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Table of contents :
Beyond Single Message Mythologies......Page 6
Psychiatry at the Crossroads......Page 9
About the Book......Page 15
About the Authors......Page 20
1.1 Prospectus: “Crisis? What Crisis?” – Psychiatrists on Psychiatry –Vincenzo Di Nicola......Page 22
1.2 Leitmotif I: The Crisis of Psychiatry as a Crisis of Knowledge – Drozdstoj Stoyanov......Page 25
1.3 Leitmotif II: The Crisis of Psychiatry Is a Crisis of Being – Vincenzo Di Nicola......Page 28
Chapter 2: Methods for Clinical Evaluation in Psychiatry: Quantitative vs. Qualitative Approaches......Page 36
2.1 Introduction......Page 37
2.2.1 Clinical Assessment Methods......Page 39
2.2.2 Legal Arguments for Aspirations at More Robust Normative Criteria......Page 40
2.2.4 Data Translation and Reification of Diagnosis......Page 41
2.3.1 The Typical Case: Myocardial Infarction......Page 42
2.3.2 Atypical Case: Depression......Page 43
2.3.3 Relevance of Reification and Translation to Drug Choice......Page 46
3.1 Classification and Nomenclature......Page 49
3.1.1 Basic Operations to Establish Nosology......Page 50
22.214.171.124 Anti-nosological Approaches......Page 51
126.96.36.199 The Dimensional Approach......Page 53
3.1.3 Nomothetic vs. Ideographic Classification and Nomenclature......Page 55
3.2.2 The Biopsychosocial (BPS) Model......Page 57
4.1.1 Introduction: Mind-Brain Problem Opposition in Historical Traditions......Page 60
4.1.2 Current Implications of the Mind-Brain Debate in Psychiatry......Page 62
Chapter 5: The Beginning of the End of Psychiatry: A Philosophical Archaeology......Page 70
5.1 Psychology: Introspection and Consciousness......Page 71
5.2 Foundations of Modern Psychiatry......Page 72
5.3 Phenomenology in Psychiatry......Page 74
5.4 “Philosophical Shortcuts” or Founding Science?......Page 76
5.5 One Hundred Years of Phenomenological Psychiatry......Page 77
6.1.1 V1.0 – Der Fall Ellen West......Page 80
6.1.2 V2.0 – “Poor Little Rich Girl”......Page 82
6.1.3 V3.0 – The Absent Body......Page 83
188.8.131.52 “A letter always arrives at its destination …”......Page 85
6.1.5 V4.0 – “A Life Unworthy of Life”......Page 86
6.1.6 Katechon – “That Which Withholds”......Page 87
6.1.7 Ellen West: A Case Study for Evental Psychiatry......Page 89
184.108.40.206 Badiou’s Subjectizable Bodies......Page 90
220.127.116.11 Subjectivating Ellen West and Her Circle......Page 91
6.1.8 Caseness: A Wager Against Finitude......Page 93
6.2 Coda: Is There a Philosophical Analogue of the Case History?......Page 95
7.1.1 Overview: A Philosophical Archaeology......Page 98
7.1.2 Psychiatry and Anti-psychiatry......Page 99
7.2 Anti-Psychiatry: “Negation and Its Vicissitudes” (Cf. Baudry 1989)......Page 109
7.4 R.D. Laing: A Radical Return to Psychiatry’s Roots......Page 110
7.5 Jacques Lacan: Psychoanalytic Subversive, Psychiatric Rebel......Page 112
7.6 “Psychoanalysis as Subversion”14......Page 114
7.7 Franco Basaglia: Reforming Psychiatry by Transforming the Asylum......Page 115
7.8 Italy: “Jesters and Madmen” – Anti-Psychiatry as a Cultural Revolution......Page 118
7.9 The Myth of Thomas S. Szasz: Psychiatry in Reaction......Page 120
7.10 Frantz Fanon: The Unfinished Revolution of Psychiatry......Page 122
7.11 Michel Foucault: Reordering Medical Perception and Psychiatric Thought......Page 123
7.12 The Ship of Fools......Page 127
7.13 Envoi......Page 130
Chapter 8: Cleaning the House of Psychiatry......Page 139
8.1 Psychiatry, Fast and Slow......Page 140
8.3 Reductionism in Medicine and Psychiatry......Page 142
9.1 The Crisis of Psychiatry Is a Crisis of Being......Page 150
9.2 Di Nicola’s Frame Shift: Re-visioning Phenomenology – D Stoyanov......Page 152
9.3 Types of Thinkers: Systematic, Edifying, and Methodological......Page 153
9.4 Ideology and Temperament......Page 156
9.5 Ideology......Page 157
9.6 Psychiatric Temperaments......Page 158
9.8 Asymptote: The Law of Diminishing Returns......Page 159
10.1 Philosophy as Therapy......Page 164
10.2 The Need to Create a New Synthesis......Page 165
10.3 The Long Habit......Page 172
Saving Psychiatry......Page 179
Vincenzo Di Nicola Drozdstoj Stoyanov
Psychiatry in Crisis
At the Crossroads of Social Sciences, the Humanities, and Neuroscience
Psychiatry in Crisis
Vincenzo Di Nicola • Drozdstoj Stoyanov
Psychiatry in Crisis At the Crossroads of Social Sciences, the Humanities, and Neuroscience
Vincenzo Di Nicola University of Montreal Montreal, QC, Canada
Drozdstoj Stoyanov Medical University of Plovdiv Plovdiv, Bulgaria
The George Washington University Washington, DC, USA
ISBN 978-3-030-55139-1 ISBN 978-3-030-55140-7 (eBook) https://doi.org/10.1007/978-3-030-55140-7 © Springer Nature Switzerland AG 2021 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
We must think the event…. We must think change in life. –Alain Badiou (2006) To my children – Carlo Dante, Nina Mara, and Anita Sofia – the event of my life and harbingers of change. –Vincenzo Di Nicola and So the problem is not so much to see what nobody has yet seen, as to think what nobody has yet thought concerning that which everybody sees. –Arthur Schopenhauer (1851) To the people who supported me and to my beloved family, who gave me the courage to believe. To the people who opposed and challenged me, who gave me the stamina to persist. –Drozdstoj Stoyanov References Badiou, Alain (2006). Polemics, trans. and with an introduction by Steve Corcoran. London: Verso, p. 8. Schopenhauer, Arthur (1851). Parerga und Paralipomena. In: Kleine Philosophische Schriften, Volume 2, Section: 76. Berlin: A. W. Hayn, p. 93.
Beyond Single Message Mythologies ‘Psychiatry in Crisis’ could have been old news. Psychiatry after all has been under attack right back to the 1960s. This has been variously from other academic and clinical disciplines (such as psychology and psychoanalysis) and even from those it aims to help (patients and their families). Latterly it has come under further attack this time from within. Senior figures in the research community, in particular, frustrated by the failure of the new neurosciences to translate into improvements in clinical care, have called for ‘a new paradigm’. Taking the long view, their concerns are consistent with the German psychiatrist and historian Paul Hoff’s analysis of the history of psychiatry as a history of ‘serial collapses into single message mythologies.’ It is all the more exciting therefore to find that in their remarkable book, Vincenzo Di Nicola and Drozdstoj Stoyanov bring such a refreshingly open and innovative vision to bear on the challenges facing contemporary psychiatry. They are perhaps uniquely well placed to do this. Both are pre-eminent academics in psychiatry. Yet both draw on extensive clinical experience on the front line of care. Both furthermore have been active in the emerging interdisciplinary field of philosophy and psychiatry. Their debt to philosophy is clear. Neatly avoiding the trap of premature closure on yet another single message mythology, their thesis is presented in the form of a critical dialogue between two philosophically framed perspectives. Stoyanov casts the crisis in psychiatry in epistemological terms as a crisis of knowledge. Di Nicola by contrast casts it ontologically as a crisis of being. The counterpoint between these two perspectives makes for an inspiring and deeply illuminating read with the added bonus of the introduction of (for many Anglo-Saxon readers at least) fresh names. Di Nicola for example draws deeply on the work of the French philosopher and contemporary of the perhaps better-known Michel Foucault, Alain Badiou, notably on his analysis of what it is to be a human being.
In drawing in this way on philosophical sources Di Nicola and Stoyanov are themselves exemplars of an important if minority development in contemporary psychiatry. The 1990s as they describe was hailed in psychiatry as the ‘Decade of the Brain’, the decade in which the neurosciences were set to emerge as the dominant influence on the field under their banner ‘the mind is the brain’. But the 1990s was also the decade of the mind, the decade in which, somewhat to the surprise of many, a long-standing if minority tradition of cross-disciplinary work between philosophy and psychiatry sprang into new life. Di Nicola’s and Stoyanov’s Psychiatry in Crisis reflects many of the virtues of the ‘new’ philosophy and psychiatry. Besides its evident scholarship and originality, and an ethos of mutual respect between protagonists, it is overtly and inclusively international in perspective. That the ‘new’ philosophy and psychiatry should have emerged in parallel with the ‘new’ neurosciences should not perhaps have come as a surprise. Psychiatry’s ‘first biological phase’, driven by developments in bacteriology and brain pathology in the late nineteenth and early twentieth centuries, was paralleled by a first philosophical phase in the foundational work of the German psychiatrist and philosopher, Karl Jaspers. The parallel is not coincidental. The conjunction of challenging empirical research with high level conceptual thinking is a mark of a science that is very much at the cutting edge. We need look no further than theoretical physics for another science that is in this sense at the cutting edge. The current standard model of particle physics was derived in the first half of the twentieth century by just such a combination of challenging empirical findings and innovative conceptual thinking. It is this combination, too, many expect, that in the first half of the twenty-first century, will be needed to overcome the limitations of the standard model. These limitations, furthermore, again echoing the current status of psychiatric science, are the limitations of conflicting paradigms. For all its success as a theory of the very small, the standard model is incompatible with the no less successful physical theory of the very large, Albert Einstein’s general relativity. Psychiatry is of course not physics. For one thing, despite a number of promising developments in computational psychopathology, it lacks a formal structure of the kind that in the past has turbocharged so many sciences. Its conceptual challenges, too, are different. Where physics struggles with concepts such as time, location and event, psychiatry struggles, as Di Nicola and Stoyanov so ably illustrate, with, as it were, more visceral concepts such as mind, agency and person. Psychiatry’s conceptual struggles, moreover, are the more urgent for the immediacy of their practical impact. Yes, theoretical physics has practical impact (think computers, think atomic bombs). But these are at one remove from the theoretical insights on which they are based. In psychiatry, by contrast, our conceptual model – the largely implicit set of background ideas we bring to making sense of our work and of our interactions with our patients – matters directly and immediately to the care we provide. This adds to the many other merits of Di Nicola’s and Stoyanov’s book an extra frisson of practical necessity. Yet for all this, the new philosophy and psychiatry of which Di Nicola and Stoyanov are exemplars, remains a minority development in a psychiatry dominated by the contemporary hegemony of ‘mind is brain’ neuroscience. This I believe
reflects yet another crisis to which contemporary psychiatry is heir, a crisis of confidence. Measuring itself against less conceptually challenging sciences, such as those of surgery, psychiatry misperceives itself as a science not at the cutting edge but at the trailing edge. No one – least of all our patients – benefits from what, in the terms of our art of our discipline, is the ‘learned helplessness’ to which this misperception has led. Di Nicola’s and Stoyanov’s conceptually nuanced and practically informed dialogue on the crises respectively of knowledge and of being in psychiatry could do much to make psychiatry’s crisis of confidence an opportunity for change. St Catherine’s College, University of Oxford K. W. M. (Bill) Fulford Oxford, UK March 2020
Psychiatry at the Crossroads The field of academic psychiatry is in crisis, everywhere. It is not merely a health crisis of resource scarcity or distribution, competing claims and practice models, or level of development from one country to another, but a deeper, more fundamental crisis about the very definition and the theoretical basis of psychiatry. Psychiatry is at a crossroads where the kinds of questions that represent this crisis include whether psychiatry is a social science (like psychology, sociology, or anthropology), whether it is better understood as part of the humanities (like philosophy and history), or if the future of psychiatry is best assured as a branch of medicine (like its first two branches, internal medicine and surgery)? In fact, the question often debated since the beginning of modern psychiatry concerns the biomedical model so that part of psychiatry’s perpetual self-questioning is to what extent it is or is not a branch of medicine. So the third option is itself in question: is psychiatry to be guided by a more narrowly focused medical model privileging genetics and neuroscience or an enlarged vision of medicine that encompasses social and human sciences? Critical psychiatrists have been casting about for a new model in every generation. Since the foundations of modern psychiatry as a medical discipline in the late nineteenth century and the beginning of the twentieth century, psychiatrist Karl Jaspers introduced phenomenology from philosophy as a fundamental part of contemporary psychiatry. Every generation since then has introduced other humanities and social sciences, with the flourishing of many schools of psychotherapies, the introduction of sociology and anthropology which created branches like social and cultural psychiatry, and an always intimate relationship with psychology. Meanwhile, the intimate relationship between psychiatry and continental or European philosophy and critical theory continued, posing key epistemological questions about meaning and ontological questions about being. Along with other trends, this culminated in the antipsychiatry movement of the 1960s and 1970s, reviewed in “Part II: Psychiatry in Crisis as a Human & Social Science.” xi
In parallel, following psychiatry’s Linnaeus, Emil Kraepelin who established the modern basis for psychiatric classification and nomenclature, there has been a more rigorous project to establish a scientific basis for psychiatric diagnosis, using increasingly sophisticated methodologies for research. A key text by a leading researcher in Kraepelin’s footsteps is Samuel Guze’s Why Psychiatry Is a Branch of Medicine, published in 1992. Now, this approached has dovetailed with advances in epidemiology, brain or neurosciences, and genetics to produce the neuroscience model of psychiatry, emblematic of the influential US National Institute of Mental Health (NIMH) whose mantra is “mind is brain.” This approach to psychiatry in turn also has philosophical schools in the Anglo-American tradition of analytic philosophy and philosophy of science supporting its approach to questions about mind as a progressive scientific project focusing on the brain. The “Decade of the Brain” declared in the 1990s with increased funding for the US NIMH culminated in the Nobel Prize for psychiatrist Eric Kandel’s neuroscientific research on memory in 2000. Not all researchers in the allied fields of psychology, psychiatry, and neuroscience are convinced by the claims of the biomedical model and neuroscience in particular so that a prominent developmental psychologist Jerome Kagan made An Argument for Mind in 2006. Arguing from the perspective of cultural psychiatry, the influential Arthur Kleinman pleaded for Rethinking Psychiatry in 1991 and later declared in an editorial that “academic psychiatry is in trouble,” reaching for the “narrowest of biological research approaches of decreasing relevance to clinical practice and global health.” Many other voices have joined him in this recognition that “psychiatry is in the midst of a crisis,” as articulated by Bracken and associates in 2012. We will examine their diagnosis and their prescription for “rebalancing academic psychiatry” (Kleinman) by going “beyond the current paradigm” (Bracken and associated) in more detail. Furthermore, the classification system called the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA), now in its fifth edition and an ongoing progeny of Kraepelin, has been dismissed as a mere “dictionary” by Thomas Insel of the NIMH where he pursued genetic predispositions and neural substrates in the brain as explanatory models for mind. From psychiatry in crisis as a medical discipline to critical psychiatry casting for a new model, what will be the result? Will it be the end of psychiatry or its renaissance as something new and different, either as a more comprehensive theory and practice of the humanities and social sciences or as a new branch of medicine called the neurosciences? This volume offers a representative and critical survey of the history of modern psychiatry with deeply informed transdisciplinary readings of the literature and practices of the field by the two of us who are professors of psychiatry with dual training in scientific psychiatry and philosophy. More important, we are both active in practice and engaged in research and confront these issues in our daily practices as clinical psychiatrists and researchers. Yet, this is not a case-based study. The reason is that we are addressing psychiatry’s philosophical and scientific foundations rather than appealing to the sometimes compelling narratives of clinical
practice. References to clinical syndromes are used throughout the text to illustrate contentions and critiques. The single major case presented is a detailed investigation of “The Case of Ellen West” by Ludwig Binswanger, the foundational case of existential analysis, because this approach claims to elucidate the subjective phenomenology or lived experience of psychiatric patients. Di Nicola shows in Part II that this is not only impossible but destructive and why his philosophical archaeology of Ellen West spells with her suicide the death of existential analysis and the end of subjective phenomenology in psychiatry. The major arguments marshaled here are from philosophy and biomedical science. This book does not directly address the claims and critiques of psychiatry launched by the human and social sciences nor the concerns of patient groups, although we are richly aware of their positions. Even in the review of Critical Psychiatry in Part II, we see anti-psychiatry largely as a movement within psychiatry – psychiatry against itself. A major exception is the work of psychologist turned philosopher and historian, Michel Foucault, because of his extraordinary impact as one of the most cited and influential authors in the human and social sciences. In alternating sections presenting contrasting arguments for the future of psychiatry, we conclude with a call for renewal in psychiatry to flesh out the theoretical, research, and practical implications of psychiatry’s current crisis, outlining areas of divergence, consensus, and fruitful collaborations to revision psychiatry today. The volume is richly documented and offers capsule summaries of key areas of theory, research, and practice for the student and specialist alike in the humanities and social sciences, and in medicine, psychiatry, and the neurosciences. Montreal, QC, Canada Vincenzo Di Nicola Plovdiv, Bulgaria Drozdstoj Stoyanov
The inspiration for this project together came out of enduring hopes and lingering disappointments over the state of psychiatry. Both of us were inspired by philosophy to read psychiatry more critically and not be satisfied with either the “standard model” of our training days or the emerging model of neuroscience. Our dialogue started at the regional congress of the World Psychiatric Association in Bucharest, Romania, in 2013, just after Di Nicola completed his doctorate in the philosophy of psychiatry in 2012, where we expressed mutual concerns over the current crisis in psychiatry, continued with Stoyanov’s presentation on psychiatry in crisis at the First Eastern European Conference of Mental Health in Galati, Romania, in 2017 and Di Nicola’s visits to Stoyanov’s departments of psychiatry and psychology in Plovdiv and Sofia, Bulgaria, later that year, followed by our presentation on our project at the annual meeting of the American Psychiatric Association in New York City in 2018. For Di Nicola, a seminar on the social sciences and psychiatry that he initiated in his Department of Psychiatry and grew into the postgraduate course he co-directs at the University of Montreal on “Psychiatry and the Humanities” serves as a transdisciplinary laboratory of ideas cross-pollinating psychiatry from the social sciences and the humanities. For Stoyanov, as he describes it in the text, the dual engagement in philosophy and neuro-imagining research was a more conventional laboratory replete with high expectations, intriguing findings, yet deep frustrations. Psychiatry in Crisis has been a collaborative work-in-progress with both detailed analyses and general conclusions presented or published in different forms over the past several years, as noted below. Part I – Psychiatry in Crisis as a Medical Discipline Stoyanov’s theoretical and empirical contributions to neuroscience and philosophy presented in Part I were elaborated in his thesis for a doctorate of science, supported by a sabbatical grant from his department in Plovdiv, Bulgaria: Stoyanov, D.S. (2018). Psychiatry in crisis: Opportunities of translational neuroscience. Medical University of Plovdiv.
Part II – Psychiatry in Crisis as a Human & Social Science Di Nicola’s philosophical critique of phenomenology in psychiatry presented in Part II is adapted from his doctorate in the philosophy of psychiatry: Di Nicola, V. (2012). Trauma and event: A philosophical archaeology. European Graduate School. His analysis of “The Case of Ellen West” by Ludwig Binswanger, elaborated in Part II, Chap. 6, evolved over numerous presentations at McGill University (2010, 2013) and the University of Montreal (2010, 2012) and was first discussed briefly in print in: Di Nicola, V. (2011). The enigma of Ellen West: Twentieth-century psychiatry’s projection screen. In Letters to a young therapist: Relational practices for the coming community (pp. 105–110). New York/Dresden: Atropos Press. “Psychiatry Against Itself”: Radicals, Rebels, Reformers, and Revolutionaries, presented in Part II, Chap. 7, was prepared for a seminar on “Psychiatrie et sciences sociales” (Department of Psychiatry, Université de Montréal, 2013–2015) and a postgraduate course on “Psychiatrie et sciences humaines” (Faculty of Medicine, Université de Montréal, since 2016); both in French. It was presented in Portuguese as part of a panel on “Psychiatry in Negation and the Roots of Family Therapy,” organized by Di Nicola who contributed, “Psychiatry Against Itself: How AntiPsychiatry Provoked the Family Therapy Movement,” at the XII Congresso Brasileiro de Terapia Familiar, ABRATEF, Gramado, RS, Brazil (11 June 2016); and in French at the Colloque Psy-ences: L’institutionalisation de l’esprit, Dept. of Philosophy, Université du Québec à Montréal (8 June 2017). The ideas were first developed in my doctorate in philosophy at the European Graduate School, Trauma and Event: A Philosophical Archaeology (Di Nicola 2012). An earlier version was published in: Di Nicola, V. (2015, December). Psychiatry against itself: Radicals, rebels, reformers & revolutionaries. A philosophical archaeology. Journal of The International Association of Transdisciplinary Psychology, 4(1), 1−18. Progress reports and discussions of our “Psychiatry in Crisis” project include: Stoyanov, D. S., Di Nicola, V. (2017). “Psychiatry in Crisis: Epistemological and Ontological Concerns.” In and Out of Your Mind: 1st Eastern European Conference of Mental Health, Galati, Romania, May 12, 2017. Abstract published in: American Journal of Psychiatry and Neuroscience, November 2017, 5(6−1): 6. Stoyanov, D. S., Di Nicola, V. (2018, May 7). Poster: “Psychiatry in a state of crisis: A conceptual, methodological, and practical critique.” Annual Meeting, American Psychiatric Association, New York. Stoyanov, D.S., Di Nicola, V. (2020). Plenary Address: “Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience,” In 3rd national congress in clinical psychology with international participation, Institute for Mental Health and Development, Sofia University Dept. of Psychology, Sofia, Bulgaria, October 18, 2020. (Presented in Bulgarian). Finally, Di Nicola wrote an editorial in the inaugural issue of the Bulgarian Journal – Mental Health on the crisis in mental health and psychiatry summarizing the conclusions of this volume:
Di Nicola, V. (2020). Editorial—“Crisis? What crisis?” The crisis of psychiatry is a crisis of being. Bulgarian Journal – Mental Health, 1(1): 4−10. We would like to thank two fellow psychiatrists for their contributions to this volume – KWM (Bill) Fulford, Fellow of St Catherine’s College, Oxford, who is a pioneer of the academic field of philosophy and psychiatry, for his warm enthusiasm for our project and for opening this volume with his generous but provocative Foreword, and Allen Frances, Professor Emeritus and former Chair of the Department of Psychiatry at Duke University and past chair of the APA’s DSM-IV, for his early support of our work and for writing a cautiously hopeful Afterword to close and round out our arguments.
About the Book
This volume is a report on the critical state of contemporary psychiatry. It offers a representative and critical survey of the history of modern psychiatry with deeply informed transdisciplinary readings of the literature and practices of the field by Di Nicola and Stoyanov, two professors of psychiatry with dual training in scientific psychiatry and philosophy. In alternating sections presenting contrasting arguments for the future of psychiatry, Di Nicola and Stoyanov conclude with a call for renewal in psychiatry to flesh out the theoretical, research, and practical implications of psychiatry’s current crisis, outlining areas of divergence, consensus, and fruitful collaborations to revision psychiatry today. The volume is richly documented and offers capsule summaries of key areas of theory, research, and practice for the student and specialist alike in the humanities and social sciences, and in medicine, psychiatry, and the neurosciences. The authors are both professors of psychiatry in respected university departments of psychiatry. They also share professional training and engaged activities in the philosophy of psychiatry. Moreover, they are both active practitioners who confront these issues in their daily practices as clinical psychiatrists and researchers. As fellow Europeans, with Di Nicola working in North America and Stoyanov working in Europe, both are active in national and international psychiatric organizations and together bring varied international expertise to this study. From these informed perspectives, Stoyanov and Di Nicola pose fundamental epistemological (dealing with knowledge) and ontological (related to being) questions about the crisis of psychiatry, what they imply, and how to go about resolving them to renew psychiatry today.
