeding.
Doctor: I’m sorry to hear that, alcohol can really do us a lot of damage.
Patient: It does a lot of damage to the liver, doesn’t it?
Doctor: That’s right, but it doesn’t just do harm to our body, it also does harm to our lives: our work, our finances, our relationships.
Patient: Funny you should say that. My wife’s been at my neck…
Doctor: So, you’ve told me that you’re currently drinking about 16 units of alcohol a day. This has placed severe strain on your marriage and on your relationship with your daughter Emma, not to mention that you haven’t been to work since last Tuesday and have started to fear for your job. But what you fear most is ending up lying on a hospital bed like your friend Tom. Is that a fair of summary of things as they stand?
Patient: Things are completely out of hand, aren’t they? If I don’t stop drinking now, I might lose everything I’ve built over the past 20 years: my job, my marriage, even my daughter.
Doctor: I’m afraid you might be right.
Patient: I really need to quit drinking.
Doctor: You sound very motivated to stop drinking. Why don’t we make another appointment to talk about about the ways in which we might support you? (…)