Thursday, 1 December 2016

Enough is enough: The phenomenology of sastifaction

Enough is enough: 

The phenomenology of satisfaction.

Dr David Straton

The engravings of the famous proverbs, "Know thyself" and "Nothing in excess," are found on the walls of the most important building in the sanctuary of the Temple of Apollo at Delphi. Western civilization, and psychiatry in particular, has been more successful at promoting the first proverb than the second.


       There are three states on any quantitative continuum: 


Many psychiatric disorders are concerned with these three states. For example, anorexia nervosa involves too little food. The decision to end a relationship, or commit suicide, follows the decision ‘enough is enough’. Substance abuse, bulimia, obsessional cleaning in OCD, and behaviour in hypomanic or manic states commonly involve ‘too much’.

The management of patients frequently requires decisions involving quantities: enough medication, frequency of visits, time to admit to hospital. Winnicott described the concept of ‘good enough mothering’.

In everyone’s life there are decisions that lie on the same continuum: enough money, enough superannuation, enough holidays, where to ‘draw the line’ with children.

In national and global affairs, the same pattern comes up and must be dealt with. Enough population, enough economic growth, too much crime, too much inequality

When these matters are discussed, they are invariably considered from an objective point of view.

Eating disorders are assessed in the light of the Body Mass Index. 


Alcoholism is measured in standard drinks, or occasionally a more flexible definition such as ‘anyone who drinks more than their doctor!’

Traffic cops measure speed and levels of alcohol in the breath.


Financial planners calculate interest rates, tax, and future spending levels.


When considered objectively, the key question is ‘Enough of What?’ Alcohol, Money, Weight, Psychiatrists in the Bush, whatever.

I have recently become interested in the subjective experience of ‘Enoughness’. The phenomenology of the subject. Just as one can discuss the phenomenology of hallucinations and delusions without getting overwhelmed by their content, one should be able to consider the process of the appreciation of ‘Enough’ as distinct from the content of the specific issue.

Perception.
From a cognitive point of view, one can hypothesize that a subject, facing a quantitative continuum requiring a judgement, could have a template representing their value of ‘enough’ of whatever the quantity is. They then estimate the present state in comparison to this template, and initiate a push towards More, or Less, if there is a discrepancy.

A comparison can be made with someone waiting for a passenger to arrive. They have a template in their mind of the person they are waiting for, and they check each arriving passenger against this until they get a ‘fit’.

In this model, a failure of fit between the quantity and the ‘enoughness’ template can occur as a result of either:

- the quantity being too small,
- the template being too large, or
- both.

The objective school of thought traditionally concentrates on only the first of these possibilities.

Transition.
The second issue I want to raise is the transition between ‘Not enough’ and Enough’. This is the interface between the zone in which ‘More’ is required, and it is not. The top of the plane’s climb. The last drink. ‘Rock Bottom’. The time to retire. The announcement of leaving home. The shift from dieting to eating, or vice versa.

This is the shift from the quantitative response to a qualitative one. The end of the ‘More’ paradigm, and the beginning of the ‘Stable’, ‘Sustainable’, or just ‘Different’ one.

It seems to me that the challenges of this transition sometimes lead to the template being adjusted up. In other words, the achievement of the fit between the quantity and the template requires a response. If that response is too difficult, the template is changed to fit the quantity.

‘Just one more drink’. ‘I’ll give you one more chance’. ‘Try increasing the pills’. ‘If the natives don’t understand you, just shout at them!’

These are quantitative responses to situations requiring a qualitative response.

The failure to make a transition at the enough spot is a huge caterpillar, failing to metamorphose into a chrysalis and butterfly.


The cancer cell, reproducing when reproduction is not needed.

Enough is where quantitative hits qualitative. Where the accelerator is released and the wheel is turned.

Cognitively, there are three aspects to this transition:

The recognition that the threshold of enoughness has been reached.
The engagement of the schemata of changing behaviour.
The consolidation of the schemata of the novel behaviour.



In a therapeutic context, this provides a framework for tackling the change cognitively.

Schema Deficit theory

A schema is any sequence of sensory, motor, cognitive, or emotional processes. A psychological ‘sub-program’. Schemas are much easier to create than to destroy.

If a subject has several schemata in a particular area, they generally use the best one available.

If they are lacking a range of schemata in a particular area, they will use whatever they have.

Increasing the menu of available schemata is a better route to change than trying to eliminate a dysfunctional schema.

We all have a schema for putting on a lace-up shoe.


- Perceptual. Which foot, which shoe?
- Gross motor. Dock foot in shoe.
- Sensory. Check for pebbles, laces, etc.
- Fine motor. Tie bow.
- Pressure sensation. Tight enough?
If this schema was causing you trouble, and it couldn’t be modified, there are no psychiatric treatments I know that would eliminate it. No medication, no ECT, no neurosurgery, and no psychotherapy. Far easier, and far better, would be to teach you schemata involved in using other types of footwear, such as:

Sandals
Thongs
Velcro shoes
Tooled Texan boots
Gumboots
Slippers

The ‘Not enough zone’ requires schemata like:
Initiating
Spontaneity
Saying ‘yes’
Demanding
Shopping

The ‘Enough zone’ requires schemata like:
Tolerating boredom
Buffering destabilizing inputs, either Up or Down.

The ‘Too much zone’ requires schemata like:
Garage sales
Going to the tip
Coping with loss
Grieving
Saying ‘no’ to invitations

EXAMPLES

Eating disorders: The capacity to experience satiety may be disrupted. One theory about the efficacy of fluoxetine in bulimics is that it assists neurological pathways used in the experience of satiety. To resist the impulse to eat requires the tolerance of the experience of hunger or emptiness. To maintain sensible eating practices requires regular patterns of diet and eating. Each of these can be tackled separately. The emphasis throughout should be on the identification, development, rehearsal, and practice of new schemata, not on the condemnation of old schemata.

Substance abuse. As for over-eating, except that mind-altering substances may themselves disrupt the capacity to experience satiety and also disrupt schemata of sobriety. The phenomenon of state-dependant learning often complicates change.

Emancipation of young adults. I frequently see teenagers and twenty-somethings who are living at home in conflict with one or both parents. Hosing down family bush-fires is generally a thankless task. The problems seem to improve only when some or all of the participants decide that ‘enough is enough’ and the young person leaves home, gets a job and a partner. 

I recommend focussing on: 

- the threshold (‘how will you know when you have reached the point when it would be better for you to leave?’),
- the process of leaving, (‘could you leave home in anything other than uproar, in a way that your parents actively help you without making you feel rejected?’),
- identifying the various micro-skills of independent living and rehearsing them.
This seems to be preferable to stabilizing the conflict, or urging good behaviour on all and sundry.

Marital dysfunction.
Pretty much any situation involving dissatisfaction produces a choice plan with 3 options.

Useful questions include:

- How will you know when you have put up with enough?
- How will you know when you have tried enough to improve things?
- If you decide to leave, how can you do that in such a way as to minimize avoidable drama that might rebound on you?
- What pitfalls can you anticipate after separating that might be avoided?

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