oreword – Beyond Single Message Mythologies – KWM (Bill) F Fulford ������������������������������������������������������������������������������������������������������������ vii 1 Introduction: Prospectus and Leitmotifs������������������������������������������������ 1 1.1 Prospectus: “Crisis? What Crisis?” – Psychiatrists on Psychiatry – Vincenzo Di Nicola��������������������������������������������������������������������������� 1 1.2 Leitmotif I: The Crisis of Psychiatry as a Crisis of Knowledge – Drozdstoj Stoyanov �������������������������������������������������������������������������� 4 1.3 Leitmotif II: The Crisis of Psychiatry Is a Crisis of Being – Vincenzo Di Nicola��������������������������������������������������������������������������� 7 References�������������������������������������������������������������������������������������������������� 11 Part I Psychiatry in Crisis As a Medical Discipline Drozdstoj Stoyanov 2 Methods for Clinical Evaluation in Psychiatry: Quantitative vs. Qualitative Approaches ���������������������������������������������������������������������������� 17 2.1 Introduction�������������������������������������������������������������������������������������� 18 2.2 Quantitative Decomposition of Narratives vs. Qualitative Approach������������������������������������������������������������������������ 20 2.2.1 Clinical Assessment Methods ���������������������������������������������� 20 2.2.2 Legal Arguments for Aspirations at More Robust Normative Criteria���������������������������������������������������������������� 21 2.2.3 Biomarkers and Validity�������������������������������������������������������� 22 2.2.4 Data Translation and Reification of Diagnosis �������������������� 22 2.3 Reconstruction of the Methodological Discrepancies Based on an Exemplary Case: Major Depressive Disorder�������������� 23 2.3.1 The Typical Case: Myocardial Infarction ���������������������������� 23 2.3.2 Atypical Case: Depression���������������������������������������������������� 24 2.3.3 Relevance of Reification and Translation to Drug Choice���������������������������������������������������������������������� 27 References�������������������������������������������������������������������������������������������������� 29 xxi
3 Psychiatric Nosology Revisited: At the Crossroads of Psychology and Medicine �������������������������������������������������������������������������������������������� 31 3.1 Classification and Nomenclature������������������������������������������������������ 31 3.1.1 Basic Operations to Establish Nosology������������������������������ 32 3.1.2 Categorical vs. Dimensional Approaches: Archaeology of the Psychiatric Nosology Discourse �������������������������������� 33 3.1.3 Nomothetic vs. Ideographic Classification and Nomenclature������������������������������������������������������������������������ 37 3.2 Post-modern Perspectives ���������������������������������������������������������������� 39 3.2.1 Biopsychosocial Model and Person-Centered Medicine: A Comparison ���������������������������������������������������������������������� 39 3.2.2 The Biopsychosocial (BPS) Model�������������������������������������� 39 3.2.3 Person-Centered Medicine (PCM): Conceptual Differences�������������������������������������������������������� 40 References�������������������������������������������������������������������������������������������������� 41 4 Psychiatry and Neuroscience: At the Interface�������������������������������������� 43 4.1 How to Incorporate Scientific Data from Neuroscience Without Turning Psychiatry into an Applied Branch of Neurology ������������������������������������������������������������������������������������ 43 4.1.1 Introduction: Mind-Brain Problem Opposition in Historical Traditions �������������������������������������������������������� 43 4.1.2 Current Implications of the Mind-Brain Debate in Psychiatry������������������������������������������������������������������������������ 45 References�������������������������������������������������������������������������������������������������� 51 Part II Psychiatry in Crisis as a Human & Social Science Vincenzo Di Nicola 5 The Beginning of the End of Psychiatry: A Philosophical Archaeology���������������������������������������������������������������������������������������������� 55 5.1 Psychology: Introspection and Consciousness �������������������������������� 56 5.2 Foundations of Modern Psychiatry�������������������������������������������������� 57 5.3 Phenomenology in Psychiatry���������������������������������������������������������� 59 5.4 “Philosophical Shortcuts” or Founding Science? ���������������������������� 61 5.5 One Hundred Years of Phenomenological Psychiatry���������������������� 62 References�������������������������������������������������������������������������������������������������� 64 6 The End of Phenomenology�������������������������������������������������������������������� 65 6.1 Iterations of “Ellen West” – A Mirror of Twentieth-Century Psychiatry������������������������������������������������������������������������������������������ 65 6.1.1 V1.0 – Der Fall Ellen West���������������������������������������������������� 65 6.1.2 V2.0 – “Poor Little Rich Girl”���������������������������������������������� 67 6.1.3 V3.0 – The Absent Body ������������������������������������������������������ 68 6.1.4 Making a Case: Iteration/Repetition ������������������������������������ 70
6.1.5 V4.0 – “A Life Unworthy of Life”���������������������������������������� 71 6.1.6 Katechon – “That Which Withholds” ���������������������������������� 72 6.1.7 Ellen West: A Case Study for Evental Psychiatry���������������� 74 6.1.8 Caseness: A Wager Against Finitude������������������������������������ 78 6.2 Coda: Is There a Philosophical Analogue of the Case History? ������ 80 References�������������������������������������������������������������������������������������������������� 81 7 The End of Psychiatry ���������������������������������������������������������������������������� 83 7.1 “Psychiatry Against Itself”: Radicals, Rebels, Reformers, and Revolutionaries�������������������������������������������������������������������������� 83 7.1.1 Overview: A Philosophical Archaeology������������������������������ 83 7.1.2 Psychiatry and Anti-psychiatry �������������������������������������������� 84 7.2 Anti-Psychiatry: “Negation and Its Vicissitudes” (Cf. Baudry 1989) ���������������������������������������������������������������������������� 94 7.3 Alienation Is a Negation ������������������������������������������������������������������ 95 7.4 R.D. Laing: A Radical Return to Psychiatry’s Roots������������������������ 95 7.5 Jacques Lacan: Psychoanalytic Subversive, Psychiatric Rebel�������� 97 7.6 “Psychoanalysis as Subversion” ������������������������������������������������������ 99 7.7 Franco Basaglia: Reforming Psychiatry by Transforming the Asylum���������������������������������������������������������������������������������������� 100 7.8 Italy: “Jesters and Madmen” – Anti-Psychiatry as a Cultural Revolution���������������������������������������������������������������������������������������� 103 7.9 The Myth of Thomas S. Szasz: Psychiatry in Reaction�������������������� 105 7.10 Frantz Fanon: The Unfinished Revolution of Psychiatry������������������ 107 7.11 Michel Foucault: Reordering Medical Perception and Psychiatric Thought������������������������������������������������������������������� 108 7.12 The Ship of Fools������������������������������������������������������������������������������ 112 7.13 Envoi ������������������������������������������������������������������������������������������������ 115 References�������������������������������������������������������������������������������������������������� 118 Part III Renewal in Psychiatry Vincenzo Di Nicola, Drozdstoj Stoyanov 8 Cleaning the House of Psychiatry���������������������������������������������������������� 125 8.1 Psychiatry, Fast and Slow ���������������������������������������������������������������� 126 8.2 Centrifugal Versus Centripetal���������������������������������������������������������� 128 8.3 Reductionism in Medicine and Psychiatry �������������������������������������� 128 References�������������������������������������������������������������������������������������������������� 133 9 Reframing Psychiatry: Posing the Right Questions������������������������������ 137 9.1 The Crisis of Psychiatry Is a Crisis of Being������������������������������������ 137 9.2 Di Nicola’s Frame Shift: Re-visioning Phenomenology – D Stoyanov���������������������������������������������������������� 139 9.3 Types of Thinkers: Systematic, Edifying, and Methodological�������� 140 9.4 Ideology and Temperament�������������������������������������������������������������� 143
9.5 Ideology�������������������������������������������������������������������������������������������� 144 9.6 Psychiatric Temperaments���������������������������������������������������������������� 145 9.7 Qualities of the Psychiatrist�������������������������������������������������������������� 146 9.8 Asymptote: The Law of Diminishing Returns���������������������������������� 146 References�������������������������������������������������������������������������������������������������� 147 10 Renewal in Psychiatry ���������������������������������������������������������������������������� 151 10.1 Philosophy as Therapy�������������������������������������������������������������������� 151 10.2 The Need to Create a New Synthesis���������������������������������������������� 152 10.3 The Long Habit ������������������������������������������������������������������������������ 159 References�������������������������������������������������������������������������������������������������� 162 Afterword – Saving Psychiatry – Allen Frances ������������������������������������������ 167 Index������������������������������������������������������������������������������������������������������������������ 169
About the Authors
Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, DFAPA, FCPA Dr. Di Nicola trained as a psychologist at McGill University in Montreal, QC, Canada, and the Institute of Psychiatry in London, UK, then in medicine at McMaster University in Hamilton, ON, Canada. His postgraduate medical training combined dual specialties in pediatrics and general psychiatry at McGill University, followed by subspecialty training in child psychiatry with a fellowship in child and adolescent psychopharmacology at the University of Ottawa (Ottawa, ON, Canada). His studies in trauma brought him to pursue postgraduate work at the Harvard Program for Refugee Trauma (Cambridge, MA, USA) and doctoral research in philosophy and psychiatry, leading to his doctoral dissertation, Trauma and Event at the European Graduate School in Saas-Fee, Wallis, Switzerland, which inspired this volume, part of which was integrated into Part II – Psychiatry in Crisis as a Human and Social Science. Dr. Di Nicola is a tenured Full Professor in the Department of Psychiatry and Addiction Medicine at the University of Montreal in Montreal, Canada, where he is Chief of Child and Adolescent Psychiatry at the Montreal University Institute of Mental Health. He is Honorary Professor of Psychology and Law, FADOM, Minas Gerais, Brazil; Clinical Professor in the Department of Psychiatry and Behavioral Sciences at The George Washington University in Washington, DC, USA; Teaching Faculty in Global Mental Health at the Harvard Program in Refugee Trauma at Harvard Medical School in Cambridge, MA, USA; Distinguished Member of the American Psychiatric Association (APA); Co-founder and past Chair of the APA Caucus on Global Mental Health and Psychiatry; Member of the APA Council on International Psychiatry; International Distinguished Member of the Bulgarian Academy of Sciences and Arts; Fellow of the Canadian Psychiatric Association; Founding Fellow of the International College of Cultural Psychiatry; and a partner of the Collaborating Centre for Values-based Practice in Health and Social Services at St. Catherine’s College, Oxford University. He is Founder and President (2019–2022) of the Canadian Association of Social Psychiatry as well as Honorary Fellow and President-Elect (2019–2022) of the World Association of Social Psychiatry. xxv
About the Authors
His investigations include research on obsessions and compulsions; eating and mood disorders; intergenerational impacts of severe trauma; social and cultural aspects of child psychiatry, family therapy, and trauma; and the interface between philosophy and psychiatry. Dr. Di Nicola is the author of numerous articles, chapters, and books, including A Stranger in the Family: Culture, Families, and Therapy (W.W. Norton, 1997) and Letters to a Young Therapist (Atropos, 2011, winner of the Camille Laurin Prize). Drozdstoj Stoyanov, MD, PhD, PGCert, DSc, DIFAPA Dr. Stoyanov has both a medical and philosophical background in neuroscience. He graduated from medicine and is board certified in psychiatry with further qualifications in the fields of philosophy of mental health in the MA program of the University of Central Lancashire, UK (PGCert), and in philosophy of science of the University of Pittsburgh, PA, USA. Dr. Stoyanov has trained extensively in functional neuroimaging at research centers of excellence in Basel and Lausanne, Switzerland, and in Bergen, Norway. His first doctoral dissertation (PhD) paved the ground for a methodological reappraisal program aimed at a paradigm shift in neuroscience, which was expanded into a Doctorate of Science (DSc) with conceptual, empirical, and meta-empirical contributions entitled, Psychiatry in Crisis: Resources from Translational Neuroscience. Significant portions of the latter are incorporated in this volume, notably in “Part I – Psychiatry in Crisis As a Medical Discipline.” Dr. Stoyanov is currently Full Professor and Head of the Department of Psychiatry and Medical Psychology and Head of the Neuropsychiatry and Brain Imaging Group at the Medical University of Plovdiv, Bulgaria, as well as a lecturer at the University of Sofia’s Clinical Psychology and Counseling Program. Dr. Stoyanov is Visiting Fellow in the Center for Philosophy of Science, University of Pittsburgh, PA, USA; Project Partner at the Collaborating Centre for Values-based Practice in Health and Social Care, St. Catherine’s College, University of Oxford; and Visiting Lecturer at the universities of Basel, Copenhagen, Bergen, and Vienna. Dr. Stoyanov holds offices and positions in notable national and international scientific organizations: Chair of the Philosophy Special Interest Group of the Royal College of Psychiatrists; Vice Chair and Member of its Executive Committee; Chair of Conceptual Group in the Global Network for Diagnosis and Classification, World Psychiatric Association (2008); Vice President (since 2014) of the European Society for Person Centered Healthcare; and Vice President (since 2016) of the Bulgarian Academy of Sciences and Arts. Notable honors include being a Distinguished International Fellow, American Psychiatric Association (DIFAPA). Dr. Stoyanov has authored or coauthored nearly 200 scientific publications in prestigious journals, coedited several volumes in psychiatry and philosophy, and pioneered research in the fields of philosophy, psychiatry, and psychology, and functional neuroimaging in Bulgaria and Southeastern Europe.
Introduction: Prospectus and Leitmotifs
1.1 Prospectus: “Crisis? What Crisis?” – Psychiatrists on Psychiatry –Vincenzo Di Nicola When we announced our project on the crisis in psychiatry, we received three kinds of comments and reactions. There are two extremes and a complex middle ground full of nuances and revisions. “Crisis? What crisis?” This first reaction reminds me of the 1975 album by the English group Supertramp with the album cover of a guy in a deckchair and an umbrella surrounded by a destitute post-industrial environment. These folks are naïve optimists or the reformed cynics who have found religion in “positive psychology.” “Psychiatry has always been in crisis” This is espoused by a surprising number of thoughtful psychiatrists, including Tom Burns (2006) in his brief introduction to psychiatry: “Psychiatry has always been controversial” and never had a “Golden Age … when everyone was in agreement” (Burns 2006, p. 131). Burns is of the opinion that protests notwithstanding none of us truly believe that psychiatry is just like any other branch of medicine and that this difference generates conflicts and crises. Some of these folks are cynics who dismiss the possibility of a scientific, rational, or even a clinically meaningful psychiatry. In between these extremes, there are radically different opinions as to the nature and extent of the crisis: “Psychiatry lost its way” Another opinion is that we have lost our way in North American academic psychiatry. Some believed that the wrong path was psychoanalysis with its oversold promise as psychodynamic psychiatry. In the 1970s and 1980s, mainstream academic American psychiatry adopted the DSM (APA 1980) project along with George Engel’s (1977, 1980) biopsychosocial (BPS) model. Outside the academic mainstream, a seeming endless number of new paths were © Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_1
1 Introduction: Prospectus and Leitmotifs
offered through this thicket with revolutionary rhetoric: systems theory and family therapy, social and transcultural psychiatry, community psychiatry, cognitive therapy and its avatars, and of course psychopharmacology and the biological revolution. The rhetoric was as overheated as it was naive. In the 1970s, Salvador Minuchin announced that family therapy would take over psychiatry in 20 years (Malcolm 1978). To use the language of family therapy, these “reframings” or “redefinitions” were not so radical. If you scratch most other kinds of therapists, you will find some version of Freud’s theory or practice of psychoanalysis underneath, either in disguise or in reaction. In this sense, these new paths were not so much revolutions as attempts to bring psychiatry back to its roots. Not a revolution but a rebranding of the field in the Anglo-American world as behavioral psychiatry, family psychiatry, community psychiatry, social and transcultural psychiatry, biological psychiatry, or a psychiatry based on cognitive theory and therapy. In much of Europe, there was phenomenological psychiatry and its aliases or antipsychiatry and its alliance with community and humanistic psychiatry. Now almost forgotten is the Pavlovian psychiatry of the former Soviet Union and the nations under its scientific and social influence. As for the DSM, we do not need to jettison nosology but to improve it, and as for the BPS model, we need more, not less theory. One of us (Di Nicola) has spent much of his career on other paths – child and adolescent psychiatry, social and transcultural psychiatry, community psychiatry, and family psychiatry and relational therapies. Unfortunately, while they are stimulating and intrinsically valuable, opening up space for “orphaned experiences” of children, families, communities, and cultures in mainstream academic psychiatry, these approaches do not provide a complete account of the mind and its relations (that is to say, a psychological theory), nor do they offer a comprehensive model for all of psychiatry (that is to say, a theory of psychiatry). Now, while this may have created fragmentation and even mutual incomprehension among the different practitioners on these new paths, a much more radical alternative has appeared. “Psychiatry as neuroscience, psychiatric illness as brain disorders” This is not a rebranding exercise or a return to psychiatry’s roots but a complete reset, accompanied by a radical departure and a new research paradigm taking, predictably, a new name. In the 1990s, the USA announced the “Decade of the Brain” and what was heretofore alienation in the nineteenth century, psychiatry in most of the twentieth century, and more recently behavioral or mental health, came under the rubric of neuroscience, just as academic psychology morphed from behavioral psychology to cognitive psychology to cognitive neuroscience. The mantra of this new approach is that mental disorders are brain disorders. This group exhorts us to pay more attention to the brain. This approach inspired a dual intellectual temptation for one of us (Stoyanov) who recounts his scientific journey in an Excursus in Part One: “One was the identity theory of mind as a particular form of reductive physicalism and the other was functional MRI (fMRI) as a method to deliver empirical evidence in its support” (See Stoyanov et al. 2012, 2013, 2014). For different reasons, we came to parallel
1.1 Prospectus: “Crisis? What Crisis?” – Psychiatrists on Psychiatry…
conclusions about the limits and false promises of biological reductionism in psychiatry. Besotted by what Raymond Tallis (2011) labeled “Neuromania,” these are the psychiatrists who want to jettison everything we have done in the last two centuries to found what they call a “scientific psychiatry.” (See “Excursus: Slouching Towards an Impoverished Language of Psychiatry”). Think Thomas Insel and the Research Domain Criteria (RDoC) during his tenure at NIMH. The version of this in academic psychology is “evolutionary psychology” – or what Tallis (2011) calls “Darwinitis.” So there we have it – Neuromania and Darwinitis – the Tweedledum and Tweedledee of biological reductionism in psychiatry and psychology today.
Excursus: Slouching Towards an Impoverished Language of Psychiatry The problem with jettisoning the past completely for a new language of psychiatry was articulated clearly by linguist Noam Chomsky (1972) in his critique of BF Skinner’s behavioral encomium, Beyond Freedom and Dignity (Skinner 1971). Briefly, Chomsky argued that when Skinner uses behavioral descriptions, we translate them into the language of the mind, elaborated over the last few centuries (arguably since the Enlightenment). Now, a transitional generation would “understand” behavioral descriptions by referring back to the older language using mental terms and references to the subjective inner life of the mind, yet if Skinner and behaviorism would succeed to the point of dominating psychology and our understanding of human behavior, eventually we would not have this other language that philosopher of mind Jerry Fodor (1975) called “mentalese.” And as a result, we would have an impoverished language of human psychology. In both philosophical and psychological terms, our very experience would become impoverished for lack of naming, elaborating, and sharing our inner mental states. The “alexithymia” that was bemoaned in the psychotherapy literature about a constrictive form of concrete and operational thinking would become a social and cultural phenomenon of “word failure,” that Di Nicola (1997, 2001) described in his review of language and therapy. This constriction is a direct consequence of behavioral and biological reductionism and represents the greatest threat to the theory and practice of psychiatry and why it is in crisis, bordering on collapse.
If the work of Nobelist in Medicine Eric Kandel (2005) is the greatest hope for neuroscience and the mind being understood through the brain, there are also those of us in psychiatry and beyond (among them, noted child psychiatrist and family therapist Maurizio Andolfi, philosopher Jerry Fodor, developmental psychologist Jerome Kagan, and geriatrics researcher Raymond Tallis) who decry the diminishing attention to the mind and its relational aspects along with the misguided biological reductionism of “mind equals brain” and biological evolution as the explanation for the social and cultural aspects of being human.
1 Introduction: Prospectus and Leitmotifs
1.2 L eitmotif I: The Crisis of Psychiatry as a Crisis of Knowledge – Drozdstoj Stoyanov My overall statement is that psychiatry is in a crisis of knowledge (which may well have a counterpart in, or result from, an ontological crisis). The main components of any psychiatric knowledge would consist of taxonomy – terminology and nomenclature – and methods. The first component is projected onto a crisis of identity and the second component onto a crisis of confidence. Psychiatric taxonomy in the post- DSM-III (APA 1980) era has been proven to generate more problems than solutions, both on conceptual and empirical levels. In my view, this is rooted in the mode of “escape” from theoretical foundations of psychiatry, as proposed by logical positivism. Psychiatry has always been inevitably engaged in theoretical debates such as the mind-brain problem and escaping from them into instrumental quantifications of the human narratives was a fatally flawed choice. Those theoretical debates come back to life regardless of whether we clinicians want them or not since they are relevant to our fundamental activities: diagnosis and treatment. As far as methods are concerned, I believe that the persistence of an explanatory gap between nomothetic and ideographic methods has caused complete misunderstanding in the dialogue across disciplines. Each discipline adheres to its epistemic monologue, comprised of a terminology and a methodology of its own. What represents the main problem, in my view, is the issue of translation, that is, the creation of “manuals” to translate data/ information across various disciplinary matrices, so that stable “bridge” or “law- like” connections may be established between them. The take home message of my contribution is that we need to aspire to cognitive pluralism, inter-domain translation, and synergy in order to induce change in psychiatry on a meta-theoretical level and overcome the current crisis. Here, Di Nicola and I have one major territory for dispute – Nagelian laws actually exclude any ontological commitments! Nagelian laws were meant originally as reductive. However, reduction was implied on two levels. One is homogeneous, where the terms and vocabulary of the reduced and reducing theory share more or less the same meaning. In that case, the reduction is essentially instrumental and methodological and
Excursus I: Inter-theoretical Reduction and Nagelian Laws Ernest Nagel (1961) postulated that there exist law-like cognitive structures within and between different scientific matrices, which exist in order to establish bridges to connect notions, explanatory mechanisms, and regularities. This concept has been criticized as being heavily reductionist over the second half of the twentieth century. However, in my view, the plethora of modern psychiatric theories (psychodynamic, behavioral, biological, etc.) which claim to have offered the “ultimate” explanations of mental health and disorder in fact are either utilitarian or authoritarian approaches which can
1.2 Leitmotif I: The Crisis of Psychiatry as a Crisis of Knowledge...
encompass just a small portion of the explanandum, or what needs to be explained. The instrumentalist biopsychosocial model (Engel 1977, 1980) also turned to be inefficient in terms of a better understanding of mental disorder since it is deprived of any conceptual foundation. In order to capture the entire complexity of human being and mental suffering in particular we need all those theoretical models to complement each other in a rather synergistic manner than excluding each other as they do at present. To achieve synergy, we may benefit once again from the Nagelian inter-theoretical model of analytic equivalences in a more or less updated version, where explicit reduction to basic sciences is avoided.
does not concern ontological matters, that is, the matters of whether or not the observed and described phenomenon exists or not (Nagel 1961, 339.) The other is heterogeneous, where different meanings are assigned in the reduced and reducing theory. In that case, ontological reduction applies in order to impose basic explanatory vocabulary and mechanisms on higher order phenomena, by practically eliminating them (which would be the relevant stance of eliminative materialism). That would be the case with the so-called social neuroscience, where most complex social and cultural interactions are reduced to neurochemical and neurophysiological mechanisms. However, when interpreted in the context of the neuroscience-psychiatry dialogue, the reduction will be assumed rather to be homogeneous, since the two groups of disciplines share approximately the same meaning of the employed terminology. For instance, molecular neuroscience and psychiatry share the term “depression” as clinical condition, which means they have conventional agreement about its definition. Excursis II: Identity Theory of Mind Versus Eliminative Materialism We assume that various stances in the mind-brain debate underlie the main diagnostic and therapeutic methods in psychiatry. While biological pharmacotherapy is largely expanded on the basis of eliminative materialist views, psychotherapy is endorsed on an implicit level by the dualism and perhaps, the dual-aspect monism. In fact, the crisis of confidence means that we no longer believe in our clinical evaluation methods, or in our therapeutic ones. This undermines our expert statements and their legal authority as well. I tend to believe that returning to type and token identity theories of mind might be useful. Actually, token identity is far less radical form of physicalism than epiphenomenalism or eliminative materialism for instance. As it has been stated in the seminal papers of Ullin T. Place (2004), identity might be regarded as compositional where components of lower level phenomena are incorporated in the hierarchy of the higher order ones without any ontological claims at elimination (Churchland 1981), instead of de re identity where one phenomenon is overruled by higher level phenomenon.
1 Introduction: Prospectus and Leitmotifs
Excursus III: Utilitarianism as Opposed to Validity The “atheoretic” utilitarian classifications led to various issues with validity and therefore to a crisis of professional identity. In their influential paper Kandel and Jablensky (2003) argue that validity has been replaced with utility in psychiatry. In this view, further elaborated by Zachar and Jablensky (2015) and Jablensky (2016), there are missing natural boundaries, anchored in neurobiology to distinguish different mental disorders, which is essential for the crisis in psychiatry. The crisis of identity entails such highly controversial queries as, “Are panic disorders any more psychiatric diagnosis or maybe they belong to the domain of clinical psychology?” or, “Is Alzheimer disease a psychiatric diagnosis or it is the subject of neurology?” In effect, the penultimate query raised at psychiatry from an identity perspective, is “Is psychiatry a legitimate medical discipline or an artifact of neurology?” Parnas and Henriksen (2016) address the problem of “phenomenological continuity” in psychiatric diagnosis. One study (Frederiksen et al. 2016) has compared the changes in psychiatric diagnoses in leading academic departments under the different updates of the conventional classifications. It turned out that interdepartmental heterogeneity and variability of diagnoses and the internal department homogeneity have not been improved over more than 30 years, from ICD-9 to ICD-10. This means that conventional classifications do not achieve the purpose they are designated to, that is, unification and harmonization of diagnostic standards.
Interlude Those who have handled sciences have been either men of experiment or men of dogmas. The men of experiment are like the ant; they only collect and use; the reasoners resemble spiders, who make cobwebs out of their own substance. But the bee takes a middle course; it gathers its material from the flowers of the garden and of the field, but transforms and digests it by a power of its own. Not unlike this is the true business of philosophy; for it neither relies solely or chiefly on the powers of the mind, nor does it take the matter which it gathers from natural history and mechanical experiments and lay it up in the memory whole, as it finds it; but lays it up in the understanding altered and digested. Therefore, from a closer and purer league between these two faculties, the experimental and the rational (such as has never yet been made), much may be hoped.—Sir Francis Bacon, Novum Oranum (1620/2000), Book 1, Aphorism 95. If anyone thinks he can exclude philosophy and leave it aside as useless he will be eventually defeated by it in some obscure form or other.—Karl Jaspers, General Psychopathology (1997), p. 770. The invalid assumption that correlation implies cause is probably among the two or three most serious and common errors of human reasoning.—Stephen Jay Gould, The Mismeasure of Man (1996), p. 272. A complete understanding of brain is not synonymous with a full understanding of mind.— Jerome Kagan, An Argument for Mind (2006), p. 257.
1.3 Leitmotif II: The Crisis of Psychiatry Is a Crisis of Being – Vincenzo Di Nicola
1.3 L eitmotif II: The Crisis of Psychiatry Is a Crisis of Being – Vincenzo Di Nicola In an early form of empiricism, Protagoras proclaimed that “Man is the measure of all things.” Plato criticized this as relativism and contemporary versions of Protagoras’ thought include constructivism and phenomenalism. Where Protagoras grounded his epistemology in a subjective sense-based empiricism, Plato appealed to the knowledge of objective and transcendent realities, beyond the individual’s experience and construction. With modernity at war with subjectivity (Postman 1993), science in the guise and pursuit of objectivity has now become the all-purpose yardstick that evolutionary biologist Stephen Jay Gould (1996) characterized as “the mismeasure of man.” Why in human psychology and psychiatry – of all things! – has science become the measure of all things? Why have we reduced our fields of knowledge to scientism and methodolatry, where only what is objectively measurable and quantifiable is valued (Di Nicola 2017)? My colleague Drozdstoj Stoyanov argues that these are epistemological questions, that is to say questions about knowledge, and that the crisis of psychiatry is a crisis of knowledge. While I agree that such issues are pressing and relevant, I believe that they are secondary considerations and that psychiatry is in crisis precisely because it allows itself to be sutured or yoked to its shifting methods. As a result, psychiatry’s identity crisis is not a result of the difficulties of taxonomy and nomenclature but their cause. Our lack of confidence is a lack of clarity about the mission of psychiatry which obscures three critical gaps: (1) the lack of a consensual psychology (or theory of persons); (2) the lack of an organizing consensual model of psychiatry (or theory of psychopathology, that many call the phenomenology of psychiatry); and (3) the lack of a consensual theory of change (as opposed to mere descriptions of change related to a given model). We must avoid suturing or yoking psychiatry to any given subdiscipline but that is not enough. In order to create the coherence in the field that we currently lack, we must first radically rethink how theories are built in our field. That is precisely what psychiatry cannot do and why we need philosophy. Three possibilities for a philosophy of psychiatry will be examined. We can give up trying to create a foundation for psychiatry and dismiss psychiatry’s difficulties as “pseudo-problems” (like Ludwig Wittgenstein 1922, 1953) and simply continue with descriptive projects like the DSM (APA 2013) that NIMH’s former director Thomas Insel (2013) dismissed as a mere “dictionary.” We can argue that foundational theories of the mind are “weak” (like Italian philosopher Gianni Vattimo 1988), meaning that they are doomed to be pluralistic and incomplete, like the vaunted but now much-criticized eclectic biopsychosocial model (propounded by American psychiatrist George Engel 1977, 1980; and criticized by another American academic psychiatrist Nassir Ghaemi 2010). Finally, we can reach for a new foundation for psychiatry based not on what sorts of questions we have the tools to sort out, using computational models, genetics, or neuroscience, but on the very nature of human being. That means
1 Introduction: Prospectus and Leitmotifs
ontology, the study of being, and French philosopher Alain Badiou (2005, 2009a, 2009b) offers just such a foundation for psychiatry, with a theory of the subject and the nature of being, and with the Event, a theory of change. As distinguished anthropologist Clifford Geertz (2010) affirmed, the proper study of humankind is still humanity. Psychiatry itself must now be measured by that task. By re-visioning phenomenology, psychiatry can turn again to being as the measure of humanity, not merely behavior, cognition, or emotion, and neither like a computer nor a neural network genetically wired by evolution, but in its full complement of human qualities situated historically and culturally.
Excursus I: Disciplines and Subdisciplines Following his philosophical mentor Louis Althusser, French philosopher Alain Badiou acknowledged that there are general and regional theories of knowledge. Based on this, Badiou (2008) argues that philosophy as a general theory must be separated from its “conditions” or truth procedures. Problems arise when philosophy as a general theory becomes “sutured” – we could say “yoked” – to one of its conditions and philosophy cannot be reduced to say, philosophy of science or philosophy of mind. Nobel Laureate in Medicine, Eric Kandel (2005) similarly argues that there are scientific disciplines and subdisciplines whose boundaries and definitions change based on the research problem at hand. Applying this to our field, psychiatry as a discipline cannot be sutured or yoked to any given subdiscipline. The effort to choose among its subdisciplines and impose one or another of them as the dominant model of the field is both the cause of its identity crisis and the result of it because that project is doomed to failure. Endlessly casting about for the equivalent of physics’ “standard model” is what generates psychiatry’s identity crisis, not the limitations of its methods. And like psychology, psychiatry has veered between theoretical models (what Francis Bacon in 1620 called “dogmas”) and methods of inquiry (Bacon’s “experiments”; see Bacon 2000). Theoretical models have the quality of addressing explanations and representations of the mind and may speak to questions of existence and meaning, while methods of inquiry address ways of knowing, including the reliability of observations. These positions may be translated into issues of validity and reliability or of truth and knowledge. But beyond these issues of accurate and valid representations, deeper questions emerge. Once we get to valid representations of human being, ontological questions appear. What is a person? For example, whether behaviorism is reliable and valid, does it address what is important about humans? Does cognitive science do that? In selecting language or consciousness as quintessential human qualities and subjects of inquiry, do we construct a proper psychology, a science of persons?
1.3 Leitmotif II: The Crisis of Psychiatry Is a Crisis of Being – Vincenzo Di Nicola
Excursus II: Psychiatry’s Triad of Critical Gaps Psychiatry is in crisis because of a triad of critical gaps: 1. First of all, the discipline of psychiatry does not have a consensual science of persons that is not sutured to one view of psychology or one of the subdisciplines of psychiatry. 2. Secondly, psychiatry does not have a consensual general theory of clinical psychiatry or psychopathology beyond descriptive nosographies, such as the APA’s DSM (1980, 2013) or the WHO’s ICD (1992, 1993). 3. And thirdly, psychiatry does not have a general theory of change as opposed to descriptions of change that are sutured to one or another approach (e.g., psychoanalytic, behavioral, relational, genetic/ neuroscientific). To state this more broadly, any helping profession, any approach to human problems, needs to address three things: • How people function (normal psychology – cognitive scientist Steven Pinker (1997) calls it “how the mind works,” but I would not limit it to “mind,” minimally we need to address mind, brain, behavior, and relations – these four domains are not reducible one to the other; philosophically we can ask what is a person or what is subject? One of Pinker’s critics, philosopher Jerry Fodor (2000), wrote a rejoinder to Pinker called, The Mind Doesn’t Work That Way. • How problems arise (a theory of psychiatry beyond clinical descriptions or “phenomenology,” as it has come to be known in psychiatry; cf. McHugh and Slavney 1998). • What are the conditions of change (including what is change and how does novelty arise in human experience? Badiou 2005, 2009a). In light of psychiatry’s gaps and needs, Badiou offers three profound things to psychiatry: 1. First, his theory of how philosophy works, with its conditions and truth procedures, clarifies what is proper to psychiatry and what are its subdisciplines (Badiou 2008). 2. Second, Badiou (2009b) offers a theory of the subject. 3. Third, Badiou (2005, 2009a) offers a theory of change based on the Event. In Badiou’s work, the latter two issues are connected, a theory of the subject and of change. In my reading of Badiou, the three conditions for an event are: to encounter an event, to name it, and to be faithful to it. The subject emerges through the event. By naming it and maintaining fidelity to the event, the subject emerges as a subject to its truth. Simply “being there,” as subjective phenomenology would have it, is not enough.
1 Introduction: Prospectus and Leitmotifs
Excursus III: The Search for a New Theory The philosopher’s treatment of a question is like the treatment of an illness. – Ludwig Wittgenstein (1953, p. 91). For renewal in psychiatry based on a theory of being (ontology), we must first radically rethink how theories are built in our field. There are three possibilities: 1. “Wittgenstein’s Ladder.” We can give up trying to create a foundation for psychiatry and dismiss psychiatry’s difficulties as “pseudo-problems” and simply continue with descriptive projects like the DSM that NIMH’s Thomas Insel (2013) dismissed as “at best a dictionary, creating a set of labels and defining each.” Ludwig Wittgenstein dismissed metaphysical puzzles including the question of being as pseudo-problems. This is why Badiou (2011) calls him an anti-philosopher. Rather than building a systematic philosophical foundation, Wittgenstein (1922) wanted to show that metaphysical notions are like a ladder which we use to scramble up and then discard. In a famous image, the task of philosophy is “To show the fly the way out of the fly-bottle” (Wittgenstein, 1953). Language and tradition create traps for us and philosophy’s task is to climb the ladder up out of our predicament or liberate the fly from its trap. 2. “Vattimo’s Verwendung – Convalescence.” We can argue that foundational theories of the mind are “weak,” meaning that they are doomed to be pluralistic and incomplete, like psychiatry’s vaunted but now muchcriticized eclectic biopsychosocial model (Engel 1977, 1980). Gianni Vattimo’s (1988) notion of “weak thought” argues that we cannot master or overcome metaphysics and the best that can be done is to resign ourselves to tradition and the history of metaphysical questions albeit selectively to heal ourselves of it – a kind of convalescence from unresolvable puzzles, like treating a malady that ails us. Both Wittgenstein and Vattimo are anti-foundational thinkers who want to rid us of metaphysics. Wittgenstein wants to eliminate metaphysics altogether, while Vattimo wants to show that the elimination of metaphysics will only lead to another foundation; hence, he wants to engage it through “weak thought,” with selective readings, distorting or twisting the intentions of metaphysical texts in order to undergo a “convalescence.” 3. “Badiou’s Scythe.” Finally, we can reach for a new foundation for psychiatry based not on what sorts of questions we have the tools to sort out with but on the very nature of human being. That means ontology, the study of being, and Badiou offers just such a foundation for psychiatry, with a theory of the subject (Badiou 2009b), the nature of being, and with the Event, a theory of change (Badiou 2005, 2009a; Badiou and Tarby 2013). In separating psychiatry from its subdisciplines with what I have dubbed Badiou’s scythe (Di Nicola, 2012), we can free psychiatry to adjudicate among the many methods, models, and subdisciplines what is true and useful for its clinical mission of diagnosis and treatment in seeking healing solutions.
All three philosophical solutions have in common setting out the conditions and the limits of epistemology and of being, but their projects are very different. Wittgenstein and Vattimo want to rid us of metaphysics (they are anti-foundational, hence anti-philosophers in Badiou’s sense), while Badiou wants to recover metaphysics for philosophy (he is a systematic, foundational philosopher). Doing so restores philosophy as “the queen of sciences” and thus in a position to speak to psychiatry’s critical gaps and theoretical needs.
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Engel, G. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, 535–544. Fodor, J. (2000). The mind doesn’t work that way: The scope and limits of computational psychology. Cambridge, MA: MIT Press. Fodor, J. A. (1975). The language of thought. New York: Thomas Y. Crowell Press. Frederiksen, J. E. N., Jessen, K., Sæbye, D., & Parnas, J. (2016). Variability in clinical diagnoses during the ICD-8 and ICD-10 era. Social Psychiatry and Psychiatric Epidemiology, 51(9), 1293–1299. Geertz, C. (2010). Life among the anthros and other essays (ed. with an introduction by Fred Inglis). Princeton: Princeton University Press. Ghaemi, S. N. (2010). The rise and fall of the biopsychosocial model: Reconciling art and science in psychiatry. Baltimore: The John Hopkins University Press. Gould, S. J. (1996). The mismeasure of man, revised & expanded edition. New & London: W.W. Norton & Co. Guze, S. (1992). Why psychiatry is a branch of medicine. Oxford: Oxford University Press. Insel, T. (2013). Transforming diagnosis. National Institute of Mental Health. Online post, April 29, 2013. https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming- diagnosis.shtml. Accessed 15.10.2017. Insel, T. R., & Landis, S. C. (2013). Twenty-five years of progress: The view from NIMH and NINDS. Neuron, 80(3), 561–567. Jablensky, A. (2016). Psychiatric classifications: validity and utility. World Psychiatry, 15(1), 26–31. Jaspers, K. (1997). General psychopathology, Vols. I and II (trans: J. Hoenig and Marian W. Hamilton, with a new forward by Paul R. McHugh, M.D.) Baltimore & London: The Johns Hopkins University Press. (Original published in German in 1913). Kagan, J. (2006). An argument for mind. New Haven: Yale University Press. Kandel, E. R. (2005). Psychiatry, psychoanalysis, and the new biology of mind. Washington, D.C.: American Psychiatric Publishing. Kendell, R., & Jablensky, A. (2003). Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry, 160(1), 4–12. Kleinman, A. (1991). Rethinking psychiatry: From cultural category to personal experience. New York: Free Press. Kleinman, A. (2012). Editorial—Rebalancing academic psychiatry: Why it needs to happen –and soon. British Journal of Psychiatry, 201, 421–422. Malcolm, J (1978). A reporter at large: The one-way mirror. The New Yorker, May 15, 39–114. McHugh, P. R., & Slavney, P. R. (1998). The perspectives of psychiatry (2nd ed.). Baltimore: The Johns Hopkins University Press. Nagel, E. (1961). The structure of science: Problems in the logic of scientific explanation. New York: Harcourt, Brace, World. Parnas, J., & Henriksen, M. G. (2016). Epistemological error and the illusion of phenomenological continuity. World Psychiatry, 15, 126–127. Pinker, S. (1997). How the mind works. New York & London: W.W. Norton & Co. Place, U. T. (2004). Identifying the mind. Selected papers of U.T. place (Ed. by George Graham and Elizabeth R. Valentine). Oxford: Oxford University Press. Postman, N. (1993). Technopoly: The surrender of culture to technology. New York: Vintage Books/Random House. Schopenhauer, A. (1851). Parerga und Paralipomena. In Kleine Philosophische Schriften (Vol. 2, Section: 76). Berlin: A. W. Hayn. Skinner, B. F. (1957). Verbal behavior. New York: Appleton-Century-Crofts. Skinner, B. F. (1971). Beyond freedom and dignity. New York: Knopf. Stoyanov, D., Machamer, P., & Schaffner, K. F. (2013). In quest for scientific psychiatry: Toward bridging the explanatory gap. Philosophy, Psychiatry, & Psychology, 20(3), 261–273. Stoyanov, D., Machamer, P. K., & Schaffner, K. F. (2012). Rendering clinical psychology an evidence-based scientific discipline: A case study. Journal of Evaluation in Clinical Practice, 18(1), 149–154.
Stoyanov, D. S., Borgwardt, S. J., & Varga, S. (2014). Translational validity across neuroscience and psychiatry. In P. Zachar, D. S. Stoyanov, M. Aragona, & A. Jablensky (Eds.), Alternative perspectives on psychiatric classification (pp. 128–146). Oxford, UK: Oxford University Press. Tallis, R. (2011). Aping mankind: Neuromania, darwinitis and the misrepresentations of humanity. Durham: Acumen. Vattimo, G. (1988). The ends of modernity (trans: Jon R. Snyder). Baltimore: The Johns Hopkins University Press. Wittgenstein, L. (1922). Tractatus Logico-Philosophicus (trans: C.K. Ogden, introduction by Bertrand Russell). London: Routledge & Kegan Paul. Wittgenstein, L. (1953). Philosophical investigations (trans: G.E.M. Anscombe). London: MacMillan Publishing. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines (p. 1992). Geneva: World Health Organization. World Health Organization. (1993). The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva: World Health Organization. Zachar, P., & Jablensky, A. (2015). Introduction: The concept of validation in psychiatry and psychology (pp. 3-46). In P. Zachar, D. S. Stoyanov, M. Aragona, & A. Jablensky (Eds.), Alternative perspectives on psychiatric validation: DSM, ICD, RDoC, and beyond. Oxford, UK: Oxford University Press.
Psychiatry in Crisis As a Medical Discipline Drozdstoj Stoyanov
[A] perfect correlation is identity. Two events that always occur together at the same time in the same place, without any temporal or spatial differentiation at all, are not two events but the same event. The mind-body correlations as formulated at present, do not admit of consideration as spatial correlation, so they reduce to matters of simple correlation in time. The need for identification is no less urgent in this case. —Edwin G. Boring, The Physical Dimensions of Consciousness (1933)
Reference Boring, E. G. (1933). The physical dimensions of consciousness. New York: Century.
Methods for Clinical Evaluation in Psychiatry: Quantitative vs. Qualitative Approaches
Overview: A Critical Reappraisal My overall statement is that psychiatry is in a crisis of knowledge (which may well have a counterpart in, or result from, an ontological crisis). The main components of any psychiatric knowledge would consist of taxonomy – terminology and nomenclature – and methods. The first component is projected onto a crisis of identity and the second component onto a crisis of confidence. Psychiatric taxonomy in the post- DSM-III (APA 1980) era has been proven to generate more problems than solutions, both on conceptual and empirical levels. In my view, this is rooted in the mode of “escape” from theoretical foundations of psychiatry, as proposed by logical positivism. Psychiatry has always been inevitably engaged in theoretical debates such as the mind-brain problem, and escaping from them into instrumental quantifications of the human narratives was a fatally flawed choice. Those theoretical debates come back to life regardless of whether we clinicians want them or not since they are relevant to our fundamental activities: diagnosis and treatment. As far as methods are concerned, I believe that the persistence of an explanatory gap between nomothetic and ideographic methods has caused complete misunderstanding in the dialogue across disciplines. Each discipline adheres to its epistemic monologue, comprised of a terminology and a methodology of its own. What represents the main problem, in my view, is the issue of translation, i.e., the creation of “manuals” to translate data/information across various disciplinary matrices, so that stable “bridge” or “law-like” connections may be established between them. The take-home message of my contribution is that we need to aspire to cognitive pluralism, inter-domain translation, and synergy in order to induce change in psychiatry on a meta-theoretical level and overcome the current crisis.
© Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_2
2 Methods for Clinical Evaluation in Psychiatry: Quantitative…
2.1 Introduction Psychiatry was conceived historically as a medical project in the early 1800s. Before that, it was simply an applied modus of diversity restriction imposed by societal and religious institutions. The constitution of psychiatry as a medical discipline, therefore its legitimating, was entailed from its consolidation with neurology, based on Wilhelm Griesinger’s assumption that mental disorders are disorders of the brain (Griesinger 1882). That assumption, however, was proven to be false over the next century. Its critical reappraisal underpinned both the Kraepelinian non-etiological approach to nosological classifications and phenomenological psychopathology as conceived by Karl Jaspers. There were few theoretical efforts over the twentieth century grounded on etiological concepts, such as Freud’s attempt with psychoanalysis, however with controversial implementation. Psychoanalysis and subsequent trends were influenced to a great extent by transactionist dualism. It presumes mental and physical worlds as separate ontological entities, which interact in some more or less sophisticated manner, on either the level of brain structure and functions or on the level of quantum mechanics (Popper and Eccles 1977; Georgiev 2011). Psychiatry has been considered a highly problematic discipline since its very establishment. In fact, it is a rather young discipline compared to medicine. Medicine as a systematic scientific effort has been conceived in ancient Greece in the third century BC, and psychology is usually attributed to the work of Christian Wolff in the late eighteenth century. In 1808, Johann Christian Reil coined the term “psychiatry.” The very etymology of this term suggests the curative (iatros, “healer,” and psyche, “soul or mind” in the modern sense, from the Greek) nature of psychiatry, not necessarily associated with scientific causal explanations. To a great degree, even contemporary psychiatry remains basically a “healing practice” that has not yet developed a normative disciplinary structure and language. Thus, it remains dissociated from many other areas of human knowledge (Machamer and Stoyanov 2009). Furthermore, since the definition of “psychiatry” by Johann Christian Reil in 1808, the field has neither identified a core subject nor one that is substantially different from other mdthods of human knowledge specifically inherent to psychiatry. Psychiatry still studies subjective experience and behavior either in terms of bio- medicine or in terms of psychological assessment of narratives. There is growing amount of evidence which exposes caveats in both, preventing from achieving sufficient coherence and consistence of the data acquired with different clinical assessment tools. The crucial issue here consists in the implications of mind-brain problem and the validation of psychiatric taxonomies. Let us attempt here to reconstruct the co-evolution of psychiatry with its neighboring disciplines of human knowledge: psychology as a representative of what we now constitute as the area of humanities and neurology as part of a more or less robust field of medical sciences. The term neurology was coined by the outstanding Renaissance physician Thomas Willis. The original term and conceptual structure
of neurology have remained to a great extent intact since then. There are three main pillars to identify this discipline: • General theoretical framework that captures basically diseases caused by “brain dysfunction.” By all means it implies extensive and comprehensive knowledge of the same object in its normal functioning and is further developed in the seminal work of Santiago Ramón-y-Cajal with his “neuronal theory,” which remains fundamentally unaltered this far. These premises underpin consensual theory of the brain structure and function both in norm and pathology and set the background for the axiomatic stability of neurology. • General theory of change. This was the famous program article to shape modern neuroscience published by Francis Crick (1979) which defined neuroscience as broader multi-disciplinary effort to “explain the human brain from genes and molecules to complex forms of behavior,” thereby bravely intruding the weak field of mental health by proposing a strong reductionist neurobiological theory of mind. At the same time, Crick’s program was a way to expand and shift the framework of neurology and neuroscience to a novel mainstream of positive enterprise. Essentially the ongoing major international Human Brain Project might be regarded as an extension of the same rationale as conceived by Willis, Cajal, and Crick. Psychology was introduced as an academic discipline in the late nineteenth century with the contributions of Wilhelm Wundt in Germany and William James in the USA, among others. It was missing the kind of straightforward consensual structure as described in neurology from the very beginning. Some theorists, notably Wundt, and the so-called atomists understood human psyche as divided into discrete entities, like perceptions, memory, thinking, and so forth. Thus, they claimed it might be captured and explored experimentally. Their opponents, the Gestalt theorists, however, claimed that human consciousness exists only in its totality (or gestalt) and should be explained in terms of relationships between the figure (object) and background (context). Phenomenologists in the meantime took another, completely independent position. They came to believe that human subjectivity is not liable to any experimental exploration and scientific explanation but can only be empathically understood. Most of those controversies were actually inherited or adopted almost automatically by psychiatry. Psychologists are aware probably of the limitations of their methods and launched an effort to produce a more systematic structure of knowledge in the mid-twentieth century, by validating new and ostensibly nomothetic methods and models of evaluation such as the personality theory of Hans Eysenck. There were highlights in the attempt to bring together disparate models such as the psychobiological theory of personality as developed in the contributions of Robert Cloninger. Yet none of those models transcend to the desired level of consensus, and therefore psychiatry and psychology are unable to meet the conditions met by neurology and neuroscience and introduced in the preceding section by Di Nicola, namely:
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• A consensual theory of the person (as the main object of normal psychology), besides some recent advances, yet too complex to reach broader audience (Cassell and Stoyanov 2016). • A consensual theory of mental disorder beyond descriptive psychopathology • A consensual theory of change
2.2 Q uantitative Decomposition of Narratives vs. Qualitative Approach Narrative-based clinical assessment is either derived from professional (observer- based interviews) and self-evaluating (patient) reports. Those might be qualitative, phenomenological, and quantitative. The initial material to inform the construction of the clinical tools was in fact comprised of qualitative data, based on patient reports and diagnostic interviews from the 1930s, taken in a psychodynamic manner. Those reports and actually the most common responses were then “transcribed” into structured self-assessment scales or inventories, e.g., MMPI (McKinley and Hathaway, 1943), BDI (Beck, 1967), Zung (1965), CSRS (Von Zerssen, 1986), and others. Similar to the inventories as employed in clinical psychology assessment, psychiatry has developed interviews, basically representing observer-based rating scales. What happened over the next 40 years is that the validation approach in mental health disciplines followed a pattern from scale into scale. In other words, this means that each clinical tool (both interviews and self-assessment tests) is validated against similar measures, composed of statements and questions derived in various ways from primary sources. At the end of the day, all methods in psychopathology are self-referential and tautologous, describing the same content, without clear external or independent validator.
2.2.1 Clinical Assessment Methods As it has been highlighted in our research (Stoyanov et al. 2012), the original or primary source of clinical information lies within the domain of narrative. That narrative is further fragmented in order to compose items and arrange them into statistically susceptible units of analysis. Yet the diagnosis on all levels from clinical symptoms and signs to nosology remains a matter of subjective judgment, placed in the “space of reasons.” Further, Bortolotti and Broome (2009) specifically emphasize that: … the main object of study needs to be the person. The normal and the abnormal themselves are normatively defined and are not properties of the brain.
2.2 Quantitative Decomposition of Narratives vs. Qualitative Approach
In this reference, by “normativity” the authors imply social and cultural norms. Indeed, we do not presume certain behavior or experience abnormal because of genetic or neuroimaging scan. We presume it based on our inter-subjective background as located in the domain of social, ethnical, cultural, religious, educational, and other values. Biological data in that regard are taken as adjacent and supplementary and are not considered to have any diagnostic implication. This has been the main reason behind the radical project for Research Domain Criteria (RDoC) of the National Institute of Mental Health as proclaimed by Insel et al. (2010). To summarize this framework, it aspires at complete medicalization of psychiatric knowledge by reconstructing its bottom-up causation. It has been assumed by all means as return to reductive models such as eliminative materialism and epiphenomenalism. There are a number of issues standing in the trajectory of RDoC which will be presented further down (see Sect. 1.2.4).
2.2.2 L egal Arguments for Aspirations at More Robust Normative Criteria Besides the effort to promote RDoC model, the mainstream psychiatric clinical and research methods are still believed to be structured interviews and self-assessment tests which happen to be validated each against the other. For instance, the most popular Montgomery-Asberg Depression Rating Scale (actual and observer-based instrument) is typically validated against clinical self-evaluation tools such as Beck Depression Inventory and vice versa. There is employed the so-called informant data in the case formulation which is presumed to be objective; however, it also represents certain personal narrative, just from a different perspective. In all cases the collected data remains in the field of inter-subjectivity, which corresponds to the McDowellian “space of reasons” (McDowell 1995). On the one hand, this seems to be a more humanistic, conceptually different kind of understanding of mental disorder. On the other hand, however, it undermines the content validity of psychiatric decisions and raises ethical concerns about some critical aspects of mental health expertise in the social, economic, and legal procedures. One major legal consequence which is entailed from the mental health expertise is mental incapacity in its different forms: criminal and social. Mental incapacity is linked directly to what we understand as responsibility (Hardcastle 2015) and underpins a significant trend in philosophy of science recognized as Neurolaw. The main subject of Neurolaw is the way in which evidence from neuroscience may be incorporated as a basis for judicial statements and inferences in court proceedings as well as its implementation in legislative acts. It is very complex to bring together subjective (self) reports and legal responsibility given that any form of subjectivity is par excellence liable to abuse.
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2.2.3 Biomarkers and Validity What has been regarded as highly problematic in this sense is the lack of external validators in the sense of Robins and Guze (1970). It refers particularly to the discovery and replication of external-to-the-narrative biomarkers that may sustain the claim for mental disorders as natural kinds and thereby as objects for study and intervention in a traditional biomedical framework. To date, no such stable biomarkers have been identified to be incorporated into psychiatric diagnosis. This leads us to the issues of reification and translation. Reification as defined by Karl Marx and further developed by Lukács and the Frankfurt School is a highly controversial notion (Marková 2018). In our perspective, however it is inextricable from the aspiration at translation across domains of knowledge and existing paradigms. In both the original prediction by Robins and Guze (1970) and the contemporary programs for translation, which supervene conceptually over the same intellectual platform (Insel et al. 2010), the central problem is to formulate a methodological tool to translate from neuroscience to psychopathology and vice versa. Nonetheless, in my view, this is only one of the facets of translation. It goes by implication that any model of translation claims to consider the possibility to embrace the entire biopsychosocial system of mental illness. However, this claim appears to be vacuous and counter-productive. One of the reasons the biopsychosocial approach proved to be ineffective is its adherence to a positivist stance. It is derived from the general empiricism of the Enlightenment and frequently associated with Auguste Comte (1890): True knowledge derives only from perceptual experience: truth and knowing comes only from objective observation, experiment and analyses.
Nonetheless, it should incorporate data from neuroscience by all means. Those data in fact represent what might be assumed as reification in the sense of diagnostic reification (Stoyanov 2020).
2.2.4 Data Translation and Reification of Diagnosis In my view, the issue of translation is far more complex and has various meta- empirical, linguistic, and methodological dimensions. Those dimensions actually constitute the meta-structure of and interdisciplinary nomothetic network or matrix and are summarized below: • Meta-linguistic compatibility (i.e., of different terminology and methods) • Axiomatic stability (i.e., existing uniform laws and criteria for their validity) • Integrative taxonomy (i.e., universal classification and nomenclature) Let us now attempt to dissect status of translation and the reification of diagnosis in medicine as compared to psychiatry as an atypical case of a medical discipline.
2.3 Reconstruction of the Methodological Discrepancies Based on an Exemplary Case…
2.3 R econstruction of the Methodological Discrepancies Based on an Exemplary Case: Major Depressive Disorder 2.3.1 The Typical Case: Myocardial Infarction The exploration of myocardial infarction as clinical nosology entails detailed translation across four bottom-up disciplinary domains (Stoyanov et al. 2013): • Biochemistry. The hypostasis of infarction is reflected in biochemical mechanisms of hypoxia and ischemia and results in necrosis. The damaged cells are released into the circulation proteins, which constitute their essential and functional metabolism: creatinine-phosphokinase MB fraction and troponin, respectively. Those substances are registered to be elevated in the acute phase of infarction, and their detection is assumed to constitute one significant biomarker of disease (with up to 78% specificity). However, it should be emphasized that those biomarkers themselves do not belong to the realm of clinical cardiology per se but are rather translated for use in clinical cardiology from biochemistry. Without translation to clinical symptoms and observations, they are meaningless and may be regarded as indirect measures of various processes in a living organism. The translation between the two disciplines here is a cognitive inference of this kind: Elevated troponin is a reliable marker of infarction since it is detected in statistically significant number of patients and is valid as it reflects the mechanism of disorder.
To put it in the framework of reification, it is troponin that reifies the diagnosis, and it is the clinical hypothesis that reifies the troponin as a biomarker. Therefore, translation across disciplinary networks and reification of the underlying cognitive structures exist together and enhance each other. • Physiology. The other basic domain involved in this exemplary case is physiology and more specifically electrophysiology. On the ECG record, there is an observed deviation known as elevation of the ST segment. Once again, taken as a sole measure, it has little sense as it is just a curve on the ECG. It requires specialized knowledge in electrophysiology to interpret it as a marker of infarction in the context of patient’s complaints. Furthermore, it needs to be translated to the biochemical measures as mentioned above and to the radiological investigation as stated below. • Radiology. Radiological scans include the X-ray contrast-based technique of coronary angiography. It provides real-time images of where and to what extent are the coronary vessels obstructed. In this sense angiography reflects on the primary cause of infarction: the obstructed blood and oxygen supply of the heart. Radiology is not cardiology from an epistemological point of view either. Yet the data acquired inside this domain are successfully translated to reify the ECG and biochemical data as well as the clinical hypothesis (Fig. 2.1).
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Fig. 2.1 Circular causal model of medical knowledge
Currently a circular process of translation is implemented. Radiography gives information about the effects of the cause, biochemistry and electrophysiology provide correlates of the mechanisms which conduct this cause to a disorder of homeostasis, and altogether these measures reify the diagnosis which in turn motivates therapeutic intervention (see Fig. 2.1). The latter is also angiography based in most cases as it involves restitution of the normal coronary blood flow by implantation of coronary stent. In ordinary cases, not all medical settings have clinical laboratory or angiography facilities at their disposal. This is why the simplest and minimum resource methods available, like ECG, are employed to perform diagnostic assessment. What makes such an approach feasible is the “triangulation” of knowledge as acquired within discrete disciplinary matrices as described above (see Fig. 2.2) (Stoyanov et al. 2017). In this model, diagnosis on any level of evaluation is sustained by an integrative nomothetic network of translational connections to other disciplines, whereby it is reified in terms of biological measures, which penetrate into the very substrate of disease. The procedures of translation are maintained for most medical nosology by means of continuous medical training and professional guidelines.
2.3.2 Atypical Case: Depression If we take it for granted that the above case represents typical example for traditional bio-medicine, then the case of psychiatric diagnosis is rather atypical or extraordinary. In an effort to escape from both psychoanalysis and neuroscience
2.3 Reconstruction of the Methodological Discrepancies Based on an Exemplary Case…
CLINICAL DOMAIN: Subjective Reports of the patient and professional observation
DIAGNOSIS: Syndrome Nosology
BASIC DOMAIN: Biochemistry
BASIC DOMAIN: Electrophysiology
Fig. 2.2 Triangulation of knowledge in medical diagnosis
which were considered to be a theoretical and controversial burden, psychiatry took the route of logical positivism as influenced by Hempel and construed “atheoretical” instrumental classifications, beginning with DSM-III in 1980, influenced by the neo-Kraepelininan school of Robins and Guze. Those classifications were based on a de-contextualized quantification of phenomenological narratives (by patients or professionals) and reassembled into various medical categories, based on subjective criteria instead of biomarkers. Several epistemological queries are raised by such an attempt. From the phenomenological point of view, the criteria diagnostic system introduced in DSM is poor in terms of subjective content and prevents a comprehensive assessment of the deep complexity of human narratives. From the point of view of traditional medicine, it is insufficient as well since it replaces validity based on strong biological correlates with pure reliability of the professional reports. Psychiatric observational semi-structured interviews (e.g., SCID, MADRS, HAM-D, and PANSS) were complemented with self-reported psychological measures (e.g., BDI), which were falsely regarded as providing external validity. With the exception of psycho-organic syndromes as discussed elsewhere, the process of translation, reification, and triangulation in clinical assessment is yet far out of reach. All data acquired “externally” to the domain of clinical psychopathology
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are regarded as irrelevant to diagnosis and serve for experimental research only. This refers to all recent and current studies in neuroscience which are supposed to be the subject of translation, such as genetics, immunology, electrophysiology (EEG), and functional MRI, among others. In reality, triangulation is performed within one and the same realm of knowledge, and it is the realm of narrative, either professional (interviews) or patient’s (self-assessment), whereby both converge into the quantitative measures named scales. Scales are usually composed of structured questions/ statements, called items, that require different kinds of item response. The dichotomous scale is a two-category scale that can be answered by yes/true or no/false but gives no information about the subjective frequency or degree of the complaints. The Likert scale, on the other hand, either in the 5-point or 7-point scale [I added this. Agreed], gives the opportunity to express a degree of assent frequency and degree of the complaints. In that way, the subject is able to give an answer about the frequency of the symptom manifestation. Usually, the answers on a Likert scale are summed up, and, through a standardized coefficient, the level of manifestation of a characteristic is evaluated. Although psychological and psychiatric assessment tools (scales) belong nominally to different disciplinary frameworks, they still exert one and the same matrix: the matrix of quantified statistical narratives. There are poor or no investigations of the role of external validator or validity operation. If we take the case of depression, then the translation across disciplines to operationalize diagnostic procedure will appear like this: • Psychiatry. Psychiatry employs a variety of clinical interviews to evaluate depressive disorder. The most common among those are the Montgomery- Asberg Depression Rating Scale (MADRS) and Hamilton Scale for Depression (HAM-D). Those consist of eight to ten items, and the evaluation on each item is applied according to Likert scale. For instance, a score on MADRS over 20 is considered as a measure of mild to moderate depression and a score ranging above 30 an indicator of severe depression. • Clinical psychology. The usual psychological tests (or inventories) that are employed in depression are the Beck and Zung Inventories. In German-speaking countries, the depression scale by Von Zerssen is used to measure treatment outcomes in clinical psychopharmacology trials. The translational procedure here appears like this: If a depression score on MADRS of 25 is corresponding to a Von Zerssen DS score of 22, it is most likely that the patient has major depressive disorder, with a current episode of mild depression.
Of course, in this framework there is no agent of reification, and much confusion is caused by diagnostic mistakes and overestimating or underestimating the clinical data. Any discrepancy/dissociation between the two measurement scores is interpreted as a rule in favor of the rater-based evaluation (the interview); however, there are no official guidelines to regulate this (see Fig. 2.3). As has already been stated, the lack of translation toward other disciplines and reification of psychiatric
2.3 Reconstruction of the Methodological Discrepancies Based on an Exemplary Case…
Fig. 2.3 Triangulation of knowledge in psychiatric diagnosis
diagnosis undermine its normative expert validity in many situations with heavy social, legal, and economic burdens, ranging from the choice of drug and therapeutic monitoring to expertise of mental disability and social incapacity.
2.3.3 Relevance of Reification and Translation to Drug Choice The issues described above further project onto what usually motivates any effort in medicine: drug choice. The clinical pharmacological decisions such as drug choice and therapeutic monitoring are regulated in medicine based on strict criteria which demarcate nosological entities (disease, syndrome, and symptom – see next chapter) and biomarker measures which consistently correspond with the presence (or remission) of clinical manifestations. Table 2.1 summarizes the different approaches to drug choice in medicine with their degree of confidence. The “proof” in this table is assumed reification by means of cross-disciplinary translation with basic science clinical data. Evidence is taken to be accumulated quantitative data from randomized clinical trials (RCTs) and meta-analyses. Common standards are produced by temporary conventions of the professional communities which are typically fragile.
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Table 2.1 Degrees of confidence in psychopharmacology Relevance of the choice High
Proof based Pharmacogenomics Pharmacodynamic monitoring
Individual experience Para-motivation
Although there is an extensive database in psychiatry that claims to provide sound evidence (and perhaps proofs) motivating drug choice, it remains inconsistent, controversial, and with persisting limitations of inference (Bolton 2008). Compared to the progress in other fields of medicine, pharmacological therapy in psychiatry appears to be governed by the “instinct” of the clinician (clinical judgment) and drug choice influenced by subjective factors such as the professional experience of the doctor and/or marketing interventions from industry. This comes at a high cost both for the patients and the health-care system. Of course, there are established post hoc correlations between the different types of clinical tools (interviews and inventories) on the one hand and neuroscience on the other. However, they do not triangulate to converge on the construct of “depression” as a diagnosis. To this end the different kinds of measures represent mere statistical correlations with no reference to the mechanism of disorder and therefore cannot be effectively translated and embodied into diagnostic standards and procedures. Moreover, a fundamental issue arises: what is the subject of reification that procedures of translation may address? Is it the interview/inventory that is reified by means of functional MRI, for example, or is it the opposite? Which method/ dataset is the object and which is the subject of reification? The original assumption would be that the narrative method, comprised of more or less subjective item reports, should be the subject of reification and its object is the biological method. Yet this corresponds to a rather reductionist stance to the problem. Mind-brain dualism promotes another view which is that either both methods reify each other or that there is no room left for any reification at all since the very object of psychiatry happens to be subjective human experience and it is not liable to any kind of reification and/or validation outside the domain of narrative. This leads us to the crucial importance of the mind-brain problem in psychiatry.
References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: American Psychiatric Association. Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New Yotk: Hoeber Medical Division, Harper & Row. Bolton, D. (2008). The epistemology of randomized, controlled trials and application in psychiatry. Philosophy, Psychiatry, & Psychology, 15(2), 159–165. Bortolotti, L., & Broome, M. R. (Eds.). (2009). Psychiatry as cognitive neuroscience: Philosophical perspectives. Oxford: Oxford University Press. Cassell, E., & Stoyanov, D. S. (2016). The person as center of health. In J.E. Mezzich, et al. (Eds.), Person centered psychiatry (pp. 19–34). Berlin/Heidelberg: Springer International Publishing. Compte, A. (1890). Discours sur lensemble du positivisme, 1849, Ed. Paris: Société positive internationale. Crick, F. H. (1979). Thinking about the brain. Scientific American, 241(3), 219–233. Georgiev, D. (2011). A linkage of mind and brain: Sir John Eccles and modern dualistic interactionism. Biomedical Reviews, 22, 81–84. Griesinger, W. (1882). Mental pathology and therapeutics (Vol. 69). New York: W. Wood & Company. Hardcastle, V. G. (2015). Would a neuroscience of violence aid in understanding legal culpability? Cognitive Systems Research, 34, 44–53. Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., & Wang, P. W. (2010). Research Domain Criteria (RDoC): Developing a valid diagnostic framework for research on mental disorders. American Journal of Psychiatry, 167(7), 748–751. Machamer, P., & Stoyanov, D. S. (2009). The scientification project of psychiatry. In IAHPM “Asklepios” (Vol. III(XXII), pp. 51–56). Marková, I. S. (2018). Translational neuroscience and psychiatry: A conceptual analysis. Journal of Evaluation in Clinical Practice, 24(4), 791–796. McDowell, J. (1995). Knowledge and the Internal. Philosophy and Phenomenological Research, 55(4), 877–893. McKinley, J. C., & Hathaway, S. R. (1943). The identification and measurement of the psychoneuroses in medical practice: The Minnesota Multiphasic Personality Inventory. Journal of the American Medical Association, 122(3), 161–167. Popper, K.R., & Eccles, J.C. (1977). The self-conscious mind and the brain (pp. 355–376). In The self and its brain. Berlin/Heidelberg: Springer. Robins, E., & Guze, S. B. (1970). Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry, 126(7), 983–987. Stoyanov, D. (2020). The reification of diagnosis in psychiatry. Neurotox Res, 37, 772–774. Stoyanov, D., Machamer, P. K., & Schaffner, K. F. (2012). Rendering clinical psychology an evidence-based scientific discipline: A case study. Journal of Evaluation in Clinical Practice, 18, 149–154. Stoyanov, D., Machamer, P., & Schaffner, K. F. (2013). In quest for scientific psychiatry: Toward bridging the explanatory gap. Philosophy, Psychiatry, & Psychology, 20(3), 261–273. Stoyanov, D., Kandilarova, S., & Borgwardt, S. (2017). Translational functional neuroimaging in the explanation of depression. Balkan Medical Journal, 34(6), 493–503. Von Zerssen, D. (1986). Clinical Self-Rating Scales (CSRS) of the Munich Psychiatric Information System (PSYCHIS München). Assessment of Depression, 270–303. doi:10.1007/978-3-642-70486-4_25 Zung, W. W. (1965). A self-rating depression scale. Archives of General Psychiatry, 12(1), 63–70.
Psychiatric Nosology Revisited: At the Crossroads of Psychology and Medicine
3.1 Classification and Nomenclature Nosology is a division of medical diagnostics committed to explanation and categorization of nosographic entities (diseases). In theory, diseases in medicine have a clear and distinct etiology, pathogenesis, clinical presentation, and treatment that are targeted at the causes. However, this is not the case in psychiatry, since the etiology and pathogenetic mechanisms of mental disorders are not yet clarified to a sufficient extent to underpin a true medical nosology. Qualification is the attribution of certain quality to a given object of observation. This quality for medicine is regarded “pathology” or “abnormality” as a deviation from referent limits of normal values for biological measures. For instance, values for the concentration of blood glucose over the referent limit of 5.5 mmol/l are considered a pathological condition, called hyperglycemia. The clear and precise definition of the normal (biological) limits and hence of pathology as a deviation from it is regarded as the straight paradigm of medicine. On the contrary, the reverse paradigm erroneously takes the norm as the absence of pathology. There is no precise range of the norm in this paradigm, and, therefore, mental health is regarded as the absence of illness. To put it in other words, we are mentally healthy if we do not hear voices that other people around us cannot hear. Taxonomy is an aggregate of units of observation, in ascendant and descendent hierarchical order and systematized according to selected principles and criteria. An example for taxonomy in biology is phylum, class, order, family, genus, and species. In medicine, clinical taxonomy includes the following ascending order: symptom, syndrome, nosological entity, and disease. However, in contrast to somatic medicine, in psychiatry this hierarchical order is not strictly established and is susceptible to many modifications due to the influence of various theoretical paradigms and cultural and professional traditions. Because of this, psychiatric taxonomy is mainly syndrome-based.
© Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_3
3 Psychiatric Nosology Revisited: At the Crossroads of Psychology and Medicine
Nomenclature refers to the attachment of specific terms to the units of investigation, i.e., coining of a disciplinary language based on observation and investigation of objects existing in reality. Nomenclature in medicine is formulated mainly in Latin, while the terminology of psychiatry is rooted in the ancient Greek. Classification is a taxonomic nomenclature system established for the purposes of statistical analysis of the phenomena and in order to facilitate a uniform language of professionals in different countries. Classification systems in medicine, hence in psychiatry, are composed of nosological entities. Nosological entities and the relevant methods for their exploration are characterized with the criteria of validity, reliability, specificity, and sensitivity.
3.1.1 Basic Operations to Establish Nosology Validity Whenever we introduce some term, method, or assessment system, we should inquire whether it can capture the exact phenomenon it is intended to capture. In other words, when we introduce a term like “depression” or “depressiveness” as a symptom and develop relevant instruments to measure it (such as inventories and clinical interviews), we are supposed to ascertain that it measures specifically depression and not some other related, collateral phenomenon, such as anxiety. When two different assessment tools for depression happen to coincide in their scoring and interpretation, it is regarded as convergent validity, and whenever their results are discrepant, it is considered as divergent or discriminative validity. Divergent validity should generally characterize phenomena which differ each from other and in this respect is supposed to assist differential diagnosis between them. In this context, a valid measure (such as a test) for depression should have convergent validity with another test, established to assess depression and discriminative validity with tests and designed for the assessment of anxiety. In other fields of medicine, external criteria for validity are introduced, such as biological measures. No such criteria have been introduced so far in clinical psychiatry. Specificity corresponds to the extent to which a given method can discriminate one morbid condition from another. In practical terms, it is far out of reach in psychiatric diagnosis. Reliability refers to the extent to which certain measurement is repeated under controlled conditions of the environment. Sensitivity refers to the degree in which certain method can differentiate norm from disease. To summarize, psychiatric diagnosis is characterized by a relatively high level of reliability (repeated, approximately equal clinical assessments from different clinicians) and disastrous validity (lack of commonly used biological markers to reify the diagnosis). Comment by Di Nicola This is coherent with Stoyanov’s schema, but I think this is too narrowly defined. Validity simply means that a thing such as a label reflects
3.1 Classification and Nomenclature
that which it is supposed to represent. Stoyanov signifies “biological markers” as reflecting some kind of reality, whereas I do not, and this is a core disagreement. This is an absolutely crucial difference between us which nonetheless generates a fruitful debate. In my view, these differences are not ultimately realities but reflect what I call “temperament” or the core interests of the investigator, as elaborated in Part III.
3.1.2 C ategorical vs. Dimensional Approaches: Archaeology of the Psychiatric Nosology Discourse 18.104.22.168 The Categorical Approach Over a period of 200 years of existence as a nominally medical discipline, the psychiatric nosological system has entered into several stages of its legitimation. Initially, it has been justified to be a branch of neurology, until the mid-twentieth century, when independent academic structures were set up in medical settings (faculty hospitals, research institutions). In fact, as a medical specialty, neurology has adopted the official doctrine of categorical diagnosis. This approach shaped each and every nosological entity with sharp boundaries, by the application of strict inclusion and exclusion criteria. Some of those criteria were clinical in essence, presenting consensual descriptions of symptoms; others were pathological or etiological, focused on the underlying substrate of disease. Ideally, the clinical and bio- pathological criteria should converge in the process of diagnostic reasoning and inference. However, this did not happen to be the common case in psychiatry, despite the profuse efforts of Kraepelin. There was limited evidence supporting the circular causal model in medicine, integrating etiology, mechanisms, diagnosis, and treatment as illustrated on Fig. 2.1: Circular causal model of medical knowledge in the previous chapter. The few exceptional nosological entities were progressive paralysis and Alzheimer’s disease. Unfortunately, most of the so-called psychosomatic disorders – with causal agents clearly identified in the realm of biological factors – presented with rather typical and then specific in terms of linear dependence “cause-effect” clinical manifestation. This means that the cause has linear dependence with manifestation. This observation has triggered the anti-nosological debate. 22.214.171.124 Anti-nosological Approaches • Unitary Psychosis Concept Two very influential authors of the twentieth century led on it. One was Karl Bonhoeffer who insisted in 1913 that there exists a non-specific type of nervous system reaction to all exogenous and/or organic causal agents. He considered the reaction on the clinical level to be delirium (“sub-acute psycho-organic syndrome”).
3 Psychiatric Nosology Revisited: At the Crossroads of Psychology and Medicine
The other was the outstanding neuropsychiatrist Klaus Konrad, who divided psychosis into two polarities: unitary exogenous psychosis and unitary endogenous psychosis. Konrad moved several steps forward from his predecessors in the debate – Wilhelm Griesinger and Ernst Albrecht von Zeller, who had defined the so-called Einheitspsychose (unitary psychosis) in the pre-Kraepelinian era. Conrad assumed it that there are two further distinctions within the unitary psychosis: the “Copernican and Ptolemaic positions” (Todeva-Radneva et al. 2020). He employed astronomic metaphor to explain this continuum, in which the person is the Earth. One pole is called Copernicus position, which corresponds to depression (in the same way as the Earth is a small and insignificant planet to circle in the orbit of Sun). The other pole is regarded as Ptolomy position where the Earth (the person) is in the center of the universe and everything is revolving around it. It corresponds to paranoid understanding of the world. In Konrad’s view, it is not the adherence to either of those two positions which is morbid itself but the inability to shift between the two (see Fig. 3.1). That ability, in Conrad’s explanation, is mediated by Gestalt mechanisms like Einsicht or Insight. As it is described in the classical Gestalt contribution (Wertheimer), human perception (and experience) is divided into object (figure) and background. The object is prominent in the “field of perception,” and the background exists as a context. Normal cognition operates switching between figure and context. Conrad transfers the same model to psychopathology. If we assume, for instance, that a speakerphone in the room normally should exist in the background as an irrelevant object and a person in front of us should constitute the figure, which is the basic focus of our interest, then the paranoid (Copernican) position is to assign subjective significance with reference to the subject to the irrelevant object (e.g., this speakerphone is specifically installed in order to execute surveillance on my conversations), and what is abnormal about that is that a psychotic person is simply incapable of changing that position. In mental health, we may be suspicious enough to guess that such a device might be used in order to record our conversation; however, we can still return back to the common sense reality as defined by the figure in Gestalt psychology. The psychotic person cannot. Konrad also believed that the etiological factor and pathogenetic mechanisms can initiate biochemical reactions in the organism which are more or
Fig. 3.1 Copernican position and Ptolomaic position
3.1 Classification and Nomenclature
less specific for the particular causal factor. The latter was in line with the contemporary descriptions of transient syndromes by Henry Wieck and “relative noso- specificity” by Georgy Usunoff. • Mental Health Movement Meanwhile, under the heavy influence of psychoanalysis, a significant portion of psychiatry “abducted” away from bio-medicine into what has been conceived broadly as “mental health” since Adolf Meyer coined this term. This was a field of cross-section for psychopathology, psychology, and sociology, aiming to expand the borders of what is perceived and interpreted as “normal,” and narrows the borders of “mental illness” on both conceptual and pragmatic levels by introducing the notion of “reaction.” Mental disorder in this framework has been defined and understood as a “normal” reaction to abnormal events rather than as abnormal sui generis. From the perspective of clinical bio-medicine, both Konrad’s and Meyer’s approaches ended in anti-nosologism and a denial of the Kraepelinian aspiration to introduce the classical medical model in psychiatry. On the other hand, both Meyer and Conrad were inclined to accept the existence of some biological mechanisms underlying the explanation and production of mental disorders. • Phenomenological Psychopathology Phenomenological psychopathology since Karl Jaspers’ has contributed to a similar trend, namely, the replacement of categorical nosology with phenomena or so-called symptoms (subjective reports of the patient) and signs (observation reports of the clinician), in which the two are supposed to bring together more a comprehensive, person-centered, inter-subjective understanding of mental suffering. Unlike Meyer and Conrad, Jaspers did not believe that in the long run, there might be revealed any nosologically specific organic substrate of mental disorder. His anticipation was that there exist certain bio-pathological correlations which do not have deterministic effects on the causation of mental phenomena. In this sense, Jaspersian views might be regarded as closer to psychophysical parallelism as advocated by Wilhelm Wundt a few decades earlier, and parallelism is assumed to be another version of the mind-brain dualism (see previous section). 126.96.36.199 The Dimensional Approach At the same time, experimental psychology developed novel evaluation tools with the prototypical example of the Minnesota Multiphasic Personality Inventory by McKinley and Hathaway. Those tools actually quantified human experience into structured datasets, convenient for statistical processing and analysis. Taken as a synergetic effect, these two historical premises produced the new, dimensional stance in psychiatric nosology. The dimensional approach is driven by the quantitative measurement of pathology. It is assumed under this model that whatever we define as “abnormal” in psychopathology actually exists in mental health, however in different quantities. For example, a healthy person may well be “normally paranoid” toward a challenging
3 Psychiatric Nosology Revisited: At the Crossroads of Psychology and Medicine
environment full of objective hostility and threats for him and is “abnormally paranoid” when being too sensitive about everything and everyone around him and presuming threats even in situations where there is no practical ground to be suspicious. There is a normal dimension of anxiety which keeps the person alerted to any potential threats, and there is transitional area of basic anxiety which is relatively high but might be considered adaptive under some circumstances. Furthermore, there is an overtly elevated level of anxiety which is a clinical measure for anxiety disorders. This approach has been partly adopted in the alternative model of personality disorders for the DSM-5 (APA 2013). What is common in these concepts is their opposition to the traditional categorical medical model. Yet, they are fundamentally incompatible. Anti-nosologism in Conrad’s and Meyer’s perspectives defines continuous transition between normal and abnormal reactions as rather qualitative process. The dimensional approach in clinical psychology since MMPI defines mental disorders and their manifestations as a quantitative, statistical measurements. In order to escape from theoretical embedding, psychiatry has gradually adopted the neo-positivist stance of “instrumental classifications” (Aragona 2013). The rationale behind those systems is to operationalize conventions, guidelines, and criteria which combine in various ways categorical approach with dimensional measures (in DSM-5). In pragmatic terms, this approach was supposed to move psychiatry away from the controversies and debates described so far and to bring it back in under the umbrella of a sound medical specialty. Under the influence of instrumental classifications after 1973, psychiatry has been gradually compromised as a medical discipline, with complex clinical evaluation being substituted by auxiliary medical tools like “checklists” of what has been presumed as “signs” (observational reports) and “symptoms” (subjective self- reports). This process initially took place in Northern America and was then transferred to Europe by the adoption of assessment based on DSM classification as the standard clinical operational procedure at the end of the twentieth century. Two major factors contributed to this process. One was the abandonment of the phenomenological (qualitative) method of evaluation and almost complete reliance on conceptually vacuous categorical criteria for mental disorders, and the other was related to the persistent lack of biomarkers to endorse and reify diagnostic criteria employed in both DSM-IV and ICD-IX. Subsequent revisions of the current taxonomies were fatally flawed. The group led by Josef Parnas delivered evidence that inter-center diagnostic variability and homogeneity within each psychiatric center have been maintained when compared to different periods of ICD standards (Nordgaard et al. 2016). In other words reference academic clinics maintain diagnostic homogeneity inside the center while having inter-center disagreements in all the period from the 1970s to 2010, which corresponds to three revisions of ICD. The inference here is that conventional classifications do not contribute to harmonization of psychiatric diagnostic process.
3.1 Classification and Nomenclature
In terms of an alternative to the two mainstream approaches to psychiatric classifications, there have been proposed some “high umbrella” approaches as listed below. 1. Prototype. This represents a nosological entity which is broader as compared to the typical category by means of primary excluding criteria and limitation of the role of the inclusion criteria. The prototype looks like a summary of a brief exemplar case. The clinician is expected to evaluate the level of overlap between his actually observed case and the prototype (Westen 2012). 2. Cluster diagnosis. This refers to the agglomeration of the existing categories into broader classification units based on a shared or common signs. This approach has been implemented to classify the personality disorders in DSM-IV and DSM-5.
3.1.3 N omothetic vs. Ideographic Classification and Nomenclature According to Immanuel Kant, there exist two kinds of human knowledge. One is focused on noumena which is immanent (persistently located within a particular space-and-time physical configuration) and objective (belongs to the realm of facts, objects which are captured and exist in the empirical world). The other kind of knowledge is related to phenomena and is transcendent (does not belong to a specific space-and-time configuration) and subjective (belongs to the realm of human experiences, does not exist in empirical or perceptual reality). In his original works, Kant did not refer to any particular fields or disciplines which constitute human knowledge. Almost a century later, yet in the same tradition, known as Neo-Kantian, German sociologist Wilhelm Windelband coined the famous dichotomy between ideographic and nomothetic knowledge. Ideographic knowledge is narrative-based, subjective, and inter-subjective transcendent knowledge, and it is represented within such human sciences as psychology, cultural and religious studies, and significant sections of sociology, among others. Ideographic knowledge in practical terms addresses qualitative phenomena and rests upon what phenomenology, after Husserl and Heidegger, names “understanding.” Nomothetic knowledge, on the other hand, is quantitative and is formulated in the quest for natural mechanisms, therefore in a structured taxonomy. These are “explanatory” sciences, such as biology or medicine. The great challenge before psychiatry is its hybrid disciplinary status: I belong to both nomothetic and explanatory domains of science and am still not identified properly with neither of them which actually constitute the so-called explanatory gap (Broome 2008).
3 Psychiatric Nosology Revisited: At the Crossroads of Psychology and Medicine
What happens in clinical reality is that somatic medicine is missing more ideographic (understanding) person-centered perspective of the patient’s narrative and psychiatry is missing the more ideographic, normative, robust approach to the explanation of mental disorders and, therefore, to setting clear boundaries between mental health and disease.
The process of the gradually expanding influence of evidence-based medicine (EBM) has resulted in a marginalization of the attempt to understand in a reflexive manner the person’s narrative, since all “physical” diagnoses were literally reduced to their underlying mechanisms, and human subjectivity has been eliminated from medical procedures of diagnosis and treatment over the last century. This is to a great extent a consequence of the expansion of novel technologies, but it is also due to the methodological claim of positivist knowledge or the Newtonian type of science: invariant, objective, and always replicable. This claim might be seen as a way to escape from the inevitable uncertainty of medical practice or a way to ascertain strict guidelines to prevent medical errors. In both cases, however, medicine has been de-humanized, human suffering being extracted from its complex, multi- variant context as comprised by social, ethical, ethnical, cultural, and religious values. The Person-Centered Medicine (Mezzich et al. 2010; Miles and Mezzich 2011; Cassell and Stoyanov 2016) and the values-based approach (Fulford and Woodbridge 2004) have initiated a debate for a revision of that status quo. On the other hand, the ongoing crisis of psychiatry might result from both the process of de-humanization (and estrangement from the suffering person) and the lack of a scientific effort to establish a coherent interdisciplinary language for translation of data and reification of diagnosis. Reification has certainly contributed to the heavy reductionist trends in bio-medicine. Yet, it cannot be discarded on such ethical grounds from the agenda to achieve normative standards in psychiatry as a medical discipline. It means that ethical considerations of person-centeredness and empathy cannot dismiss the need for robust diagnostic criteria in the biomedical sense when it comes to taking responsibility in fields like forensic psychiatric expertise, expertise of disability and social incapacity, as well as health insurance reimbursement of long-term anti-psychotic drug treatment. Therefore neuroscience methodology remains critical factor in order to sustain certain normative and validation standards of the diagnostic measures whenever it comes to legal, social, and economic responsibility in psychiatry. It has already been stated above that a scientific discipline is sustained by a meta- language capable of connecting properly diverse methods, perspectives, and data across disciplines. In order to abridge the “explanatory gap” as produced by the Neo-Kantian dichotomy, psychiatry needs to move forward to a more robust nomothetic knowledge, and medicine has to drift away from it and embrace a more ideographic and subjective approach to health and disease.
3.2 Post-modern Perspectives
3.2 Post-modern Perspectives There are two more or less limited attempts in this direction as emerged in the late twentieth century. These are the biopsychosocial model and person-centered medicine.
3.2.1 B iopsychosocial Model and Person-Centered Medicine: A Comparison Since the seminal work of George Engel (1977), the BPS model has been considered a way to provide a sound and complex inter- and multi-disciplinary framework for medicine and psychiatry.
3.2.2 The Biopsychosocial (BPS) Model Proposed as a compromise between these two contradictory positions, nomothetic and ideographic, the biopsychosocial (BPS) model of mental disorder was introduced in 1977. It is derived to a great extent from the general systems theory. According to the BPS model, a comprehensive assessment of mental disorder is possible if only and if four systems are taken into account: • Biological, including anatomical, cellular, and biochemical factors • Personality, including motivation, habits, and cognitive characteristics • Social systems, where characteristics of large groups are related to the dynamics of disease and different forms of behavior • Cultural systems, where customs and norms of a particular ethnic, religious, or cultural group are investigated in order to establish their influence over disease The BPS model adopts the view that each person is on one hand constituted by intrinsic systems and, on the other, is a part of greater external systems. Each human is composed of cells, molecules, and organs and at the same time is a member of a family, a community, a culture, a nation, and the world. Every individual has biological, psychological, and social systems interacting with other levels of systems and vice versa: and these other systems continually interact with the individual. Currently, the BPS model is considered to be too eclectic and instrumental. In other words, it lacks the conceptual foundations for an integrative and holistic understanding of the human nature. Many contemporary authors take Person- Centered Medicine as such a foundation.
3 Psychiatric Nosology Revisited: At the Crossroads of Psychology and Medicine
3.2.3 P erson-Centered Medicine (PCM): Conceptual Differences 1. BPS relies on quantitative assessment of patients’ psychological experiences via structured clinical tools and social dimensions via questionnaires. PCM is mainly qualitative and relies on a comprehensive assessment of the person in its unique context. 2. BPS endorses a categorical model of diagnosis. This means that there exist sharp boundaries between normal conditions and disease. PCM endorses dimensional diagnosis, where we acknowledge the existence of borderline transitions between health and disease. For instance, hypochondria may not be regarded as a disease in the narrow sense, yet it may cause discomfort and impact the person’s quality of life. The emphasis of BPS remains on disease in its biological, psychological, and social dimensions. The emphasis in PCM is on the person and in health and disease. Disease is regarded as a component of the person and not vice versa. We explore in the first place personal vulnerability and resilience to disease. For instance, people with dominating extroversion and neuroticism as personality traits are more vulnerable to heart and vascular diseases. 3. PCM is influenced by values-based medicine (Fulford and Woodbridge 2004), which considers the critical role of the patient’s narrative in the respective social, cultural, and spiritual context. For example, organ transplantation and blood transfusion are prohibited among certain specific religious groups. 4. PCM is focused on both the person of the patient and the person of the clinician. In this respect, we pay attention to personal vulnerability to job burn-out in health care as the quality of the health-care delivery is largely dependent on the subjective well-being and satisfaction of the caregivers. 5. Therefore, PCM integrates into the biopsychosocial model and the quantitative and dimensional notion of quality of life along with the qualitative and experiential characteristics of well-being. It adopts the view that neither an evidence-based (biological, quantitative) nor a values-based (qualitative) approach can actually serve as a sole foundation of medical knowledge and practice. Both sources of inquiry can actually “inform” clinical judgments and decision-making, which means they can complement each other in shared decision-making process, with mutual respect and awareness.
The most likely development of psychiatric diagnosis is toward unification of the three approaches, with cluster groups and further dimensional or prototype guidelines for personal assessment. As a result, the existing 100 categories (in ICD) and over 300 (in DSM) are supposed to be reduced to 10 clusters: psychotic, affective, anxiety, organic, psychoactive substance abuse and addiction, personality, and developmental disorders (specific for a lifespan period, e.g., childhood development and old-age disorders). Such broader clusters should be underpinned with robust evidence from molecular biology and neuro-pathophysiology and accompanied by further guidelines to individualize the diagnosis. A person-centered approach is supposed to supervene on those nosological entities. In this regard, the US National Institute of Mental Health has developed the most recent project for classification based on neuroscience evidence – Research Domain Criteria (RDoC) (Insel et al. 2010).
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Association. Aragona, M. (2013). Neopositivism and the DSM psychiatric classification. An epistemological history. Part 1: Theoretical comparison. History of Psychiatry, 24(2), 166–179. Broome, M. R. (2008). Philosophy as the science of value: Neo-Kantianism as a guide to psychiatric interviewing. Philosophy, Psychiatry, & Psychology, 15(2), 107–116. Cassell, E., & Stoyanov, D. S. (2016). The person as center of health. In J.E. Mezzich, et al. (Eds.), Person centered psychiatry (pp. 19–34). Berlin/Heidelberg: Springer International Publishing. Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. Fulford, K. W. M., & Woodbridge, K. (2004). Whose values? A workbook for values-based practice in mental health care. London: Sainsbury Centre for Mental Health. Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., & Wang, P. W. (2010). Research Domain Criteria (RDoC): Developing a valid diagnostic framework for research on mental disorders. American Journal of Psychiatry, 167(7), 748–751. Mezzich, J. E., Salloum, I. M., Cloninger, C. R., Salvador-Carulla, L., Kirmayer, L. J., Banzato, C. E., et al. (2010). Person-centred integrative diagnosis: Conceptual bases and structural model. The Canadian Journal of Psychiatry, 55(11), 701–708. Miles, A., & Mezzich, J. E. (2011). Person-centered medicine: Advancing methods, promoting implementation. International Journal of Person Centered Medicine, 1(3), 423–428. Nordgaard, J., Jessen, K., Sæbye, D., & Parnas, J. (2016). Variability in clinical diagnoses during the ICD-8 and ICD-10 era. Social Psychiatry and Psychiatric Epidemiology, 51(9), 1293–1299. Todeva-Radneva, A., Paunova, R., Kandilarova, S., & Stoyanov, D.S. (2020). The value of neuroimaging techniques in the translation and transdiagnostic validation of psychiatric diagnoses selective review. Current Topics in Medicinal Chemistry, 20(7), 540–553. Westen, D. (2012). Prototype diagnosis of psychiatric syndromes. World Psychiatry, 11(1), 16–21.
Psychiatry and Neuroscience: At the Interface
4.1 H ow to Incorporate Scientific Data from Neuroscience Without Turning Psychiatry into an Applied Branch of Neurology This section will review the interactions of the mind-brain problem with the paradigms formation in psychiatry and the way in which it contributes to a miss-sense in the dialogue across disciplines which constitute mental health knowledge.
4.1.1 I ntroduction: Mind-Brain Problem Opposition in Historical Traditions We assume it that various stances in the mind-brain debate underlie the main diagnostic and therapeutic methods in psychiatry. While biological pharmacotherapy is largely expanded on the basis of eliminative materialist views, psychotherapy is endorsed on an implicit level by the dualism and, perhaps, the dual-aspect monism. In fact, the crisis of confidence means that we no longer trust our clinical evaluation methods, or our therapeutic ones. This undermines our expert statements and their legal authority as well. In the ages before neuroscience evidence has been delivered – though controversial in the fields of psychology and psychiatry – mind-brain debate has been transferred from the field of philosophy into the field of explanations. This entails causal structure, mechanisms of production of mental disorders, and thereby clinical decision-making based on/informed by different stances in the mind-brain debate. There are two traditions that may be demarcated in the long and tortuous history of psychiatry in respect to the mind-brain problem (Machamer and Stoyanov 2009). First, there is the medical tradition as found in anatomy and physiology. Perhaps Thomas Willis (1621–1675) is the best known early modern practitioner of this © Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_4
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science. Willis studied the brain carefully and compared the normal brain with the abnormalities found in patients who had congenital mental retardation. His most detailed works on abnormal behaviors are Pathologiae Cerebri et Nervosi Generis Specimen (1670) and Affectionum quæ dicuntur hystericæ et hypochondriacæ pathologia spasmodica vindicata, contra responsionem epistolarem Nathanael Highmori. Most often this tradition sees the brain to behavior connection as strictly causal. In one version, this tradition is ontologically reductive. The second tradition relates the brain (and other bodily workings) to the mind and then the mind to behavior. Perhaps the best known early theorist in this research was René Descartes (1596–1650) who, in his Les Passions de l’Âme (1649), attempted to describe the bodily bases for human passions, theorizing how unchecked passions lead to abnormal or excessive behaviors. Various types of relations are hypothesized in this tradition as to how the brain (and body) affects the mind and as to how the mind then affects behavior. In this tradition – known as Cartesian dualism – the mind is often treated as a separate ontological kind and is taken to have representational properties that are responsible for behaviors. In some versions, the way in which the mind brings about behavior is held to be noncausal. Of course, there are intermediate positions and some confusing attempts at combination. One such would be the position of Sigmund Freud (1856–1939), who held that the mind was explanatorily independent from the brain, but not ontologically. He held that one day we would be able to explain every psychopathology in terms of brain functions, but until that time one needed independent mental constructs to explain the etiology of such pathologies. So Freud was not reifying the mind as a separate ontological entity, but did hold that due to its representational (or ideational) nature, the mind could be (and for therapeutic purposes had to be) discussed in ways independent of the physiology of the body. In addition, beyond the frontiers of scientific contexts, there are the spiritual explanations of mental disorders, generated by religious traditions. “Treatment” was by exorcism, though in some forms this spiritual cause may be seen even in the nineteenth century (“psychics” and Jacobi in Germany). During the period of Enlightenment, a number of attempts were made to bridge the brain research to the issues of mental health and disease. Worth mentioning are two of the treatises written by Friedrich von Schiller (1780) which consist the essentials of the later psychophysiology. Actually, there were no empirical data collected before the beginning of the twentieth century and the mind-brain relationships were still described and explained through philosophy. In the eighteenth and nineteenth centuries, there was achieved significant progress in the brain-to-brain field of research – with respect to the experimental and descriptive investigation of the brain anatomy and physiology itself. Probably some of the outstanding contributions were associated with the names of Felix, conte de Vicq D’Azyr, Francois Magendie, Emil du Bois-Reymond, and others. Nevertheless, most of them were not opened to the problems of mental disorders.
4.1 How to Incorporate Scientific Data from Neuroscience…
4.1.2 C urrent Implications of the Mind-Brain Debate in Psychiatry One leading tacit position in current psychiatric explanations remained Cartesian dualism. Without explicit commitment or reference to it, most of the psychotherapeutic are influenced by interactionist dualism. The main postulate of psychotherapy, which is typically taken by implication, is that mind and brain are separate but interacting entities. Psychotherapy claims to address the mind (or psyche); however, it admits that the effect from psychotherapeutic interventions is due – at least in part – to modifications of the underlying neural networks and to chemical neuroplasticity in particular. Interestingly many antidepressants actually claim to have a similar mechanism of action. Over the past few decades, there were developed several trends which aim at experimental confirmation that psychotherapy affects neural substrate in first place. Different results have been reported with both psychoanalytic psychotherapy (Solms and Turnbull 2002) and cognitive-behavioral approaches (Morgiève et al. 2014). More specifically, Solms’ research has led to a new area of transdisciplinary interactions, called neuro-psychoanalysis. It triggered a novel interpretation of the mind-brain physicalism, known as “dual-aspect monism,” which assumes human psyche and brain mechanisms as two manifestations of one and the same core substrate. This view is controversial since it resembles the outdated concept of epiphenomenalism, in which human mental life was regarded as collateral by-product of brain activity; in the same way as the bile is by-product of the liver activity (this metaphor is usually associated with the neo- Cartesian philosopher Pierre Cabanis). Summary Mainstream psychotherapy is still committed to one extent or another to a dualistic understanding of the mind and brain. On the other hand, biological psychiatry (often referred to as neuropsychiatry) is looking into various forms of monistic physicalism. The latter might be seen as both reductive and non-reductive, depending on the approach. Reductive physicalism has been employed in order to provide a sound explanation for mental disorders and presumably effective approach to manage them. Reductive physicalism has developed in the twentieth century into several influential traditions relevant to psychiatry: eliminative materialism and identity theory of mind. Both of them assume supremacy of neurobiological models and tend to reduce psychological and psychopathological phenomena to events and processes in the brain. Eliminative materialism is attributed to the works of Paul and Patricia Churchland in the 1980s without particular reference to psychopathology. It comes to a great extent as a logical consequence from the strict identity theory of mind exposed below, with stronger metaphysical commitment. This is to say commitment to the theoretical stance that mental phenomena are computational neural processes and nothing else. The crucial claim is considered to be that folk psychology; therefore psychology and psychopathology as terms and vocabulary were supposed to be entirely dismissed (eliminated) by computational neuroscience. For instance,
4 Psychiatry and Neuroscience: At the Interface
empathy will be displaced with “firing of mirror neurons.” However, as often happens in science, the core field has been gradually expanded and displaced to occupy new territories of debate. The conceptual background of the Human Brain Project (Markram 2012) is actually derived from the Churchlands’ theory (cf. Churchland 1986). Furthermore, most of the pharmacological interventions in psychiatry are also rooted back in eliminative materialism on the level of “tacit knowledge.” Psychopharmacology’s modus operandi is developed in statements like, If we provide a drug to bind with a receptor (sub) population for the substance X, then it will reduce the symptom Y. Let us assume that the drug substance is a dopamine receptor antagonist and the symptom in question is verbal hallucinations. In this case, the tacit content of such statement might be reformulated like this: Verbal hallucinations are caused exclusively by dysfunction/deregulation of the dopamine receptor and its blockade will remove them. Therefore, verbal hallucinations are merely and external manifestation of dopamine dysregulation in the brain.
Essentially this implies that we no longer need to articulate the subjective content (phenomenology) of verbal hallucinations since all of them are completely reducibly to biochemical entities. Thus, phenomenological psychopathology, both as method and vocabulary, is futile, and hearing voices is nothing but a disturbance of the dopamine metabolism. It is critical to stress here that this inference is taken without residuum, i.e., no further social, cultural, or religious interference is assumed as being related on causal level to production of the phenomenon. Besides eliminative materialism, another reductive paradigm, known as identity theory of mind (ITM), has been introduced. ITM has grounded its basic claims in the field of experimental arguments namely the so called “c-fiber’ argument. This argument refers to the differential activation of the c- and a-delta-fibers of the pain perception system. The c-fibers provide slower transduction of the neural signal from the peripheral pain receptors to central areas as compared to c-fibers. Identity theorists claim that firing of a-delta fibers is the correlate of the physical perception of the pain (triggering the adaptive response of withdrawal), whilst “firing” of c-fibers in the immediate correlate of emotional experience of pain. Identity theory expands this explanation to the entire realm of subjectivity or consciousness. There are two versions of ITM. One of the more radical is the type-type identity as formulated by Ullin T. Place, and the other is token-ITM token identity (ITM) as formulated by JJC Smart. Type identity takes it for granted that human consciousness is literally reducible to lower entities or levels of explanation in the same way as the lightning might be reduced to “electrical discharge” and heat to “molecular motion.” As it has been stated in the seminal papers of Place, identity might be regarded as compositional where components of lower level phenomena are incorporated in the hierarchy of the higher-order ones without explicit ontological claims at elimination of higher-order phenomena (human consciousness). This is essentially different from De re identity where the higher-order phenomenon is overruled: mental states and processes are taken to be presumably equal to brain ones. This view overlaps with eliminative materialism as described above.
4.1 How to Incorporate Scientific Data from Neuroscience…
Token identity, on the other hands, assumes identity between mental and brain states and processes in a rather metaphorical manner. In this perspective “brain processes” and “sensations” (or emotional states) are understood as two descriptions of one and the same underlying substance in the same way as “morning star” and “evening star” both refer to the planet Venus in astronomy. This distinction, however, is not of any particular significance when extrapolated to psychiatry. What actually matters to psychiatry (and in this sense to psychology as well) is what kind of objections might be delivered against reductive physicalism in general and ITM in particular. There are two main objections of relevance to mental disorders: the presence of qualia and multiple realizability. Qualia is an argument which is pertinent to phenomenological psychopathology and refers to the qualitative dimension of human experience. For instance, if we accept it provisionally that all verbal acoustic hallucinations (VAH) are produced by one and the same brain mechanism (which is in itself a controversial statement), then what might be the feasible explanation why they differ on inter-individual level in terms of their content? Some people hear voices of their deceased relatives; others hear the voice of God or demons, for example. Also, some of the patients’ voices are experienced as external to their subjective body construction, as coming from the objective world, yet other patients report the voices to be experiences “inside” their heads, delivered or embodied into their subjectivity by means of special devices or telepathy. This complex phenomenon was described by Russian psychiatrist Viktor Kandinsky on the example of his own psychopathological experiences under the term pseudo-hallucinations and later, independently by Gaëtan de Clérambault. Multiple realizability is an argument derived from neuroscience, and it refers to the observed fact that there are different loci in the brain involved in the production of certain psychopathological phenomenon (like VAH) and the data reported to correlate as a neural substrate of VAH in the current literature are highly inconsistent. However, the opposite observation is also true: different VAH psychopathological manifestations (like delusions) converge on the same neural substrate as VAH. The advances of computational neuroscience, inspired by eliminative materialism, have facilitated groundbreaking research programs with far more sophisticated, high-technological data processing facilities, like the various platforms of Human Brain Project which are practically designed to accumulate data from many basic disciplines in order to reconstruct a computational bottom-up model of the brain functions and disorders which includes mental disorders by all means. If we step aside from the arena of speculation, any of the above stances in the mind-brain debate is counterproductive in itself, as it reproduces reality in a more or less deterministic, paradigmatic, and ontologically fragile (if not vacuous) manner. This observation unfortunately is valid through all other fields and specialties of medicine and leads to the fragmentation of knowledge and superficial understanding of the human nature in health and disease. The diverse implicit positions on the mind-brain debate obstruct the establishment of uniform criteria for validity and validation across subdisciplines involved in psychiatry. Therefore, it seems that revisiting identity theory of mind might be more
4 Psychiatry and Neuroscience: At the Interface
useful. Actually, a moderate form of physicalism has been formulated in response to the critical accounts on epiphenomenalism or eliminative materialism, based on the argument of the multiple realizability. This is the supervenience theory of mind (STM) brought forward by Donald Davidson and Jaegwon Kim (1993, 2010).
Excursus: My Journey Toward and Away from Reductive Physicalism When I was a graduate student of medicine in 2002, I became fascinated by two tempting intellectual extremes. One was the identity theory of mind as a particular form of reductive physicalism, and the other was functional MRI (fMRI) as a method to deliver empirical evidence in its support. As a matter of fact, those were the times of the first significant breakthrough in cognitive neuroscience using fMRI. It appears to be that every person is aspiring at certain level of confidence and certainty in order to manage his or her own intrinsic anxiety. Reductive physicalism and the corresponding colored fantasy that some “brain imaging activations will reveal physical evidence of the mind and its disorders” seem to have been my own escape into materialism after the collision with the ongoing crisis in psychiatry and the challenging professional reality. Furthermore, at that moment there was no fMRI facility in my country (Bulgaria), which added some allure to the fantasy. If interpreted psychodynamically, I was so frightened by the unmanageable uncertainly of the profession that I needed to create some alternative world to design and to allocate my mechanistic dreams. I claimed that the identity theory is the right solution to the mind-brain problem and that a proper fMRI protocol might capture an integrated system of mind and brain. My original protocol was to apply self-assessment psychological inventories simultaneously with the fMRI scan. After defending a PhD thesis with this claim in 2005, I spent 10 years in philosophical studies. The main purpose of those studies was to figure out a way to articulate in proper terms (“with the due tribal colors”) of the dominant paradigms in philosophy and neuroscience this experimental rationale in peer-reviewed journals. I trained in the Philosophy of Science of the University of Pittsburgh and Philosophy of Mental Health at the University of Central Lancashire to be able to deliver the conceptual basis of my model in a series of papers in 2012–2013 (Stoyanov et al. 2012, 2013, 2014). In 2013, I took part in a project proposal of my university funded by the European Commission to deliver the first, and so far only, fMRI research facility in Bulgaria. Based on my collaborations with the University of Basel in Switzerland and the University of Bergen in Norway, my group has managed to justify successfully and implement the experimental protocol and paradigm for simultaneous administration of the Depression Scale of Von Zerssen and fMRI (Stoyanov et al. 2014). Then I spent 2 years (2015–2017)
4.1 How to Incorporate Scientific Data from Neuroscience…
studying more than 100 patients and age-/sex-/education-matched healthy controls in order to discover for myself that identity theory of mind has limited range of application, namely, the self-assessment narrative of the patients. There were revealed significant contrasts in the BOLD signal (activations) in the item responses of the patients when contrasted the diagnostically relevant and neutral items from an interest scale (mainly in the central areas and medio-frontal cortex). Further, there were significant differences in the between-group analysis, as the depressed patients had increased activity of the medial frontal gyrus, anterior thalamus, parahippocampal gyrus, and hippocampus when compared to healthy controls. Yet all these data refer to a self-assessment scale only. When the observer-based evaluation (MADRS) was applied, there were significant discrepancies and anomalies which undermine the identity thesis and have caused a drop off of more than 50 patients from the project data reports. Many of the patients had reported item responses which resulted in a Depression Scale score corresponding to the diagnosis of depression; however, this was not confirmed by the MADRS interview score. The opposite phenomenon has been observed as well. Some patients reported relatively low (normal) score on Depression Scale, and the psychiatrists evaluated the same patients on MADRS as moderately or mildly depressed. Finally, some of the healthy controls reported high Depression Scale with expected contrast activations in the brain regions of interest but inconsistent with the MADRS assessment. That falsification brought me away from reductive physicalism as I needed a more liberal cognitive framework in order to interpret the results. This is how I came back to the supervenience theory of mind (STM). Perhaps U.T. Place walked through the same intellectual confusion himself, given that according to his last will, his own brain was to be exposed in a vat at the University of Adelaide with the rhetorical inscription: “Does this brain contain the consciousness of U.T. Place?” This was most likely a reference to the famous “thought experiments” of his opponent Hilary Putnam – “Brain in a Vat” and “Twin Earth” – which were used to disprove his identity theory of mind (ITM) and lay the grounds for STM.
Supervenience theory adopts the thesis that any difference in physical properties (neural events or mechanisms) should cause differences in the mental world (states or traits dependent), but not vice versa. This means that any contrast measured by means of functional MRI between patients and healthy control group should be associated with a difference in the clinical manifestations (observations), respectively, in the score on various rating scales. However, not every difference in the clinical observation might be reduced to physical properties of the brain, i.e., if two different clinicians report different scores on Montgomery-Asberg Depression Rating Scale (MADRS) in one and the same patient, this does not necessarily imply contrasts in the BOLD signals on fMRI in the same patients.
4 Psychiatry and Neuroscience: At the Interface
There are two forms of supervenience: global and local. Transferred to the field of psychiatry and psychology, global supervenience may appear like this: There are differences in patterns of brain activations in all patients with depression when compared to patients with schizophrenia or healthy controls.
This position appears to be false for many empirical and meta-empirical reasons as discussed elsewhere, so we should rather adhere to the local supervenience. In our case it applies like this: There are differences in the patterns of brain activations between the item responses on depression inventory as compared to diagnostically neutral items and to paranoid items in patients with presumed depressive disorder when compared to patients with schizophrenia and to healthy controls.
In this perspective, the remaining question is whether there is still any some room left for ITM here. The provisional answer is “maybe,” under specific conditions and in particular reference to the self-evaluation measures. Contrasted activations in the middle frontal gyrus (MFG) between patients and healthy control group are immediately associated with clinically significant differences in the scores of the Von Zersson’s Depression Scale, and any difference in this scale is associated with contrast measured in the underlying brain processes with fMRI (Stoyanov et al. 2017). The first condition in order to maintain the identity thesis here is that the determined differences in the mental states (normal and depressed) and the differences in the correlated brain activations should present not only at the level of statistical aggregates but on individual level without any inter-individual variability which is certainly not the case. Another condition would be to further investigate necessary and replicable differences in comparison to other constructs employed in psychopathology, e.g., paranoia, anxiety, and other symptoms. Our current investigations to establish discriminative validity of the paranoid and depressive scale by Von Zerssen are preliminary and inconsistent to draw inferences. Nonetheless, there are interesting contrasts described at the single subject level in the hippocampus and amygdale.
My basic claim here is that the intra-subjective (introspective) evaluation embodied in self-evaluation instruments and fMRI measures as proxy variables might be approached with local supervenience theory and are partly liable to empirical reduction according to the strict identity theory of mind. The inter-subjective evaluation (observer-based interviews) can only supervene in terms of global supervenience on physical (neurobiological) properties. This is associated with the complex irreducibility of the reflexive and intuitive space of inter-subjectivity. Interviews cannot be validated from/with/ against neurobiological measures, because they are designed to be reflexive, inter-subjective, experiential, and intuitive.
References Churchland, P. S. (1986). Neurophilosophy: Toward a unified science of the mind-brain. Cambridge: MIT Press. Kim, J. (1993). Supervenience and mind: Selected philosophical essays. Cambridge: Cambridge University Press. Kim, J. (2010). Essays in the metaphysics of mind. Oxford: Oxford University Press. Machamer, P., & Stoyanov, D. S. (2009). The scientification project of psychiatry. In IAHPM “Asklepios” (Vol. III(XXII), pp. 51–56). Markram, H. (2012). The Human Brain Project. Scientific American, 306(6), 50–55. Morgiève, M., N’diaye, K., Haynes, W. I. A., Granger, B., Clair, A. H., Pelissolo, A., & Mallet, L. (2014). Dynamics of psychotherapy-related cerebral haemodynamic changes in obsessive compulsive disorder using a personalized exposure task in functional magnetic resonance imaging. Psychological Medicine, 44(7), 1461–1473. Solms, M., & Turnbull, O. (2002). The brain and the inner world: An introduction to the neuroscience of subjective experience. London: Other Press, LLC. Stoyanov, D., Machamer, P. K., & Schaffner, K. F. (2012). Rendering clinical psychology an evidence-based scientific discipline: A case study. Journal of Evaluation in Clinical Practice, 18, 149–154. Stoyanov, D., Machamer, P., & Schaffner, K. F. (2013). In quest for scientific psychiatry: Toward bridging the explanatory gap. Philosophy, Psychiatry, & Psychology, 20(3), 261–273. Stoyanov, D. S., Borgwardt, S. J., & Varga, S. (2014). Translational validity across neuroscience and psychiatry. In P. Zachar, DS Stoyanov, M Aragona, & A Jablensky (Eds.), Alternative perspectives on psychiatric classification (pp. 128–145). Oxford: Oxford University Press. Stoyanov, D., et al. (2017). Towards translational cross-validation of clinical psychological tests and fMRI: Experimental implementation. Comptes rendus de L’Académie bulgare des Sciences, 70(6), 6. Von Schiller, F. (1780). Versuch über den Zusammenhang der thierschen Natur des Menschen mit seiner geistigen. Stuttgart: Ingelheim a. Rh., Boehringer, 1959. (On the Philosophy of Physiology).
Psychiatry in Crisis as a Human & Social Science Vincenzo Di Nicola
The “laws of medicine” are really laws of uncertainty, imprecision, and incompleteness. They apply equally to all disciplines of knowledge where these forces come into play. They are laws of imperfection.—Siddhartha Mukherjee, The Laws of Medicine: Field Notes From an Uncertain Science (2015, p. 7)
Reference Mukherjee, S. (2015). The laws of medicine: Field notes from an uncertain science (p. 7). New York: TED Books/Simon & Schuster.
The Beginning of the End of Psychiatry: A Philosophical Archaeology
We will start with a survey of the issues at stake in the history of academic psychology and psychiatry, using trauma as a case in point. These revolve around consciousness and phenomenology, the definition of the subject, and issues of language, memory, and representation. I have collected and consulted many histories of psychology and psychiatry. We may eliminate the more partisan or chauvinistic forays into establishing nationalistic or sectarian claims. First, let us separate the history of madness from the history of psychiatry, which are not only two different maps, but altogether two different territories. For our purposes, the history of psychology revolves around the question of consciousness, both as a philosophical question and as a technical or methodological matter. The history of modern psychiatry, on the other hand, revolves around the crucial question of the experiential chasm, as Karl Jaspers put it: either we can or cannot cross an empathic bridge to understand the most alienating experience that psychiatry had encountered at that time, schizophrenia. We can line up all the approaches and contributions around this question: those who agree with diagnostic categories (whether based on Kraepelinian aetiopathology – the so-called medical model – or Jaspers’ phenomenology as a science of understanding signs and symptoms) see a phenomenological chasm between the psychotic patient and the psychiatrist, while those who are continually looking for other ways to understand alienating experiences (from Viktor Tausk’s psychoanalytic interpretation of the “influencing machine” to Eugène Minkowski’s existential psychiatry to R.D. Laing’s social phenomenology but we may also include behaviorism and systems theory) explicitly reject, as in the case of Minkowski and Laing, or simply do not adhere to this way of framing the question, as in the case of John Watson’s behaviorism or Gregory Bateson’s systems theory.
© Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_5
5 The Beginning of the End of Psychiatry: A Philosophical Archaeology
5.1 Psychology: Introspection and Consciousness Academic psychology had a promising start in the late nineteenth century at Harvard University with the brilliant William James, whose Principles of Psychology (1890) remains a canonical text integrating European influences from Franz Brentano to Wilhelm Wundt, in the experimental study of consciousness by the introspective method. In his authoritative history of introspection in psychology, Edwin Boring regarded consciousness as “the most fundamental of all the postulates of Psychology” (Boring 1953). The philosophers, physiologists, and physicists who founded the new experimental psychology in 1850–1870, such as Fechner, Lotze, Helmholtz, Wundt, Hering, Mach, and others, were all in agreement: Psychology—even the new “physiological psychology”—was essentially the study of consciousness, and its chief method was introspection (Boring 1953).
Yet, American psychology soon became defined in a very different way by John Broadus Watson whose 1913 manifesto is a nodal point in the history of psychology: The time has come when psychology must discard all reference to consciousness. [...] Its sole task is the prediction and control of behavior; and introspection can form no part of its method (Watson 1913).
Half a century later, British psychologist Cyril Burt proclaimed: Today, […] the vast majority of psychologists, both in this country and in America, still follow his lead. The result, as a cynical onlooker might be tempted to say, is that psychology, having first bargained away its soul and then gone out of its mind, seems now, as it faces an untimely end, to have lost all consciousness (Burt 1962).
Psychology as a profession became invested in the project of carving out an identity in the academy, veering from a mindless behaviorism to a meaningless cognitivism. When psychology finally started taking consciousness seriously again, it took a detour into artificial intelligence and the mind as a computer and is now occupied with the neo-Darwinian project of proving that the mind has evolutionary roots.1 A large part of academic psychology has been continually subordinated to the research paradigm of the day, ready to redefine its core interests based on what is operationally possible as opposed to what is meaningful, and is thus reduced to methodolatry. What mainstream academic psychology lacks is a coherent overall theory, notably on such central questions as defining what is a subject, emotion, and meaning. Academic psychology finally got over its physics envy only to substitute it with biology envy – from “the ghost in the machine” (Koestler 1975) to “the selfish gene” (Dawkins 1989). Airily dismissive of psychoanalysis and the concept of the unconscious, cognitive sciences now privilege the study of language and memory. Jerome Bruner, an architect of the “cognitive revolution” expressed chagrin that the field became “subordinated to the ideal of computability” (p. 10) and “simulated mentalism” (p. 7) where meaning became computability. His thinking about psychology and its subordination to its subdisciplines is strikingly similar to Badiou’s notion of philosophy and its conditions. See Jerome Bruner, Acts of Meaning (1990). His overview of the history of psychology is deeply informed and philosophically nuanced. 1
5.2 Foundations of Modern Psychiatry
Summary The salience of the debates over consciousness and introspection as academic psychology’s object and method of study, respectively, is that we see them mirrored and repeated in the dichotomous discourse on trauma today. In a nontrivial way, the polysemic question “What is the subject?” is never resolved/resolvable in psychology, neither as a general definition of the field (the study of consciousness, the prediction of behavior, the science of mental life2), as an object of study (consciousness, behavior, cognition), nor as an understanding of persons (mind and thus identity as emergent from physiological processes, as a historical fiction ascribed to bodies emitting behaviors, consciousness emergent from a computer-like brain shaped by evolution). As a result, the aporias of the trauma experience – from intense remembering to repression, from a kind of concrete dulling of affective life to overwhelming anguish and dread, and from the impossibility of communicating painful experiences to exquisitely wrought witnessing through memoir, fiction and poetry, invoking questions of language, memory, and representation – have no sure address in psychology. Again in a nontrivial way, it is as if psychology has to reinvent itself (and the world) for each new subject of study. It is certainly the case with trauma.
5.2 Foundations of Modern Psychiatry To study a complex clinical problem like trauma, we need careful and critical essays of the type attempted by thoughtful clinician scholars such as Karl Jaspers in Germany and Aubrey Lewis in Britain.3 We may characterize them as descriptive nosography, staying very close to clinical observations and patients’ subjective experience with selective naturalistic studies of patients’ lifeworlds. Their contributions are very similar to Agamben’s essays in philosophical archaeology. A school of psychiatry was founded on this notion, with phenomenological and existential elements, to become one of the pillars of psychiatric practice. Mayer- Gross’ Clinical Psychiatry is the cornerstone of modern British psychiatry. The Preface to the Third Edition in 1969, after his death in 1961, puts Willy Mayer- Gross squarely in the tradition of German psychiatry and as a pioneer contributor along with Jaspers and others “to the remarkable flowering of clinical psychiatry in the development of “phenomenology,” i.e., the exact study and precise description of psychic events, which are a primary requisite for their understanding” (Mayer- Gross 1969, p. xiii). The first sentence on the first page of this volume reads: 2 William James (1890) called psychology “the science of the mind”; George Miller (1991), a pioneer in cognitive psychology, called it “the science of mental life.” 3 Aubrey Lewis, Inquiries in Psychiatry: Clinical and Social Investigations (1967a); The State of Psychiatry: Essays and Addresses (1967b); The Later Papers of Sir Aubrey Lewis, introduction by Michael Shepherd (1979). There are essays on the terms anxiety, hysteria, psychogenic, paranoia and paranoid, classifying phobia, endogenous versus exogenous, the psychopathic personality, as well as more general reflections on whether the basis for psychiatry should be empirical or rational, philosophy and psychiatry, and the history of classification and diagnosis in psychiatry.
5 The Beginning of the End of Psychiatry: A Philosophical Archaeology This book is based on the conviction of the authors that the foundations of psychiatry have to be laid on the ground of the natural sciences.4
A section about existential analysis and related theories makes a distinction between Jaspers’ phenomenology and existential analysis, describing the latter as “a variety of attempts to solve the problems of psychopathology by the use of philosophical short-cuts, instead of the relatively slow method of investigation with the disciplines of natural science.”5 What follows is a characterization of the appeal of existential analysis to those with philosophical or metaphysical interests rather than scientific methodology, with “adherents in philosophy and literature as well as in psychiatry” and is likened to previous eras in the history of thought, especially with romantic writers and philosophers in the first half of the nineteenth century. Against the “Cartesian prejudice” – the split of the subject and the object – the existentialist, it is argued, “wishes to start by using as a basic unitary concept for the understanding of all human life the awareness of the individual himself in the world, ‘Being-in-the-World’,” from which are derived “the concept of ‘ontology,’ the doctrine of being and the basis of all philosophy,” noting that Heidegger’s formulation of “Being-in-the-World” as “a state of solitude and anxiety” and “pessimistic outlook” had a “natural appeal” to the postwar European generation. This is contrasted with the work of such “serious and humane psychiatrists as L. Binswanger, V. von Gebsattel and E.W. Straus” who championed a “more direct, more total, less piecemeal approach to psychiatric patients and their symptoms.” Their aim was to “bracket together all objective phenomena” by placing “subjective experience into the centre of psychology” and linking it to Jaspers’ phenomenology. Lacking another description, the author calls this approach the “opposite of behaviorism.” Under such descriptions as constructive-genetic anthropology, existential analysis, and existential anthropology, these workers used empathy to “understand the world of the depressive, the obsessional, the manic or the patient with ideas of reference.” Empathy is described as “putting themselves into the patient’s situation,” using the “totality of this understanding to interpret individual symptoms” (Mayer- Gross 1969, p. 25). To highlight the distinction, Mayer-Gross repeats that phenomenology is “a factual approach, based on the work of Jaspers,” while existentialism seeks “philosophical shortcuts.” It attributes to this group the view that psychology is not part of natural science or that scientific psychology is “irrelevant for the understanding and treatment of psychiatric patients.” Binswanger is cited as the philosophical spokesman: “the ground and soil, in which psychiatry can take root as a science in its own right, is neither cerebral anatomy or physiology, nor biology, neither psychology, characterology and typology, nor the science of the person, but man (‘der Mensch’).” While noting some strengths of this school, Mayer-Gross’ summary concludes that the existentialist would isolate psychiatry from “all other modes of study of the mentality of man” and be deprived of mutual fertilizing among them.6 This prediction has been entirely borne out in the four decades since this was written. Mayer-Gross (1969, p. 1), emphasis in the original Mayer-Gross (1969, p. 25), emphasis added 6 All quotes from Willy Mayer-Gross (1969, pp. 25–26) 4 5
5.3 Phenomenology in Psychiatry
5.3 Phenomenology in Psychiatry Now, what is this founding science of psychiatry called phenomenology? In his classic textbook, Allgemeine Psychopathologie, published in German in 1913 and translated as General Psychopathology (1997), Karl Jaspers describes it thus: Phenomenology sets out a number of tasks: it gives a concrete description of the psychic states which patients actually experience and presents them for observation. It reviews the inter-relations of these, delineates them as sharply as possible, differentiates them and creates a suitable terminology.7 Jaspers then adds that as we cannot perceive the psychic experiences of others directly, we must make “representations of them,” for which we need an “act of empathy, of understanding.” Phenomenology is often invoked today by psychiatrists who wish to emphasize precisely this empathic approach.8 “Our chief help in all this comes from the patients’ own self-descriptions,” Jaspers wrote, adding, “An experience is best described by the person who has undergone it.” In a footnote, Jaspers references his 1912 paper (Jaspers 1912) and outlines a history of the term phenomenology: The term phenomenology was used by Hegel for the whole field of mental phenomena as revealed in consciousness, history and conceptual thought. We use it only for the much narrower field of individual psychic experience. Husserl used the term initially in the sense of ‘a descriptive psychology’ in connection with the phenomenon of consciousness; in this sense it holds for our investigations also, but later on he used it in the sense of ‘the appearance of things’ (Wesensschau) which is not the term we use in this book. Phenomenology is for us purely an empirical method of inquiry maintained solely by the patients’ communications. It is obvious that in these psychological investigations descriptive efforts are quite different from those in the natural sciences. The object of study is non-existent for the senses and we can experience only a representation of it. Yet the same logical principles are in operation. Description demands the creation of systematic categories, as well as a demonstration of relationships and orderly sequences on the one hand and of sporadic appearances, unheralded and unforeseen, on the other.9 Let us go back to the contrast that Mayer-Gross suggests between phenomenology and behaviorism. Another section on Pavlovian psychiatry reviews Pavlov’s work in physiology in the Soviet Union and the application of learning theory, including Western forms of behavior therapy, to psychiatry very positively, especially with neurotic conditions but not with schizophrenia and other psychotic states. In retrospect, behaviorism and learning theory have had their day, but the contrasts of the questions posed by behaviorism and phenomenology are still instructive and were addressed in a unique volume with leaders in psychology, philosophy, and history.10 For our purposes, the issues revolve around the question of consciousness and the experiential chasm. Jaspers (1997), emphasis in the original For a fine example by a compassionate clinician, see Mollica (2006). 9 Jaspers (1997, p. 55), emphasis in the original 10 Wann (1964). The contributors include committed phenomenologists (R.B. MacLeod, Carl Rogers, both psychologists) and behaviorists (B.F. Skinner, a psychologist; Norman Malcolm, a philosopher), as well as scholarly commentators from both psychology and history and philosophy of science (Sigmund Koch, Michael Scriven). 7 8
5 The Beginning of the End of Psychiatry: A Philosophical Archaeology
Derek Bolton, who is both a philosopher and a psychologist, revisits Jaspers’ legacy, as the distinction between meaningful and causal connections, understanding and explaining. In this analysis, twentieth-century psychiatry is the transition from the meaning model to the causal model, and there is no doubt that most people who see it this way see it as progress. Jaspers had an understanding of the difficulties encountered by the subject and subjectivity and the question of consciousness, with roots in German scientific traditions. Reading the same texts, I see different landmarks in this territory. “Causal” and “meaningful” are punctuations. Bolton states that, “Jaspers was the first to grasp the relevance of the new problematic to psychiatry, and perhaps the last to be able to hold on, even-handedly, to both epistemologies. Jaspers emphasized the importance of both the science of psychopathology and the indispensable need to understand meaning by empathy.”11 He laments, however, that “no coherent account of how these two methodologies could together be coherent and valid” (Bolton 2004). I disagree insofar as there is an implicit model in Jaspers who uses empathy as a useful discriminating tool. We can describe experiences phenomenologically and empathize to arrive at understanding and meaning of the patient’s lifeworld, to use Husserl’s term. Where these fail, as in psychosis (and, no doubt, by extension dementia, profound mental deficiency and neurological disorders), the construction of meaning fails, as does empathy for self and other, and, this approach would conclude, we are dealing with brain disease. Again, Jaspers’ experiential chasm is a cut in two senses. It describes the chasm between patient and psychiatrist into which meaning and empathic understanding fall into an abyss; and it is a cut, a separator of this dual approach of phenomenological psychiatry from psychoanalysis and other hermeneutic approaches that persist with the attempt to understand notwithstanding the difficulties and limits of the task. In the early history of modern psychology, the move away from consciousness was motivated by the lack of a scientific method, so researchers simply studied what could be measured, such as physiological responses or behavior. In the history of psychiatry, the split concerns whether phenomena can be understood and given meaning or explained causally with a strong preference for brain explanations. Summary The way Jaspers used phenomenology in psychiatry is inspired by but differs from Husserl’s use of it in philosophy; Jaspers founded the modern era of descriptive or phenomenological psychiatry based on patients’ own self-descriptions. This makes him a co-founder with Kraepelin of modern psychiatry. Today, we read Kraepelin as being more concerned with causal connections and explanation and Jaspers with meaning and understanding. What makes this a complex judgment is that they introduced these notions to bring order to a mass of information, and while they show these tendencies, each tried to address both tasks, especially Jaspers. The philosophical critique that phenomenology is concerned with appearances rather than ontology is not altogether true for Jaspers’ phenomenological psychiatry and his continued influence in psychiatry today. Bolton’s characterization is historicist Bolton (2004). Bolton did his doctoral work with Wittgenstein’s student G.E.M. Anscombe at Cambridge University.
5.4 “Philosophical Shortcuts” or Founding Science?
and distorts Jaspers’ influence on one hand and misconstrues his contributions on the other. Jaspers offered a bridge between what we perceive today as reductive causal explanatory models and more embracing models aimed at meaningful understanding. That he reads this as lacking a coherent theory reveals positivist preferences. Bolton champions cognitive behavior therapy (CBT) which I call a chimera. Where is the explanation in that theory of how cognition is related to behavior? It is a series of assumptions of that relationship and practical ways of managing that link. Except for a plethora of outcome studies that meets the needs of the psychology industry, CBT represents no advance in our understanding, and its contributions were already present in a more lucid form in Viktor Frankl’s logotherapy (Frankl 1959). Furthermore, Mayer-Gross’ overview introduced a sharp distinction between this use of phenomenology and the disparate group of psychiatrists who, inspired by the same sources and aporias, constructed versions of existential psychiatry and analysis. The real epistemological cut is between those approaches dedicated to a search for meaning in all experiences, however absurd or destructive (witness Tausk and Frankl), and those who introduce an experiential cut as a tool in itself to explain alienated and alienating experiences, such as schizophrenia (Jaspers). The interesting question concerning trauma is how would Jaspers have understood trauma? Would he have undertaken a kind of phenomenological archaeology to empathize with a traumatized patient, or would he have experienced a chasm with the most profoundly traumatized patients?
5.4 “Philosophical Shortcuts” or Founding Science? For the last century, during the modern era of psychiatry, philosophers have been privileged interlocutors in creating new vistas in psychiatry. This is a different story than either psychiatrists or philosophers usually tell and only partly told by Foucault who is part of the story himself. While Jaspers established phenomenology as a founding science of psychiatry which was respected by authorities such as Mayer-Gross, kindred approaches in existential psychiatry are accused of looking for “philosophical shortcuts.” The story told by philosophers about psychology, psychiatry, and psychoanalysis is perhaps even more complex because, I would argue, they have been privileged interlocutors as well as critics of these disciplines. Substantive philosophical commentaries range from Wittgenstein’s papers on psychology (Wittgenstein 1991) to Heidegger’s correspondence with Binswanger whose work he followed with interest (Heidegger 2001). In Foucauldian terms, these various disciplines come together to create a discourse or épistémè, and these discursive elements combine with nondiscursive elements such as clinical practice, social policies, and legislation to form an apparatus. Together with psychologists, psychiatrists, and psychoanalysts, philosophers worked to found a science of phenomenology ranging from an account of existence (Edmund Husserl, Martin Heidegger, Jean-Paul Sartre) to a psychology of
5 The Beginning of the End of Psychiatry: A Philosophical Archaeology
perception (Maurice Merleau-Ponty) and, above all, phenomenological psychiatry (Karl Jaspers) and existential psychiatry (Eugène Minkowski), and its offshoots, especially existential analysis (Ludwig Binswanger) and social phenomenology (R.D. Laing). These contributions, whose avatar is Jaspers’ phenomenological psychiatry, join Kraepelin’s aetiopathological model as the twin foundations of modern psychiatry. This is a selective view of psychiatry’s foundation and evolution. It is not a history as such, although it is historically informed, nor is it an exhaustive survey. What I have left out are the cognate disciplines, allied professions, and subdisciplines of psychiatry. They have their own importance, but they are not what defines the core of psychiatry’s mission. While a number of subdisciplines have made their bid to redefine psychiatry, they have not managed to convince the field with their wager: child psychiatry, for example, tries to make the argument that development should be the core of psychiatry, either through attachment theory or developmental neurobiology; family therapy made the argument that systems theory could radically redefine the field both in theory and in practice. Many other examples may be elaborated, from community psychiatry to epidemiology and public health and social and transcultural psychiatry. Two others are in a different class: first, the dethroned paradigm of psychodynamic psychiatry based on Freudian psychoanalysis, and, second, the newly crowned paradigm, a two-stroke engine comprised of evidence-based medicine and a scientific soup of neurobiology and cognitive neuroscience.
5.5 One Hundred Years of Phenomenological Psychiatry This is a sketch of the phenomenological era in philosophy and psychiatry during the last century, using Jaspers’ 1912 paper as a historical milestone (Jaspers 1912). Throughout this century, these two discourses have been imbricated in ways that suggest Badiou’s notion of a suture. For some, like Althusser, psychoanalysis (and by extension, psychiatry) is subordinated to philosophy, while Freud and Lacan privilege psychoanalysis in defining and treating the subject. Karl Jaspers, who genuinely straddled both fields in which he excelled, created the synthesis of phenomenological psychiatry as a founding science. Many of those who followed addressed both disciplines with ease, including Ludwig Binswanger, Jean-Paul Sartre, R.D. Laing, and Michel Foucault. In the two columns below, key thinkers in philosophy and psychiatry and their major works and key ideas are listed side by side to show their affinities and collaborations:
5.5 One Hundred Years of Phenomenological Psychiatry
Philosophy Edmund Husserl (1859–1938) Subjective/intentional phenomenology Influenced the entire school of phenomenological and existential psychology, psychiatry, and psychoanalysis Martin Heidegger (1889–1976) Being and Time (1927) (dedicated to Husserl)
Jean-Paul Sartre (1905–1980) Being and Nothingness (1943) “Existential psychoanalysis has not yet had its Freud”
Psychiatry Karl Jaspers (1883–1969) “The Phenomenological Approach to Psychopathology” (1912) General Psychopathology (1913)12 Eugène Minkowski (1885–1972) Existential psychiatry Ludwig Binswanger (1881–1966)13 The Case of Ellen West” (1944–1945) Daseinsanalyse – Existential analysis Dream and Existence (1930; French translation with a preface by Michel Foucault, 1954) R.D. Laing (1927–1989) The Divided Self (1960), Self and Others (1961) Reason and Violence: A Decade of Sartre’s Philosophy 1950–1960 (preface by Sartre, 1964) Ontological insecurity, mystification, disqualification Frantz Fanon (1925–1961) A new theory of consciousness, combining the psychiatric and the political Black Skins, White Masks (1952) The Wretched of the Earth (preface by Sartre, with the memorable line, “Violence, like Achilles’ spear, can heal the wounds it inflicts, 1961”)
With his major works, Theory of the Subject, Being and Event and Logics of Worlds, Being and Event II, Badiou broke with intentional phenomenology and redefined the subject as a relation between an event and a world, forcing a rereading of the psychiatric projects founded on phenomenology and its implicit theory of the subject. This creates the conditions for a critique of what I have come to call trauma
Karl Jaspers (1997). Jaspers cites Husserl in both of his works noted here. Binswanger trained with Bleuler and Jung and conducted detailed and lengthy correspondence with both Heidegger and Freud. Binswanger was also influenced by Martin Buber’s I and Thou.
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psychiatry and, by engaging Badiou’s triad of “being, event, subject” in the pairing of “trauma and event,” we may encountenance the possibility of announcing a new psychiatry of the event. Philosopher Alain Badiou Theory of the Subject Being and Event I & II Objective phenomenology Multiplicity Evental site Concerned with the uncounted
Psychiatry (proposed) Vincenzo Di Nicola “Trauma and Event”14 Evental psychiatry Relational psychology Predicament Liminality, threshold people
References Bolton, D. (2004). Shifts in the philosophical foundations of psychiatry since Jaspers: Implications for psychopathology and psychotherapy. International Review of Psychiatry, 16(3), 184–189; p. 185. Boring, E. G. (1953). A history of introspection. Psychological Bulletin, 50(3), 169–189; p. 170. Burt, C. (1962). The concept of consciousness. British Journal of Psychology, 53(3), 229–242; p. 229. Dawkins, R. (1989). The selfish gene. Oxford: Oxford University Press. Frankl, V. (1959). Man’s search for meaning: An introduction to logotherapy (trans. by Ilse Lasch, preface by Gordon W. Allport). Boston: Beacon Press Heidegger, M. (2001). Zollikon seminars: Protocols, conversations, letters, ed. by Medard Boss, trans. by Franz Mayr and Richard Askay. Evanston: Northwestern University Press. Jaspers, K. (1912). Die phänomenologische Forschungsrichtung in der Psychopathologie. Zeitschrift für die gesamte Neurologie und Psychiatrie, 9, 391–408. English Translation: “The phenomenological approach to psychopathology,” British Journal of Psychiatry, 1968, 114: 1313–1323. Jaspers, K. (1997). General psychopathology, trans. by J. Hoenig and Marion W. Hamilton (p. 55). Baltimore: Johns Hopkins University Press. Koestler, A. (1975). The ghost in the machine. London: Pan Books. Mayer-Gross, W. (1969). Clinical psychiatry (p. xiii). London: Baillière Tindall. Mollica, R. (2006). Healing invisible wounds: Paths to hope and recovery in a violent world (pp. 14–19). Orlando: Harcourt. Wann, T. W. (Ed.). (1964). Behaviorism and phenomenology: Contrasting bases for modern psychology. Chicago: University of Chicago Press. Watson, J. B. (1913). Psychology as the behaviorist views it. Psychological Review, 20, 158–177. Wittgenstein, L. (1991). In G. E. M. Anscombe, H. Nyman, & G. H. Von Wright (Eds.), Remarks on the philosophy of psychology Vol. 1, Oxford: Basil Blackwell, Vol. 2 (1994).
I am grateful to Alain Badiou for his “blessing” to entitle my work, “Trauma and Event,” in the spirit of this line of inquiry.
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6.1 Iterations of “Ellen West” – A Mirror of Twentieth-Century Psychiatry 6.1.1 V1.0 – Der Fall Ellen West On only one occasion do we see her eat something which, in contradistinction to all nourishment, only gives her joy, only gives her new strength, only “nourishes” her hopes, only serves her love, and only brightens her mind. But this something is no longer a gift of life but the poison of death. —Ludwig Binswanger (1958, pp. 293–294)
In 1944–1945, Ludwig Binswanger,1 a Swiss psychiatrist, published Der Fall Ellen West (Binswanger 1944), The Case of Ellen West, the founding case of Daseinanalyse – “existential analysis” and one of the most famous cases in modern psychiatry. Searching for a meaningful alternative to the reductive models of contemporary psychiatry, I began rereading this case and entered a labyrinth where I investigated the founders of clinical psychiatry, questioned phenomenology, discovered a “whodunit” mystery, and triggered a crisis of conscience as a psychiatrist. With his account of the treatment of a “non-Swiss” Jewish woman at the private sanatorium he directed, Binswanger proposes an analysis of “the existential Gestalt to which we have given the name Ellen West” (1888–1921). To do this, he consults the patient’s clinical notes as well as her private journal, poems, and letters to grasp the “totality of her existence.” Her two psychoanalysts are quoted – the first one, Viktor Emil von Gebsattel (1883–1976), whom she saw from February to August of 1920, sees hysteria, while the second, Hans von Hattingberg (1979–1944), whom
1 Ludwig Binswanger (1881–1966) came from a Swiss family with a long-standing medical tradition. His grandfather had founded the private Bellevue Sanatorium in Kreuzlingen (1857–1980) where numerous celebrated cases of twentieth-century psychiatry and psychoanalysis were treated, notably Freud’s “Anna O” (Bertha Pappenheim), Aby Warburg, and “Ellen West,” who was treated there from January to March 1921.
© Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_6
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she saw from sometime at the end of 1920 to January 1921, pronounces her a severe obsessional neurotic with manic-depressive oscillations. After two suicide attempts, a series of consultations with the founders of modern psychiatry begins. Emil Kraepelin (1856–1926), architect of today’s psychiatric classification, diagnoses melancholy (a profound depression akin to psychosis), while an unnamed “foreign” psychiatrist finds simple psychasthenia (obsessive-compulsive disorder). Binswanger has another idea – schizophrenia – confirmed by consultation with Eugen Bleuler (1857–1939), who named this emblematic condition of psychiatry (Woods 2011). Ellen West’s melancholy and suicide attempts persist, accompanied by serious eating problems. Convinced of her incurable diagnosis, more hopeless than ever, Ellen West demands to be released from hospital. After 3 days with her family, she appears transformed: she has breakfast, at midday she eats well for the first time in 13 years, and in the afternoon she goes for a walk with her husband, reads poems, and writes letters; all heaviness is lifted from her. In the evening, she takes poison. The next day, at the age of 33 years, Ellen West is dead. Writing more than 20 years after her death, when most of the principals of the case are also dead, Binswanger assures us no less than 17 times that her suicide is “authentic.” Who was he trying to convince? Was her death an “authentic suicide” as he insists, an “assisted suicide” (Akavia 2008), or a case of “psychic homicide,” (Lester 1971) a kind of soul murder? Stripped down, little in Binswanger’s account supports the diagnosis of schizophrenia and then an incurable disease. Binswanger consults a foreign psychiatrist who can now be named, Alfred Erich Hoche (1865–1943), known to support euthanasia for life unworthy of life;2 all therapy is suspended; and, in spite of her suicidal plans, she is discharged home where her husband provides the poison that kills her (Akavia 2008). In spite of the efforts of many great twentieth-century thinkers – from her psychiatrists to later psychiatric readings by Mara Selvini Palazzoli (1982), R.D. Laing (1983),3 Salvador Minuchin (1984), and even philosopher Michel Foucault (1954) – “Ellen West” remains an enigma. The case of “Ellen West” is a mirror of twentieth-century psychiatry, but the issues and the risks that we find there are still relevant. And they speak to the debates about the state of psychiatry today. After more than 30 years as a practicing psychiatrist, this case makes me wonder: What is the mission of psychiatry? Is it to understand (Binswanger’s goal with existential analysis), to classify (Kraepelin’s and Bleuler’s contribution), or to heal (Freud’s contribution through psychoanalysis)? Are these different goals compatible or mutually exclusive? Critics of the case of Ellen West assert that she was misunderstood and mistreated. What lessons does her case demand that we learn, at last? Can we let her find a voice to express her suffering, as Minuchin tries to do in his family drama about her (Minuchin 1984)?
2 Alfred Hoche and Karl Binding (1920). Giorgio Agamben dedicates a chapter to this work (Agamben 1998). 3 R.D. Laing, The Voice of Experience (1983), pp. 53–62.
6.1 Iterations of “Ellen West” – A Mirror of Twentieth-Century Psychiatry
6.1.2 V2.0 – “Poor Little Rich Girl” [I]n this attempt at an existential analysis, we see psychiatric diagnostics carried to the extreme, and to the extreme of absurdity. —R.D. Laing (1983, p. 54)4
If a clinician’s task is to elucidate an accurate understanding of a case as a road map for treatment, then this is not possible with historical cases, such as Ellen West or Aby Warburg. If diagnosis is precarious and porous in a face-to-face encounter, imagine how much more difficult it is at a remove, despite Binswanger’s assumption that distance increases analytic objectivity. Ellen West would not live the same life today. We cannot rediagnose her although we can document what was done and examine the interventions to decide if the procedure was correct, like a court of appeal, which does not retry the case but reviews procedure to judge if mistakes were made. Adopting another legal term for our purposes, let us think of such mistakes as misprisions – misapprehensions. Most of the commentaries, while criticizing the original case report, cannot resist the temptation to “get it right,” to diagnose her “correctly.” Selvini Palazzoli is the most perceptive and coherent as a psychiatrist-psychoanalyst (this preceded her construction of systemic family therapy) (Palazzoli 1982). Minuchin is inconsistent in his account; while he criticized her diagnosis and let her have the last word in his play about her – “No” – he cannot resist the urge to diagnose her as anorexic, an illness in which he was a specialist (Minuchin 1984). Even feminists appropriate “Ellen,” discuss her experience under the rubric of eating disorders, as anorexia nervosa, simultaneously criticizing psychiatry and affirming its power by offering nuanced readings of her situation without confronting its inherent aporias. The single critical commentator that harshly criticizes Binswanger and refuses to offer a new diagnosis? R.D. Laing, who reads the case that he characterizes as “generally taken to be a standard work in its field, an exemplary model of its kind,” offering “a way to understand a human situation in human terms” with deep disappointment. “It is a tragi-comical paradox that Binswanger’s account is,” Laing judges, “a perfect example of just what he is striving, not desperately enough, not self-reflectively enough and self-ironically enough, to eschew, and leave behind.”5 Laing is constantly astounded at Binswanger’s distance, indifference, and even callousness in offering her husband the choice of transferring his wife to a closed ward or leaving with her. Her husband would accept only if a cure or great improvement could be promised. Acknowledging that “a release from the institution meant certain suicide” (Binswanger 1944, p. 266), Binswanger confirms his desperate prognosis and releases her. Three days later, unable to deal with life, Ellen West commits suicide, the poison provided by her husband. Laing addresses Binswanger’s methods for understanding “the existential gestalt to which we have given the name of Ellen West” (Binswanger 1944, p. 292) not through direct contact but through written documents such as poems, her diary and letters, and a report written by her R.D. Laing, op. cit., p. 54 R.D. Laing, op. cit., p. 54
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husband of her recollections told under hypnosis as directed by Binswanger. Laying this material out for his existential analysis, Binswanger is “dissecting a dead butterfly,” Laing complains, “not depicting the pathetic life of a defeated person.”6 Binswanger’s study exemplifies what it attacks, Laing continues, furthering the same “institutionalized depersonalized-depersonalizing objectivizing psychiatric diagnostic look” he disavows (Binswanger 1944, p. 62). Laing concludes his iteration of Ellen West with the pithy phrase, “poor little rich girl.”7
6.1.3 V3.0 – The Absent Body I was nothing. No one. A poor, mortified body, waiting for someone to take it. —Luigi Pirandello (2005)
Poor Ellen West! Not just Laing’s “poor little rich girl,” but icon, emblem, and mirror for a succession of discursive apprehensions and preoccupations. Among specialists in eating disorders, the case of Ellen West became the proving ground for the battle of theories contending to explain anorexia nervosa, which is among the two or three emblematic psychiatric conditions of the twentieth century. Clinicians, historians, and cultural theorists vied with each other to discover old cases, reveal hidden ones, and construct explanatory models. Barely aware of the aporias of conflating historical research with retrospectively or cross-culturally imposed disease categories, researchers combed the archives for cases of “holy anorexia”8 and “holy fast” (Bynum 1987) among the “fasting girls” (Brumberg 1989) across cultures and epochs with the reductive scythe of a misconstrued medical model.9 Feminist interpretations of eating disorders, including readings of Ellen West as suffering from anorexia nervosa, are intriguing, but they found a misunderstanding of what Badiou calls the subjectizable body (elaborated below in Sect. 6.1.7). Anorexia nervosa, a complex and very serious medical, psychiatric, social and human predicament (the mortality rate, e.g., is higher than in any other psychiatric condition), cannot be reduced to a “hunger strike” (Orbach 1986; see Di Nicola 1988) against social control in the form of patriarchy by women who are “fed up
R.D. Laing, op. cit., p. 55 Binswanger (1944, p. 62). This recourse to the vernacular, like Žižek’s invocation of “the truth is out there” in The Plague of Fantasies (1997, p. 3), is neither incidental nor gratuitous. After all, Laing wrote a book about Sartre’s philosophy with David Cooper called Reason and Violence (1964). His contribution was notably in a reading of Sartre’s Critique of Dialectical Reasoning – a rereading of Marx. Be sure, more than in another case discussion by him, Laing’s reading of Binswanger’s “Ellen West” is a revolutionary one. 8 Rudolph M. Bell, Holy Anorexia, with an epilogue by William N. Davis (1985) 9 See my monograph on the historical evolution and cultural distribution of anorexia nervosa: Vincenzo Di Nicola (1990). 6 7
6.1 Iterations of “Ellen West” – A Mirror of Twentieth-Century Psychiatry
and hungry.”10 There is a world of difference among the predicaments of a political prisoner like Bobby Sands on a hunger strike in a British prison, the ascetic-mystic Simone Weil voluntarily choosing to live on the rations meted out to prisoners of war, and someone who appears to starve herself (see Nasser and Di Nicola 2001). In Badiou’s terms, we may understand the feminist hypothesis as a protest against the reactive subjectivation of her body, but in her case, we must also explain a profound distortion of the body habitus and a desire for destruction. What we see in Ellen West is not fidelity to novation but adherence to stagnation. If we see her as traumatized (and I do), the case of Ellen West is an example of the improbability of trauma becoming an event. Let me be clear: the alternative to patriarchy and other forms of social control is not to starve, mutilate, or annihilate the body; neither is it to regress into dissociation, flee into fugue states, or take refuge in paranoid interpretations of the world. While we are moved by the suffering this represents, we would surely not wish this for anyone. There are healthy ways to take a stand, be faithful to an event, and change society. My position as a therapist has always been simple and coherent: instead of defenses, ruses, and incoherent confrontations and manipulations, we always have a choice to speak the truth in the simplest, most direct terms we can muster. Wasn’t Socrates – “an untaught man,” as he describes himself in his dialogue with Phaedrus – more simple, more direct than the tortuous, repetitious Sophists whom he so ably disarmed?11 A better understanding of Ellen West’s predicament is not an emaciated body on a “hunger strike” but rather (and this is much closer to her own words and dreams) the “absent body” (Leder 1990). It is instructive to compare her to Pierre Janet’s case of Nadia who shared a similar distaste and loathing for her physical being.12 Their goal did not seem to be an ascetic mortification of the body as kind of discipline, which in the Christian tradition originates with Paul (this is an approach to understanding Simone Weil),13 but a denial of the body that is so total as to lead to consciously, willingly to death. For Ellen West and Nadia, unlike Simone Weil, the goal is not a disciplined mortification to reach another plane, another kind of life, but a desperate denial of embodied being (New Advent 1911).
Marilyn Laurence, ed., Fed Up and Hungry: Women, Oppression and Food, foreword by Susie Orbach (1987) 11 What first caught my attention in Žižek’s The Plague of Fantasies (1997) is not the theoretical depth and complexity of his arguments but the clarity and directness of his examples, cf. “The truth is out there” about Michael Jackson. In “Billie Jean,” Jackson sang about false paternity claims, loudly proclaiming “I’m bad” and so on. If one listens carefully without distorting the message, people will say everything. Jackson lived a negation. 12 Pierre Janet’s case of Nadia is discussed by Binswanger in his case report; Binswanger (1944, pp. 331–340). 13 “If you live after the flesh, you shall die, but if through the spirit you mortify the deeds of the flesh, you shall live,” wrote the Apostle Paul in his Letter to the Romans 8:13. 10
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6.1.4 Making a Case: Iteration/Repetition If we cannot diagnose her, what is left for us in our reading of the case of Ellen West? What we can comment on are the iterations of her life. We cannot and should not pretend to treat her; she is not here before us and asks nothing of us. But we need to understand what makes her case so open to iteration/repetition. What makes of her life a “case,” beyond the obvious, that is, the fact that she was a patient and that Binswanger named his account, Der Fall Ellen West? What makes a “case”? Why do we remember Freud’s two women, Dora and Anna O, and that odd pair of males, The Wolf Man and The Rat Man,14 not forgetting his sole child case, Little Hans? And what of Phineas Gage, “the American Crowbar Case,” A.R. Luria’s The Mind of a Mnemonist, Binswanger’s Ellen West, Brenda Milner’s HM, or Oliver Sack’s man who mistook his wife for a hat? The usual answer for Freud is that it is their literary quality (he won the Goethe Prize for his contribution to German literary culture). As for family therapy, Sal Minuchin’s dramatization of Ellen West comes close but is not widely known, even among family therapists. One would think that working with families gives therapists access to material that is literally dramatic and worth recounting. In fact, the most famous lines about families come to us from Leo Tolstoy’s Anna Karenina, not from a family therapist.15 And why the poverty of famous case histories in other approaches? We can answer this best by considering two questions: What is a case? And, what makes a case canonical? 188.8.131.52 “A letter always arrives at its destination …” Lacan left us no notable patient histories (he told vignettes to highlight theoretical arguments), although his reading of Edgar Allan Poe’s story of “The Purloined Letter” has become canonical as a case study of the interface between psychoanalysis and literature (Lacan 1966). With his analysis of the stolen letter hidden in plain sight, Lacan concludes that “a letter always arrives at its destination”. There are several layers of “caseness” here. The movement is from a story by Poe that is a detective’s case, which becomes a case for the psychoanalytic movement with
I can still hear the echo of philosopher Alan Montefiore of Oxford at the time, pronouncing “Rat Man” as if it were a German-Jewish name, “Rotmann.” An instructive misprision. Cases are like that: they take on the names attributed to them, even when we know their real names. Freud’s case of “Anna O” is a different history than the life of Bertha Pappenheim. Binswanger’s “Ellen West” is different than the portrait of her that is emerging from recent research; see Naamah Akavia (2008). 15 In the opening lines of Anna Karenina, Tolstoy writes: “Happy families are all alike. Every unhappy family is unhappy in its own way.” While Tolstoy was a great writer, he was not a very good observer of families. Happiness is like the Event – unpredictable and open to change. It is unhappiness, like trauma, that is predictable and repetitive. 14
6.1 Iterations of “Ellen West” – A Mirror of Twentieth-Century Psychiatry
Marie Bonaparte and Lacan’s seminar, turned back into literature by Jacques Derrida (1987), and deployed as literature/case history in my therapeutic work.16 These two “cases” (Ellen West and “The Purloined Letter”) have something in common. In Poe’s story (or is it Lacan’s case?), the letter was hidden in plain sight, which is the key to its detection in Poe’s story and in Marie Bonaparte’s interpretation. In Binswanger’s case of Ellen West, something is hidden from us and no one commented on it for four decades! This withholding on his part is significant.
6.1.5 V4.0 – “A Life Unworthy of Life” The opening of a new path for reading this case does not concern her psychiatric diagnosis or even situating Ellen West historically and culturally, although that proves to be crucial. In Binswanger’s case –– that is, the writing of “the case of Ellen West” – something is missing. There is a lacuna, a gap. Missing, hidden, or suppressed? Let us settle on the word withheld. What is withheld is a name. The name of the real patient, of course, for which we are offered a pseudonym, “Ellen West.” It is neither a German name nor a particularly Jewish one. Did she come from the West? Based on the internal evidence of the case report and subsequent research, most likely. What is withheld is the name of the third psychiatric consultant. Recall that with Ellen West’s admission to the Bellevue Sanatorium in January of 1920, Binswanger became responsible for her care. Faced with crises, suicide attempts, and a deteriorating clinical situation, Binswanger arranged for consultations, popularly called “second opinions.” He consults Emil Kraepelin (whom we have already encountered as the founder of modern psychiatric nosography – “psychiatry’s Linnaeus”), one of the greatest living psychiatric authorities. Kraepelin pronounces her melancholic. Ellen West continues to deteriorate. Binswanger consults the unnamed “foreign psychiatrist” who diagnoses her as psychasthenic. These terms shift in their usage and import over time. We may understand them today as roughly equivalent to a profound depression (melancholia) and obsessive-compulsive disorder (psychasthenia). Finally, Binswanger elaborates a rather different hypothesis and a much more serious one: progressive schizophrenic psychosis. To confirm this, he consults his former professor and the man who coined the term, Eugen Bleuler. Recall, too, that Binswanger lists the previous treatments, naming the two psychiatrist- psychoanalysts (in passing, they are implicated in the controversy over what Freud called “wild psychoanalysis,” meaning that they did not receive the requisite training and participate as full members of the psychoanalytic movement). Viktor Emil von Gebsattel and Hans von Hattingberg are identified, and their diagnostic opinions documented.
In Letters to a Young Therapist (Di Nicola, 2011), I use the idea of a letter as a way to reframe therapy.
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All the medical opinions are there; all the names are not. Excepting her family members and the internists responsible for her care before entering Bellevue, everyone else is named in one way or another: “Ellen West” and her husband, Karl, von Gebsattel, von Hattingberg, Kraepelin, and Bleuler. Yet the “foreign psychiatrist” is not named. But what is his name to us? To generations of readers of The Case of Ellen West, nothing. Yet his name on a book will speak to us, and the name of the book will unravel this story – Die Freigabe Vernichtung Lebensunwerten Lebens, The Permission to Annihilate Life Unworthy of Life – by psychiatrist Alfred Erich Hoche and jurist Karl Binding published in 1920, the year before Hoche’s consultation with “Ellen West” and her death. Another iteration of Ellen West, Lebensunwerten Lebens, “a life unworthy of life” V4.0. This had always already inhabited Ellen West. To have it written like a destiny, like a sentence handed to her with authority, as part of the calling card of “Herr Prof. Dr. Alfred Erich Hoche, Freiburg im Breisgau,” must surely have been overwhelming. Recall now the dates: Kraepelin had died in 1926, Bleuler dies in 1939, Hoche dies in 1943, and Binswanger publishes his case in 1944–1945, at the height of the war, raging everywhere around neutral Switzerland, with millions of other “non-Swiss Jews” being enslaved or murdered.17 Of the psychiatrists who knew Ellen West, only von Gebsattel and Binswanger are still alive when the case is published. From the written case report, there is no way to know the dates of the case except by inference through knowledge of the consultants (e.g., that Kraepelin died in 1926). How are we to understand Binswanger’s gesture? Is it an unwitting portrayal of a life unworthy of life? Is it a sense of guilt for having been involved in such a judgement or in colluding with an assisted suicide? Is it an act of defiance against the Nazis by publishing a case about someone they considered unworthy (as she was both Jewish and mentally ill)? Recent research has unearthed an archive kept by Ellen West’s family clearly demonstrating that she and her family were against this consultation – with this particular consultant – whom Binswanger consulted notwithstanding their objections. A well-to-do Jewish family would have had knowledge of Hoche’s repute and of his book with Binding on euthanasia, whose criteria of “life unworthy of life” included the incurably mentally ill. We can now confirm that they did object (Akavia 2008).
6.1.6 Katechon – “That Which Withholds” Once again, we confront a cut. What was suppressed? What was redacted? Where is the elision? What is the lacuna? Where is the cut? In searching for the meaning of this cut, the psychoanalytic terms that come to mind are suppression versus
For a review of the text by Hoche and Binding in the context of German euthanasia and its impact on the Nazi justification for the Final Solution, see Walter Wright (2000).
6.1 Iterations of “Ellen West” – A Mirror of Twentieth-Century Psychiatry
repression. The difference is in whether the cut is consciously suppressed (within one’s control) or unconsciously repressed (one is unaware of the cut). Another term is negation. Certainly, Laing was taken by Binswanger’s repeated insistence that Ellen West’s suicide was authentic. The repetition gives it the force of negation. Yet, it is not adequate simply to invoke a negation. While suppression would have dictated silence, not publication, a negation implies a statement to counter another statement, a position, a previous iteration. Where is the first iteration in this case? In his work on multitude, Paul Virno employs the notion of katechon as something withheld or restraining. Katechon is used by the Apostle Paul in his Second Letter to the Thessolonians as “the force that restrains” (Virno 2008). Virno explains katechon as “the device that ceaselessly postpones total destruction,” meaning the “end of the world” in theology or the “unraveling of the social order” in political thought (Virno 2008). To summarize a complex study briefly, Virno concludes that this is “a very particular kind of katechon, since it safeguards the ‘radical evil’ that it has engendered: the antidote, here, is no different from the poison” (Virno 2008, emphasis added). Virno uses the idea to establish a political position against negation, to negate a negation, as it were. As he puts it, to place “not” in front of “not human.” A final detail in Binswanger’s text is salient. In describing the single instance when Ellen West eats with joy for nourishment, noted as the epigraph to this section, he adds that it is “no longer a gift of life but the poison of death.” It was an exception that could not persist. The translators add a chilling footnote: “The German word Gift has the common meaning of poison and the less common meaning of gift” (Binswanger 1944, p. 294). I want to make two points. First, katechon is an example of a Janus-faced term at the bivalent core of our foundational notions. Katechon (from Greek: τὸ κατέχον) may be translated as both “the force that restrains” and “that which withholds.” Second, I believe that this covers the empirical possibilities of Binswanger’s action in withholding the information. Did he wish to restrain “evil” in a judgement against Hoche and himself, or did he withhold information in a paternalistic, protective gesture? Perhaps both? His gesture did not negate Hoche’s presence or negate Hoche’s negation (Der Vernichtung – “annhilation”) but merely held it in abeyance. Both Hoche’s presence in this case by his absence and Binsanger’s withholding are an impossible catachresis, which is invoked here as the “sealing over” or “covering” of a break, absence or aporia (Di Nicola, 2018). Even as a stop-gap, even as a temporary balm or salve, this wound cannot be sealed over.18 As for his treatment of Ellen West’s symptoms, Binswanger did not negate her negation so that “one occasion” when she ate with joy, her exception, could become her norm, to eat, to live, and to experience her body differently. With this, Binswanger articulates another version of katechon with his thought that for Ellen West, food is a Gift – poison and gift. A katechon, then, functions dialectically like the Gift, the pharmakon, the skandalon, and Achilles’ spear, cutting both ways, acting as poison and as remedy.
18 As was the case with Philoctetes whose wounded foot (the accounts differ as to how) festered and was malodourous resulting in his being abandoned on the Island of Lemnos by the Greeks.
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Now let us examine the rhetorical tropes of this story. How is Ellen West apostrophized? What is withheld, withdrawn, or occluded is another catachrestic sealing over, rendering something inoperative. (In fact, it was only deferred, postponed for four decades.) The katechon deferred our more complete understanding of the case of Ellen West, and one way to understand the equivocations of her treatment as well as the subsequent mutually incomprehensible readings of the case is that the katechonic sealing over kept slipping off, acting like a self-mutilator who cuts herself and then keeps interfering with the body’s attempt to create a scar by picking at the scab. Having wounded Ellen West mortally, Binswanger, in attempting to send his letter to us without a complete return address – that is to say, missing a name – wounds himself just as he has wounded psychiatry gravely and existential analysis fatally. With authority in the polysemy of the word Fall in German, buttressed by the dramatic arc of the story he tells of her life and her ending as a suicide, it is not too fanciful a reading to translate and understand his title and her predicament as “The Fall of Ellen West.” With the revelation of a name that was honored by the Nazis for his contribution to euthanasia and the preparation for the Final Solution19 and knowingly withheld by Binswanger and with a more complete account of this open wound in the history of psychiatry, we finally receive the news of the death of Daseinanalyse, existential analysis. This notice of Daseinanalyse’s death was encased and sealed in plain sight, like Poe’s purloined letter, and palpable in its absence, like the pharmakos in Plato’s dialogues, in its first and heretofore canonical case.
6.1.7 Ellen West: A Case Study for Evental Psychiatry Now, having rid ourselves of the last vestiges of the romance of subjective phenomenology expressed in existential analysis, let us see what an evental psychiatry, instead of a psychiatry of trauma, has to offer. An evental psychiatry will be a science of “subjectivizable bodies,” as Badiou describes the “pivotal concept” of his philosophy (Badiou 2011a). Badiou’s “subjectizable body” posits three types of subject, each with key processes and emblematic situations: the faithful, the reactive, and the obscure subject. These types of subject fundamentally define the “attitudes” or possibilities of responding to the situation (Badiou’s description in Being and Event, BE I), the world (his description in Logics of World, BE II), or the predicament in my psychiatric formulation. Badiou calls these attitudes subjectivations that “prescribe” the three types of subject noted (faithful, reactive, obscure) (Badiou 2011a, p. 92).
Walter Wright (2000). See page on Alfred Hoche at the University of Minnesota Center for Holocaust & Genocide Studies. Available: http://www.chgs.umn.edu/histories/documentary/hadamar/racism2.html. Accessed 12 May 2020.
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184.108.40.206 Badiou’s Subjectizable Bodies Here is a sketch of Badiou’s three types of subjectivation (Badiou 2011b, p. 126): 1. Incorporation within the body: the subject responds with enthusiasm for what is new, with active fidelity to the event, which is “a perturbation of the world’s order.” This is the hallmark of the faithful subject.20 2. Indifference to the event: this reactive, conservative position typifies the reactive subject.21 3. Hostility to all that is new or “modern”: this intense response to “the new body as a malevolent foreign irruption that must be destroyed” the obscure subject wants to maintain tradition at all costs. In my synthesis of Badiou’s work with my investigations into trauma, I have constructed the following schema for an evental psychiatry. Our starting point is with the project of modernity which is the ambivalent container for unresolved issues concerning the subject and subjectivity. The positivist side of modernity concerns the boundaries of the subject and paradoxically aims to tame, stabilize, or erase subjectivity through technology. Neil Postman grasped this perfectly in his notion of Technopoly which he defines as “the surrender of culture to technology” (Postman 1993). “Technopoly,” Postman observed, “wishes to solve, once and for all, the dilemma of subjectivity” (Postman 1993, p. 158). Another side of modernity, which generates and celebrates all that is new, was described by Walter Benjamin and Asya Lacis (2007) in their essay on Naples as “porosity.”22 We may connect this porosity, an openness to what is new, along with a tolerance for ambiguity and for incompleteness, to Agamben’s reflections on witnessing, in order to define the features of the faithful subject: The faithful subject is marked by porosity (cf. Benjamin and Lacis), open to radical change and witnessing (e.g., Paul of Tarsus,23 Levi, Agamben) of desire through processes of absorption/incorporation. Two responses occur when porosity becomes a threat: dissipation or mimesis. These responses are described through these pairs: centrifugal vs. centripetal, dispersal vs. containment, and evacuation vs. encapsulation. The reactive subject, who is marked by dissipation, experiences rupture as trauma through a process of dispersal/evacuation. The obscure subject is marked by mimesis, whose emblematic experience is paranoia, triggered by failed attempts at containment/encapsulation.
Jean Piaget described this with the dialectical processes of adaptation he named Assimilation and Accomodation. 21 The indifference and hostility of the reactive and obscure subject are described in psychoanalysis as resistance. 22 Walter Benjamin and Asja Lacis, “Naples” (2007). 23 The Apostle Paul of Tarsus, known as St. Paul, will henceforth be referred to as Paul. 20
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In this scheme, the three types of subject – the faithful subject, the reactive subject, and the obscure subject – are accompanied by three key psychological states: desire, trauma, and paranoia. A number of dichotomous pairs describe how the subjects and the key psychological states interact: absorption/incorporation, where fidelity translates desire into openness or absorption (Foucault and Badiou call this subjectivation); dispersal/evacuation, where indifference means that trauma is experienced as dispersal and evacuation (Agamben calls this desubjectivation); and containment/encapsulation, where obscurity triggers paranoia through mimetic attempts of containment and encapsulation (resubjectivation). If we had to select one property in this schema that distinguishes subjects and their emblematic experiences, it would be what Badiou calls novation – allied with Benjamin’s porosity and elucidated throughout Agamben’s philosophical work in such terms as infancy, zone of indifference, indeterminacy, enjambment, indistinction, potenza, and threshold. The capacity of the subject to seek out, to imbibe, to inhabit, to tolerate, and perhaps to celebrate and rejoice in this quality and thereby enter threshold being is the final feature of this schema. This offers a new way to imagine both subjects and predicaments. To what should a faithful subject be porous? Open to what? Badiou would say to the Truth-Event, Levinas would say to the face of the other, and Žižek would say that the Big Event has already happened and we should be open to living with that. I believe that for Foucault it would be discourse or the enunciation. For Agamben, clearly, it would be the threshold of potenza: something that is always already coming, a future anterior, a lived present in the coming community. We will call it meaning because it will help us position subjects and their predicaments accordingly: The faithful subject is porous, neosemic, open to the incorporation of new meaning. “Happy families,” pace Tolstoy, are uniquely different from each other, each finding new ways to be happy in response to new predicaments. The reactive subject is leaky/dissipates, monosemic, oligosemic, asemic, such that there is a constriction or loss of meaning. “Trauma” means the loss of what Pasolini described as “the idea that I have always had of myself.” The obscure subject is mimetic, polysemic, whereby there is a surfeit of meaning. What is “paranoia” if not a surfeit of meaning, where Tausk’s “Influencing Machine” is always at work, generating new hypotheses as threats that must be examined and investigated? (Tausk 1933)
220.127.116.11 Subjectivating Ellen West and Her Circle Let us apply this model to the case of Ellen West. Several aporias await us there. The first one that strikes the psychiatric reader (and audience)24 is the variety and range of psychiatric opinions expressed about Ellen West’s predicament. What generated Each time I present this case to psychiatrists, I am struck by the genuine interest in understanding Ellen West, while some clinicians cannot resist pronouncing on her diagnosis.
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so much divergence of opinion on her case? The second issue is about the management of her case: why were so many consultants involved, and why was so much control exerted by her family, her husband, and her psychiatrist about the treatment choices? What is it about the case that engenders such confusion? We have dealt with a third issue which is why in a case that is so detailed and where details matter according to Binswanger’s method, are there so many elisions, lacunae? We can attempt to characterize some of the principals in the case in terms of types of subjectivation. Based on the material available in the case, we can characterize Viktor von Gebsattel, her first psychiatrist-psychoanalyst, as probably open to what is new for Ellen West and tried to be faithful to that, but the analysis was interrupted externally. As for Binswanger himself, his objective distance and epoché mask his indifference. We may provisionally place him in the reactive camp: he aligns with the family’s conservatism and medical authority. Notwithstanding his studious stance of neutrality, the choices he makes to manage the situation are strongly on the side of social norms, the patriarchal family, and the institutional logic of the Sanatorium. There is no question that Alfred Erich Hoche occupies the obscure position with latent hostility. To repeat, Hoche is for euthanasia for incurable cases and for passive acceptance of letting disturbed and hopeless individuals take their own lives. It is also known that he was adamantly opposed to Freud’s psychoanalysis and published on psychiatric nosology. Karl, Ellen West’s cousin and her husband, in what seems to be an arranged marriage, makes efforts to understand her, to join Ellen West in her reactive attempts to conform. Her family, represented by her father, appear to be a typically reactive upper middle-class family. All the “Institutions” in this case are Lacan’s Big Other – the family, the Sanatorium (Binswanger/Bellevue), academic psychiatry as authority (Bleuler/Binswanger), and medicine as state power (Binding/Hoche). Ellen West tried to be a faithful subject but could not, and it seems that she was not allowed to be faithful to her wishes and dreams. For example, her father forbade her engagements and interrupted her medical and psychoanalytic treatment. In response to being blocked, my hypothesis is that Ellen West becomes a reactive subject, such that the rupture becomes traumatic to her, where the key process is dispersal and she experiences a constriction and loss of meaning. First, she distanced herself from her own body, experiencing feels of dissipation psychologically (as “depersonalization,” which may have led Bleuler and Binswanger to call her schizophrenic). When these feelings became pervasive in her fantasies and dreams, Ellen West wanted to get away from her own body; this is dispersal. Systemic therapy calls the reactive position not indifference but homeostasis: it ensures stability and continuity; however, it also means stagnation. For this reason, I renamed it coherence which is the opposite of rupture and is precisely what generates what psychoanalysis calls resistance. Finally, when even these attempts to stabilize the trauma were met with extreme responses (the diagnosis of an incurable disease, the provocative consultation with Alfred Hoche, and a recommendation for closed treatment, in another section of the Sanatorium for more disturbed patients), Ellen West became more obscure,
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self- destructive. The obscure subject is destructive: the search for meaning through the Influencing Machine is at work, triggering paranoia and psychosis. Ellen West shuttles between reactive and obscure positions; this explains in part the multiple readings by her treating doctors and consultants. This inability to arrive at a stable view of her predicament is perpetrated even in subsequent readings of her case. As Freud would describe the situation, “Ellen West” is overdetermined. Now, let us take up the implications of this overdetermination and instability.
6.1.8 Caseness: A Wager Against Finitude As I have argued that a text is a form-of-life in Agamben’s terms, a case is reminiscent of his “whatever being.” We can never exhaust its meaning; we can never secure it, frame it, or fix it. A case, as a text, as a form-of-life is undecidable; insofar as it is a form-of-life, it is on the threshold. A case attempts to fix just enough elements in the flux of existence to find a place. It is an attempt to find a secure harbor in the Heraclitan flux. A case has just enough fixedness to establish its existence but enough porosity and iterability as to be pliable and open to reinterpretations. Three tropes come to mind to describe a case: A case is like a boat attached to a pier during a storm. It is tethered, but is it secure? It is simultaneously anchored and adrift; never fully in one state or the other. As the boat is floating and the storm and the agitated river pull it away, each reading and rereading attempts to “ground it,” to bring it in to shore a little more securely. Yet it resists: this is what makes it canonical. It is the tension between the promise of safety and the agitated flow of the river.25 A case is like a detective story: we all want to guess “whodunit” but we do not want it to end too quickly. The best detective stories, like Poe’s “The Purloined Letter” or Stanisław Lem’s The Investigation, have built-in possibilities and the capacity to surprise us. Sometimes they do so by staying stubbornly open, with unresolvable plots and fragmented narration that withholds critical information. (Dipple 1988) What makes a case canonical is its capacity to invite us to rediscover it, to reinvent it, to grasp its essence, and to fix it in place. Readers come to cases for different reasons, however – some to learn, to affirm its authority, others to defy that same
This grounding effort is precisely at play in philosophy ever since Kant’s wager on a foundation or ground for philosophical thought. Richard Rorty attempted to answer Kant by saying there is no ground except as an edifying choice – for Rorty, there is no “mirror of nature”; all our vocabularies are contingent and ironic. To be clear, I am not adopting either position: I do not believe in a grounding authority which establishes a canon, neither do I believe that the effort to stabilize a canon is baseless or without merit. It is the effort to do so that makes of our practices an endless dialogue. See Richard Rorty (1979, 1989).
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authority, and still others to establish their own authority (I think of Lacan reading Freud or Agamben reading Foucault). Agamben describes this spectrum with delicacy and precision. Citing Feuerbach’s notion of Entwicklungsfähigkeit (German, “capacity to be developed”), Agamben suggests that in taking a text as far as one can, one arrives at the limits of hermeneutics, “a point of undecidability,” where the distinction between the author and the interpreter is blurred. The interpreter, arriving at an asymptote, abandons the text under analysis to create his own (Agamben 2009, p. 13). Agamben’s reading of Foucault, on the apparatus in this instance, makes Foucault’s notion canonical for us. It is precisely his knowledge of the boundary between interpretation and creation that allows Agamben to read Foucault so fruitfully and to further his philosophical project. We may thus see that a case has this quality – Entwicklungsfähigkeit – awaiting us. This same quality invites us to move beyond the case, even when we continue calling it by the same name. For example, Lacan took a series of comments by Freud on the notion of Nachträglichkeit (belatedness or deferred meaning) and made of them a concept he named après- coup (after the event). We recognize the family resemblance but Lacan has moved beyond Freud. When I read Minuchin or Selvini Palazzoli describing Ellen West as an anorexic, I think they have moved beyond Binswanger’s Ellen West, describing possible realities but not hers. In the end, cases become canonical, like texts, to forestall death like Scheherezade in The Thousand and One Nights. The longer we tell the tale, the more often we retell it and embellish it, and the longer we live.26 These tropes concern the tensions between apprehension and security (the boat in the storm), suspense versus closure (the detective story), and deferral versus death (Scheherezade telling a tale to save her life). Cases terrify us. We want to resolve them, to stabilize them; we want to know “how it comes out.” Yet any “case” – from Poe’s Letter to von Kleist’s The Marquise of O– to Kafka’s “Odradek” – resists stabilization. In The Investigation, Lem taunts us with probability theory and other ways to attribute cause without agency, a “whodunit” without a who. Like all stories, cases are machines for interpretation and for immortality. This is what makes them a form-of-life and renders them canonical: they are our wager against finitude. In an essay about writing called “Negotiating with the Dead,” Canadian novelist and essayist Margaret Atwood asserts that: not just some but all writing of the narrative kind, and perhaps all writing, is motivated, deep down, by a fear of and fascination with mortality – by a desire to make the risky trip to the Underworld, and to bring something or someone back from the dead. (Atwood 2002, p. 156)
A letter may always arrive at its destination, but a case never comes to a close…
In supervision, I once asked Robert Langs, the enfant terrible of American psychoanalysts, what we would discover if we could secure the frame of therapy and truly hear what the analysand is trying to tell us to which he replied that we would rediscover Freud’s death drive. Robert Langs, personal communication, Montreal, 1985.
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6.2 C oda: Is There a Philosophical Analogue of the Case History? Like a psychiatric case, a police file, or an unresolvable plot, perhaps an aporia, an exemplar or an apparatus may also constitute a case. Of these, the apparatus is the most intriguing.27 In Foucault’s study of “a case of parricide in the 19th century,” in spite of the name of “Pierre Rivière” which appears in the title of the book, not an individual life history but the apparatus becomes a case (Foucault 1975). That is to say, it is not so much the brute facts of Pierre Rivière’s life, nor even his vécus, his lived experience, but rather what he makes of them and how they are represented in a given discourse that “makes a case.” Furthermore, other actors in this drama also “made their case,” the professions contending for authority, from medicine to the law, police, and other branches of government, in order to establish their jurisdiction over the case and to determine what kind of case it was to be. For Foucault, then, it is the ensemble of these contending cases to make a case that becomes the apparatus of his study. As Clifford Geertz put it in his anthropological research, “the shapes of knowledge are always ineluctably local, indivisible from their instruments and their encasements” (Geertz 1983, p. 4). Instruments and encasements – are these not apparatuses? And is this not, finally, the meaning of problematization in Foucault’s later work? “Problematizations formulate the fundamental issues and choices through which individuals confront their exsitence” (Gutting 2005, p. 103). As Foucault said of Nietzsche, his life is of a piece, madness, and all. The line is precariously drawn between madness and reason, as in the lives of many others who are not known to us first as cases, but as poets and thinkers, starting with Nietzsche himself, but also Friedrich Hölderlin before him in Germany (see Lombroso’s essay for his list of geniuses who succumbed to unreason, 1927), and Gérald de Nerval, Antonin Artaud, and Louis Althusser in France, and those survivor-suicides of “that which occurred,” Jean Améry, Paul Celan, and Primo Levi, perhaps. Each of these is problematized not by their marginality or their madness but by the issues and choices they confront. And can we imagine this as another version of Wittgenstein’s question which is simply a reflection on the consequences of this investigation for psychiatry and psychoanalysis: The philosopher’s treatment of a question is like the treatment of an illness.
See Giorgio Agamben (2009). In this reading of Foucault’s work, Agamben proposes that “the word dispositif or ‘apparatus’ in English, is a decisive technical term in the strategy of Foucault’s thought” (p. 1). Foucault defined this term in an interview, Michel Foucault (1980).
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pp. 28-54. In John P. Muller and William J. Richardson (Eds.), The Purloined Poe: Lacan, Derrida & psychoanalytic reading. Baltimore, MD: The Johns Hopkins University Press. Leder, D. (1990). The absent body. Owensboro: Owensboro Volunteer Recording Unit. Lester, D. (1971). Ellen West’s suicide as a case of psychic homicide. Psychoanalytic Review, 58, 251–263. Foucault, M. (1975). I, Pierre Rivière, having slaughtered my mother, my sister and my brother … (trans: Frank Jellinek). New York: Pantheon Books. Laing, R. D. (1983). The voice of experience: Experience, science and psychiatry. New York: Penguin Books. Lombroso, C. (1927). Influenza della civiltà nella pazzia e della pazzia nella civiltà [The influence of madness on civilization and of civilization on madness]. In: G. Lombroso (Ed.), Psicologia e natura. Studi medico-psicologico-naturalistici [Psychology and nature. Medico- psychological-naturalistic studies] (pp. 52-67). Torino: Fratelli Bocca, Editori. (Original essay published in 1856) Minuchin, S. (1984). The triumph of Ellen West: An ecological perspective. In Kaleidoscope: Images of violence and healing (pp. 195–246). Cambridge: Harvard University Press. Nasser, M., & Di Nicola, V. (2001). Changing bodies, changing cultures: An intercultural dialogue on the body as a final frontier. In M. Nasser, M. A. Katzman, & R. A. Gordon (Eds.), Eating disorders and cultures in transition (pp. 171–187). New York: Brunner-Routledge. New Advent. (1911). Mortification. In The Catholic Encyclopedia (Vol. 10). New York: Robert Appleton Company. Available: http://www.newadvent.org/cathen/10578b.htm. Accessed 4 July 2020. Orbach, S. (1986). Hunger strike: The anorectic’s struggle as a metaphor for our age. New York: Norton. Palazzoli, M. S. (1982). L’anoressia mentale: Dalla terapia individuale alla terapia familiare. Nuova edizione interamenta riveduta. Milano: Feltrinelli. Translated as: Self-starvation: From individual to family therapy in the treatment of Anorexia Nervosa (trans: Arnold Pomerans). New York: Jason Aronson, 1985. Pirandello, L. (2005). One, none and a hundred thousand (trans. by Samuel Putnam) (p. 37). Whitefish: Kessinger Publishing. Italian original cited in: Franco Basaglia, “Corps, regard et silence. L’énigme de subjectivité en psychiatrie” [Body, gaze and silence: The enigma of subjectivity in psychiatry] (1965), L’Évolution Psychiatrique (2007), 72, 681–690. Postman, N. (1993). Technopoly: The surrender of culture to technology. New York: Random. Rorty, R. (1979). Philosophy and the mirror of nature. Princeton: Princeton University Press. Rorty, R. (1989). Contingency, irony, solidarity. Cambridge: Cambridge University Press. Tausk, V. (1933). On the origin of the ‘influencing machine’ in schizophrenia (trans: Dorian Feigenbaum). Psychoanalytic Quarterly, 2, 519–556. Reprinted in: Journal of Psychotherapy Practice and Research, 1992, 1(2), 184–206. (Original published in German in 1919). Virno, P. (2008). Multitude between innovation and negation (trans: Isabella Bertoletti, James Cascaito and Andrea Casson) (p. 189). Los Angeles: Semiotext(e). Woods, A. (2011). The sublime object of psychiatry: Schizophrenia in clinical and cultural theory. Oxford: Oxford University Press. Wright, W. (2000). Peter Singer and the lessons of the German euthanasia program. Issues in Integrative Studies, 18, 27–43.
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7.1 “ Psychiatry Against Itself”: Radicals, Rebels, Reformers, and Revolutionaries1 7.1.1 Overview: A Philosophical Archaeology This chapter inverts the logic of anti-psychiatry to describe various movements critical of the profession as psychiatry against itself. Like Alain Badiou’s contrast of philosophers with anti-philosophers, anti-psychiatrists compel the established tradition of psychiatry to confront fresh problems with new perspectives to renew psychiatric thought. The dual themes that emerge from this study are tradition vs. innovation and negation vs. affirmation. This thesis is threefold: (1) What is intriguing about the psychiatrists associated with the anti-psychiatry movement and what unites them is negation. In each case, their work proceeds by a key critical negation, to the point that the defining characteristic of anti-psychiatric psychiatrists is precisely negation. (2) Each negation and how it was practiced made each anti-psychiatrist, depending on his temperament and circumstances, into a rebel, a radical, a reformer or a revolutionary anti- psychiatrist. (3) Each anti-psychiatrist wielded an instrument for change that I have coined Badiou’s sickle. Based on a key critical negation, each anti-psychiatrist resisted the suturing of psychiatry to a given subdiscipline, regional practice, or dominant ideology by separating it gently or more forcefully with Badiou’s scalpel, scissors, shears, scythe, or sickle to liberate psychiatry as a general theory and practice and return it to its originary task. 1 Prepared for a seminar on “Psychiatry and Social Science” (Department of Psychiatry, University of Montreal) that is also offered as a postgraduate course in the Faculty of Medicine on “Psychiatry and the Humanities.” Presented at the “Colloque Psy-ences: L’institutionalisation de l’esprit,” Dept. of Philosophy, Université du Québec à Montréal, June 8, 2017. The ideas were elaborated as part of my philosophical investigations for a doctorate in philosophy at the European Graduate School, Trauma and Event: A Philosophical Archaeology (Di Nicola 2012b).
© Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_7
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Four key twentieth-century Western psychiatrists who were critical of their field are examined through their basic attitudes and contributions to the redefinition of psychiatry. Scotsman Ronald David Laing (1927–1989) was a radical psychiatrist- psychoanalyst, returning psychiatry to its clinical roots, with his trenchant critiques of Ludwig Binswanger’s existential analysis and psychiatric practice generally, calling for social phenomenology, negating the mystification of mental illness by placing the suffering of the self in social, family, and political context. The French Jacques Lacan (1901–1981) was both a subversive psychoanalyst and a psychiatric rebel, affirming the centrality of Freud in his construction of psychoanalysis while rebelling against both the psychoanalytic and psychiatric establishment, negating the institutionalization of psychoanalytic practice, whether in the academy or in psychoanalytic institutes. Italian psychiatrist Franco Basaglia (1924–1980) was a reformer who instigated psychiatric deinstitutionalization around the world with his key text, L’Istituzione negata, “The Institution Negated” (1968) and by joining the Radical Party in the Italian Parliament that reformed Italy’s mental health legislation. As a psychiatrist, philosopher, and revolutionary, Martinican Frantz Fanon (1925–1961) negated nothing less than the claim of European psychiatry to universalism in his radical critiques of the psychology of colonization and identity formation, offering a more humane psychology on which to found psychiatry in a revolutionary program for a new society. Fanon’s critiques were far more trenchant than other anti-psychiatrists, with far-reaching impacts on critical theory, postcolonial studies and Marxist political theory, yet his project remained unfulfilled when he died all-too-young, bequeathing us psychiatry’s unfinished revolution. Two other critical thinkers are examined to complete this study. One is Hungarian- American Thomas Szasz (1920–2012) whom I characterize as a reactionary anti- psychiatrist in the guise of a progressive who negated the reality of psychiatric disorders. Szasz trivialized mental and relational suffering as mere “problems in living,” arguing against the majority of psychiatric disorders having biomedical origins, thus promoting the medical model in its most reductive form. In contrast with the other anti-psychiatrists, Szasz’s negation was destructive, leading the way to greater stigmatization of mental illness and diminished resources and services. Finally, the work of French psychologist and philosopher Michel Foucault (1926–1984) overshadows the entire discourse of anti-psychiatry, just as he informs and impels us to reorder medical perceptions and psychiatric thought, upending the very “order of things.” Foucault’s negation was the most disturbing to psychiatric thought because he questioned the very basis for imagining madness and reason/ unreason.
7.1.2 Psychiatry and Anti-psychiatry The imminent demise of psychiatry has been predicted for most of its history. —Tom Burns (2006)
7.1 “Psychiatry Against Itself”: Radicals, Rebels, Reformers, and Revolutionaries
The history of psychiatry rewrites itself so often that it almost resembles the self-serving chronicles of a totalitarian and slightly paranoid regime. One-time pioneers are suddenly demoted and deemed to be little more than package tourists. —J.G. Ballard (1996)
Anti-psychiatry (Wikipedia contributors, 2020a) became an umbrella term in the 1960s for a variety of critiques of psychiatry arising in many quarters – from sociology (Goffman 1961; Scheff 1975), anthropology (Bateson 1987), and psychology (Rosenhan 1972) to philosophy (Foucault 1973; Deleuze and Guattari 1977) and the larger perspective of humanism, lucidly articulated by Fromm (1955). And not least within psychiatry itself, with the term anti-psychiatry being coined by Cooper, a South African psychiatrist working in London with R.D. Laing (Cooper 1967). This critical chorus (cf. Critical psychiatry network, Wikipedia contributors, 2020b) joined a long tradition of biting satire and social criticism, using madness, folly, and their avatars to hold up a mirror to society. Each society has terms to characterize madness as a metaphor for various ailments, deviance, and disorder. In English, “bedlam” – a corruption in common speech of the Bethlem Royal Hospital, a psychiatric hospital in London where I trained – conveys what bordel signifies in French, a mess. English printmaker and pictorial satirist, William Hogarth (1697–1764) turned the place (Bethlem) and its near-homonym (bedlam) into a moral allegory, depicting “A Rake’s Progress” (1735) from a rich and reckless roué to a violent and insane inmate of Bethlem, mimicking the anonymous seventeenth- century “mad poem” – “Tom o’ Bedlam.” Deconstructing “crazy” in English, fou in French, pazzo in Italian, and louco in Portuguese or loco in Spanish requires critical skills in the footsteps of Michel Foucault (genealogy and archaeology), Jacques Derrida (deconstruction), and Giorgio Agamben (philosophical archaeology), as we shall see. From Erasmus’ The Praise of Folly and the “Feast of Fools” immortalized by Victor Hugo in The Hunchback of Notre Dame, this tradition has morphed into a sardonic scalpel for social dissection. In modern literature, we saw Louis-Ferdinand Céline’s Journey to the End of the Night (1932), set in an insane asylum, as was Stanislaw Lem’s debut novel, Hospital of the Transfiguration (1975), and more recently, Wittgenstein’s Nephew (1982) by Thomas Bernhard is a veritable screed against psychiatry, including this observation that “he lived with his so-called mental disease just as easily as others lived without it” (Bernhard 1989, p. 7, emphasis in original). This is precisely what Foucault asserted did not happen in the modern era and what R.D. Laing hoped to achieve, against the normative demands of family and society. Intriguingly, all three are autobiographical novels. Not forgetting theatre, there is Peter Weiss’ Marat/Sade (1963), set in the Charenton Asylum, with the Marquis de Sade as an inmate directing a play about the death of Jean-Paul Marat. In film, we have explorations of mind, madness, and society in Dusan Makavejev’s W.R.: Mysteries of the Organism (1971), Philippe de Broca’s The King of Hearts (1966), and two American films, Milos Forman’s One Flew Over the Cuckoo’s Nest (1975) based on Ken Kesey’s celebrated novel and the poignant Girl, Interrupted (1999) based on Susanna Kaysen’s memoir (1993).
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This is not a history of psychiatry and anti-psychiatry but an archaeology of their opposition in a dialectic of negation/affirmation. I employ a philosophical-historical method that Giorgio Agamben, following Kant and Foucault, calls philosophical archaeology: Provisionally, we may call “archaeology” that practice which in any historical investigation has to do not with origins but with the moment of a phenomenon’s arising and must therefore engage anew the sources and traditions (Agamben 2009).
Excursus: Philosophical Archaeology Giorgio Agamben traces the term philosophical archaeology from Immanuel Kant. An archaeology of the term itself reveals it to be embedded in successive strata of thought from Nietzsche’s “critical history” to Foucault’s “epistemological field, the épistémè,” where we see glimpses of Freud’s “regression,” Marcel Mauss’ “historical a priori,” Franz Overbeck’s “prehistory,” Georges Dumézil’s “fringe of ultra-history,” and Benjamin’s “prehistory and posthistory.” The link between psychoanalytic regression and archaeology was intuited by Paul Ricoeur, carefully elaborated by Enzo Melandri, and explicitly connected to the task of philosophy through Foucault by Agamben. In sum, Agamben constructs a genealogy from Kant and Nietzsche, connecting Freud and Foucault to forge a subtle and fertile method of philosophical inquiry.2
As Burns points out in his brief survey of psychiatry, “Psychiatry has always been controversial – there was never an extended ‘Golden Age’ of peace and tranquility when everyone was in agreement” (Burns 2006, p. 84). In fact, the most trenchant critiques came from within psychiatry by psychiatrists, who after all, have to live with the limits and misdirections of our field. These include many anti- psychiatric psychiatrists in most Western countries. After its articulation in the 1960s and 1970s, anti-psychiatry provoked much stocktaking on the part of psychiatrists, often with polarized responses. A key exception was Anthony Clare’s Psychiatry in Dissent in 1976, which engaged the criticisms seriously in language that was both professional and accessible to a larger public.3 A collection of interviews with distinguished psychiatrists from around the world addressed the critiques and discontents of psychiatry, including anti- psychiatry, with deeply informed and serious responses (Shepherd 1982a). Thomas
2 This précis of Agamben’s method is adapted from my doctoral dissertation, Trauma and Event: A Philosophical Archaeology (Di Nicola 2012b). Cf. Watkin (2014). 3 Clare (1976). Two opposing reviews noted that Clare’s survey was hardly dissenting but rather a defence of “orthodox psychiatry,” while a later review described it as “psychiatry in disarray.” These are partial truths. Clare, who was my teacher at the Institute of Psychiatry, engaged the controversies honestly with a balance of studies, clinical experience and rational arguments and many young people learned of both the controversies and the balanced answers of a committed, rational psychiatrist.
7.1 “Psychiatry Against Itself”: Radicals, Rebels, Reformers, and Revolutionaries
Lambo, a Nigerian psychiatrist who was Deputy Director-General of the World Health Organization, noted that since “the anti-psychiatry movement is not a new phenomenon,” it was more accurate to speak of its “re-emergence in recent years” due to “many factors, social, economic, religious and cultural” (Shepherd 1982b, p. 115). The term critical psychiatry was used in a key British text in 1981 and appropriated by the Critical psychiatry network, a group of British psychiatrists founded in 1999.4 A survey article compares anti-psychiatry, early critical psychiatry, critical psychiatry, and postpsychiatry (Wikipedia contributors). Today, academic psychiatrists tend to acknowledge anti-psychiatry as part of the counterculture, as blind alleys or as counterexamples to the story of the scientific progress of psychiatry (See Lieberman 2015; Nasser 1995; Nasrallah 2011). One of the central issues has been to what extent psychiatry is a branch of medicine and whether mental illness can be understood through the medical model.5 Burns summarizes it well: “Psychiatry’s medical pedigree gives reassurance yet few of us believe that it is really just a branch of medicine” (Burns 2006, pp. 132–133, emphasis in original). Burns goes on to explain why: The mind is not the same as the brain. The defining characteristics of mental illnesses (and consequently psychiatry) remains their impact on our sense of self and on our closest relationships. Working with these is the hallmark of psychiatry (Burns 2006, p. 133).
I agree that the mind is not the same as the brain, which has been forcefully articulated by Kagan (2006), a leading developmental psychologist, and a leading medical researcher of geriatrics, Raymond Tallis (2011), but I have a different approach: psychiatry is a branch of medicine insofar as medicine concerns itself with the health of human beings, very broadly conceived, something I have argued for and documented all of my career (Di Nicola 2012a). Along with Michel Foucault, I was a reader of Ivan Illich who wrote Medical Nemesis, an indictment of the medical establishment (Illich 1992)6 which ironically motivated me to go into medicine in order to practice a broader and more inclusive notion of health. So, if in attending to subjective experience, the experience of illness and not just of disease, of understanding family, social, and other interpersonal relations, including cultural and political contexts and the natural environment, psychiatry is not acting as a branch of medicine, then medicine has become an impoverished and limited field. What is true for psychiatry is true for medicine. This understanding of the mission of Ingleby (1981). Cf. Bracken and Thomas (2010) See Samuel Guze (1992). In my own work, I argue for a variety of models of the determinants of health, from the family context (Di Nicola 1997a) to the social and cultural determinants of health (Di Nicola 2012a). 6 Illich (1975), p. 11. It is worth citing the entire first paragraph of this text: “The medical establishment has become a major threat to health. Dependence on professional health care affects all social relations. In rich countries medical colonization has reached sickening proportions; poor countries are quickly following suit. This process, which I call the ‘medicalization of life’, deserves articulate political recognition. Medicine is about to become a prime target for political action that aims at an inversion of industrial society. Only people who have recovered the ability for mutual self-care by the application of contemporary technology will be ready to limit the industrial mode of production in other major areas as well.” (emphasis added) 4 5
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medicine is shared by many leaders in psychiatry (Shepherd 1982a, b). Assen Jablensky, a psychiatrist of Bulgarian origin working as a Senior Medical Officer at the Division of Mental Health, WHO, described debates about a “medical model of disease” versus a “sociological model of deviance” as a “pseudo-dilemma” since: a search for a monolithic ‘medical model’ would be in vain, not least of all in psychiatry, where the parallel recognition of sociogenic causation and organic determinism has been part and parcel of the dialectics of its development since the early nineteenth century. with: (Shepherd 1982c, p. 70)
Rather than criticizing psychiatry for its identification with a simplistic medical model, I would argue that medicine should be expanded to include everything that we know is salient for the understanding and treatment of human health predicaments (Di Nicola 2012a). In order to achieve this enlarged view of the mission of medicine and psychiatry, psychiatry must engage anti-psychiatry in order to be more responsive to the current predicaments of health. For this study, I have selected four key figures in the anti-psychiatry movement, with two simple criteria: first, that they be practicing psychiatrists rather than academics or researchers. With very rare exceptions, neuropathologist Sigmund Freud and pediatrician Donald Winnicott being two of the few, non-psychiatrists do not generally shape the practice of psychiatry; non-clinicians have even less impact on the practice of psychiatry, so that Gilles Deleuze and Félix Guattari are known to only a minority of today’s psychiatrists. Two outstanding exceptions to this rule are anthropologist Gregory Bateson, notably with his double-bind theory of schizophrenia and his impact on systems theory and family therapy, and sociologist Erving Goffman whose work on the asylum contributed significantly to the movement for deinstitutionalization. The second criterion is that they have a body of writing that is accessible to me in the original language. I chose R.D. Laing, a Scottish psychiatrist-psychoanalyst who wrote in English; two psychiatrists who published in French – the French psychoanalyst Jacques Lacan and the Martinican revolutionary Frantz Fanon; and finally, Franco Basaglia, a fellow Italian who published in Italian and French. Each of them had important links with philosophy. Jean-Paul Sartre wrote prefaces to books by Laing and Cooper (1964) and Fanon (1968); Louis Althusser had important debates with Lacan, later taken up by his student Alain Badiou who engages Lacan as an anti-philosopher (Badiou 2011; Badiou and Roudinesco 2014); and Basaglia studied the works of existential psychiatrists Karl Jaspers, Ludwig Binswanger, and Eugène Minkowski and phenomenologists from Edmund Husserl and Martin Heidegger to Maurice Merleau-Ponty and Jean-Paul Sartre. Sartre himself offered a “sketch for a theory of the emotions” before integrating many of the ideas, notably consciousness, on which he insists against psychoanalysis into his major work, L’Être et le Néant (Being and Nothingness) (Sartre 1994). In fact, many philosophers in the last century and more have concerned themselves with psychology, psychiatry, and psychoanalysis, and the practitioners of these fields have turned to philosophy for edification (inspiration, consolation) on one hand and grounding (validation, justification) on the other. Psychiatric and philosophical thought are deeply imbricated in each other.
7.1 “Psychiatry Against Itself”: Radicals, Rebels, Reformers, and Revolutionaries
Unlike such figures as Félix Guattari in France or Wilhelm Reich in the USA, they all underwent mainstream, orthodox psychiatric training to which they made important contributions before their respective – and redefining – breaks with tradition.7 None of them identified with David Cooper’s term anti-psychiatry; his close associate R.D. Laing specifically eschewed the term, as did Franco Basaglia (Lagrange 2008). Frantz Fanon died before the term was coined. They were psychiatrists in the European mainstream who affirmed their psychiatric identity through a negation. That is why I read their work as “psychiatry against itself.” I will nonetheless ironically refer to them as anti-psychiatrists. What is intriguing about these figures is how they proceed by negation. Their resistance to psychiatry is marked by negation! Each figure has a key critical negation that marks their resistance. In this sense, these anti-psychiatrists are very much like Badiou’s “anti-philosophers.” Excursus: Philosophy and Anti-philosophy Anti-philosophy makes philosophy more contemporary by being more responsive to present-day problems (Badiou 2011; Badiou and Roudinesco 2014). Anti-psychiatry ensures that we do not slide into the traumatic repetition of authority in the name of tradition.
Anti-psychiatry compels psychiatry to be contemporary, to respond to its current challenges, not fall asleep into academicism and the tired repetition of authority. So while academic and institutional psychiatry, like any established profession, will tend toward conservatism, anti-psychiatry will always rouse it from its slumber to confront new problems and to update itself. For this reason, psychiatry can never rest. We will always need resistance to authority, challenges to established practice, and calls for change. This is the real meaning of what thinkers as diverse as Tom Burns (a British academic psychiatrist), J.G. Ballard (a British counterculture writer), and R.D. Laing (a Scottish psychiatric radical) perceive as the instability of psychiatry’s identity. Just as philosophy cannot be sutured to its conditions (or truth procedures), psychiatry cannot be defined by or reduced to its subdisciplines. Eric Kandel, a psychiatrist who had studied psychoanalysis and won the Nobel Prize for his research on memory, identified the concept of “disciplines and antidisciplines”: As pointed out by a number of students of science, most recently by the biologist E.O. Wilson, there exists for most parent disciplines in science an antidiscipline. The antidiscipline generates creative tension within the parent discipline by challenging the precision of its methods and its claims.8
Kandel describes the creative tensions between psychiatry and its subdiscipline neurobiology, in turn between cellular neurobiology and molecular biology at a I first made this observation in my doctoral dissertation, Trauma and Event (Di Nicola 2012b). Kandel (1979). His title reflects the times, recalling Helen Gurley Brown’s (1962).
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more fundamental level, and, finally, between molecular biology and physical or structural chemistry.9 He also introduces the useful idea that with advances in knowledge, not only do disciplines change so do the disciplines impinging on them, offering the example of psychiatry which has been nourished over time by its shifting antidisciplines – psychoanalysis, philosophy, and the social sciences – and since the 1960s, with advances in biology, neurobiology has become the privileged antidiscipline of psychiatry. Psychiatry’s subdisciplines have shifted over the last century. We can name four: 1. Body – Neurobiology and Neuroscience. Starting with Reil’s coining of the term psychiatry in 1808 and arguing for psychiatry as a branch of medicine, we have seen many avatars of this: Adolf Meyer’s psychobiology, psychosomatic medicine, biological psychiatry, psychopharmacology, and up until the current neurobiology which includes genetics, neurophysiology (mirror neurons), and neuropharmacology (endorphins). 2. Mind – Psychoanalysis, Phenomenology, and Cognitive Psychology. Understanding the “mind” and what is now called “mentalization” also has several different starting points:
(a) Freud’s psychoanalysis. (b) The phenomenologists, notably Jaspers, Minkowski, and Binswanger. (c) A third group of German, British, and American psychologists (three representative figures are Wilhelm Wundt in Germany, Cyril Burt in England, and William James in the USA) who influenced and brought back consciousness as a topic for psychology which has now, through cognitive therapy also penetrated psychiatry, notably in the work of Aaron Beck.
3. Relationships – Attachment Theory, Family Therapy, and Systems Theory. Family therapy had two undoubted masters in the twentieth century: Salvador Minuchin and Mara Selvini Palazzoli, both psychiatrists. Minuchin’s structural family therapy was a version of structuralism that had great internal coherence and consistency as a theory of the family, family problems, and therapeutic change; while Selvini Palazzoli had a more intellectually sophisticated model based on cybernetics, communications and systems theory, directly influenced by the work of anthropologist and systems theorist Gregory Bateson. In the 1980s, Minuchin predicted that family therapy would take over psychiatry. It had a strong influence for a time but its impact has receded. John Bowlby’s attachment theory, an integration of psychoanalysis and emerging research on child development seen from a dyadic perspective of parent-child relationships, con-
9 Contrast this with what Alain Badiou says in his Number and Numbers (2008, pp. 1–2): “[W]e live in the era of number’s despotism” … “And medicine itself, apart from its pure and simple reduction to its scientific Other (molecular biology), is a disorderly accumulation of empirical facts, a huge web of blindly tested numerical correlations. These are ‘sciences’ of men made into numbers, to the saturation point of all possible correspondences, between these numbers and other numbers, whatever they might be.” (Emphasis in original)
7.1 “Psychiatry Against Itself”: Radicals, Rebels, Reformers, and Revolutionaries
tinues to inspire research and is beginning to find clinical applications in couple and family therapy. 4. Sociocultural – Social Psychiatry, Epidemiology, and Transcultural Psychiatry. Turning to the broadest envelope for situating psychiatry – the sociocultural one – we may include here populational approaches, from social psychiatry, epidemiology, and public health on one side to transcultural psychiatry on the other. Each of these approaches enriches and invigorates psychiatry. None of them on their own can give a full accounting of what psychiatry is. We can understand anti- psychiatry as resistance to these sutures, as Badiou would have it, or reductions of the field to one subdiscipline. Today’s challenges are to resist the suturing or reduction of psychiatry to nonclinical domains. This challenge on its own is complex and has two elements: (1) there is a devaluing of clinical psychiatry based on a specious scientism, which is linked to positivist psychiatry, and (2) the perennial desire to found psychiatry on a scientific basis, which has shifted over the last century (recall that Freud was a true scientist of his time, having trained in neuropathology). These elements have triggered two dominant themes in current academic psychiatry – evidence-based medicine (EBM) and neuroscience: 1. Evidence-based medicine (EBM) along with best practices is a prescription for mediocrity, as it leads to uniform practices rather than a range of options explored by thoughtful practitioners. The necessary critique here comes down to two issues: What counts as evidence? and How do we come to such definitions? This puts into question nothing less than the models of scientific progress we subscribe to and whether those models are an adequate basis for medical practice (Bracken et al. 2012). 2. According to the powerful interests of academic psychiatry, the definition of a scientific basis for psychiatry now means neuroscience and genetics, which Raymond Tallis (2011) characterizes as “neuromania and Darwinitis.” The leading voice for this approach has been Thomas Insel of the US National Institute of Mental Health who has dismissed psychiatry’s standard model reflected in the DSM project as a “mere dictionary.” After the failure of various versions of existential psychiatry to get traction (despite its energetic espousal by many leading thinkers in the last century, from Jaspers to Laing, each accompanied by major European philosophers, from Husserl to Sartre), in the USA psychiatry moved to a psychodynamic model, and the standard model for many decades was psychodynamic psychiatry. As challenges to this standard model mounted, from behavioral psychology to psychopharmacology to epidemiology and public health, not excluding the “therapy wars” from Carl Rogers’ client-centered approach to couples and family therapy, the standard model attempted to be inclusive in the guise of the biopsychosocial model (BPS) (Ghaemi 2012). Since movements have as many motivations as adherents, many things are true for the adoption of the BPS model over the psychodynamic one, generally sincere and well-motived as each point of view offered new ways of thinking and new practices. Nonetheless, other forces account for the adoption of the BPS model within the
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DSM project as psychiatry’s new standard model, which held sway from circa 1980 (when DSM-III was launched) until the launch of DSM-5 in 2013 which caused a war within US academic psychiatry. Together, BPS and DSM was a radical volte-face away from psychodynamic psychiatry in the name of inclusiveness (BPS) and reliability of diagnoses (DSM-III). Sadly, this era was precisely the opposite of inclusiveness and saw the predominance of biological thinking reflected in the growing use of psychopharmacology, eventually given way to neuroscience and genetics. Nonbiological interventions became increasingly positivistic, stressing operational criteria for both diagnoses and therapeutic goals, in behaviorist terms with the addition of cognitive elements to create cognitive behavioral therapy (CBT) with manuals, highly standardized procedures, and a cottage industry for training and providing therapy. Codified manuals, hierarchical training, and vigilance over “drift” from the established model led to CBT increasing its hegemony to the point that some countries with public health systems adopted CBT as the privileged model for mental health services. Psychiatry cannot allow itself to be defined by or reduced to its subdisciplines, which change over time as the questions and our methods to deal with them shift. Inspired by Badiou’s work on philosophy and its conditions, I have named a philosophical tool I call Badiou’s scythe as an instrument of discernment and separation. Excursus: Badiou’s Scythe Following his teacher Louis Althusser’s notion of general theories and regional theories, Badiou argues that philosophy as a general theory cannot be sutured or subordinated to a regional theory or a condition such as science or psychoanalysis. I name the philosophical gesture of discerning the boundaries of general and regional theories (Althusser), philosophy and its conditions (Badiou), or disciplines and subdisciplines (Kandel) and the operation of separating them after Badiou. This gesture or operation may be described as a dispositif, apparatus, or tool – after Foucault – and we may give it a series of names, depending on the range of power with which it is deployed: Badiou’s scalpel, Badiou’s scissors, Badiou’s shears, Badiou’s scythe, or Badiou’s sickle.10
In this light, it is valuable to examine anti-psychiatry. My thesis here is threefold: 1. Anti-psychiatry proceeds by a key critical negation of the psychiatry of its time and place. Each one of the four mainstream psychiatrists who became noted for their anti-psychiatry negated a key element of psychiatry.
Di Nicola (2012b). At my doctoral defence, Slavoj Zizek quipped that if Alain Badiou bore a sickle, he would be obliged to swing a hammer.
7.4 R.D. Laing: A Radical Return to Psychiatry’s Roots
2. Furthermore, each negation and how it was practiced made each psychiatrist (along with their temperaments and the vicissitudes of their lives – what Machiavelli called virtù e fortuna, “character and contingency” in my translation) – into a rebel, a radical, a reformer, or a revolutionary anti-psychiatrist. 3. Finally, each psychiatrist and the anti-psychiatric movement that he represents wielded an instrument for change that I have coined Badiou’s scythe. Based on a key critical negation, each anti-psychiatrist resisted the suturing of psychiatry to a given subdiscipline, regional practice, or dominant ideology, attempting to liberate psychiatry as a general theory and practice and return it to its originary task of understanding the human mind and its vicissitudes and to alleviate the suffering thereof. Excursus: On Negation Negation is a way of taking cognizance of what is repressed; indeed it is already a lifting of the repression, though not, of course, an acceptance of what is repressed. – Freud, “Negation” (Sigmund Freud 1953–1974) Freud’s notion Verneinung in German, was rendered as (dé)négation in French, i.e., négation/dénégation in a construction with Derridean overtones, and translated as “negation” in English. In ordinary German usage, Verneinung denotes negation and denial, and verneinen comes close to verleugnen, “to disown, deny, disavow, or refute” (Laplanche and Pontilis 1973, p. 236). In his 1925 essay on negation, Freud effectively separates the notion of denial as repression (keeping things out of conscious awareness) from negation as a resistance to what surfaces when the repression is acknowledged. In later work, Freud further differentiated negation with the term Verleugnung or disavowal, “the refusal to perceive a fact which is imposed by the external world” Laplanche and Pontilis (1973). Freud used the interpretation of dreams to illustrate the differences. What is repressed in waking life is a form of denial that may come out in a symbolic way in a dream; when the dream is interpreted, the reaction denying the interpretation is a negation, whereas disavowal is negation in the face of external reality. Negation is a key concept for both psychoanalysis and philosophy. The link here is through Lacan’s use of Freud’s Verneinung in French as dénégation (rendered more simply as “negation” in English). Slovenian philosopher Slavoj Žižek brings the two together in readings of two major European thinkers – French psychoanalyst Jacques Lacan and German philosopher G.W.F. Hegel – thinking through the psychoanalytic negation in philosophy and the philosophical negation in psychoanalytic theory (Ver Eecke 2006). Negation has been a topic in logic since antiquity, but what Hegel brought to it is the notion that the double negative (negation of a negation) is not a simple undoing leading to an affirmation but a process that leaves traces of negation in its wake. The double negative is not a “zero sum game” but a dialectical struggle that permeates thought.
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7.2 A nti-Psychiatry: “Negation and Its Vicissitudes” (Cf. Baudry 1989) There are many varieties of experience of lack, or absence, and many subtle distinctions between the experience of negation and the negation of experience. – R.D. Laing (1967, p. 32)
The negation of anti-psychiatry is complex and embraces several elements defined in psychoanalysis and philosophy (see Excursus on Negation). Sometimes, anti- psychiatric negation disavows or rejects some aspect of psychiatric theory or practice. For example, institutionalization and coercive treatment in psychiatric practice were countered by Franco Basaglia’s anti-psychiatric measures to deinstitutionalize psychiatric patients in Italy and offer voluntary treatment with truly informed consent and real choices. At other times, anti-psychiatry uncovers some masked truths, and psychiatry responds with a negation that confirms the truth of the belief or practice. R.D. Laing and Jacques Lacan, for example, both rejected Karl Jaspers’ notion of a phenomenological chasm (Jaspers 1997) between psychiatrist and psychotic patient, arguing for the accessibility and intelligibility of psychotic experiences, however complex and laborious, and their writings are full of such efforts. Psychiatry responded to this negation of the phenomenological chasm with a series of negations that do not bring us back to square one and leave us unconvinced. The first negation argues that the psychotic produces a kind of unintelligible “word salad.” Second, when the likes of Silvano Arieti11 in psychoanalytic psychiatry and Gregory Bateson and associates (1987) in anthropology and family therapy attempted to show that schizophrenic communication may be meaningful, psychiatry answers that it is too difficult, time-consuming, and ineffective. Third, psychiatry answers that in any case, the diagnosis is not based on the bizarre content of thought and speech but the abnormal form of it, reflecting a biological disease process of the brain. This is reminiscent of “kettle logic,” based on Freud’s invocation of the joke about the borrowed kettle whereby the neighbor, accused of returning a kettle in damaged condition, responds with a series of incompatible and irrational denials, viz., that he had returned the kettle undamaged, that it was already damaged anyway, and, finally, that he didn’t borrow it in the first place! Denial, opposition, and contradiction are mixed uncritically in the logic of dreamwork, where, as Freud famously asserted, there is no “no,” and the law of noncontradiction is violated (Mills 2004). In a scientific discourse and in the construction of an ethical profession, on the other hand, we expect rationality even in the face of unreason.
Arieti (1974). Winner of the US National Book Award in Science, this masterful review of the available evidence on schizophrenia – from individual and family studies to social and transcultural studies and the biological aspects known at the time – concludes that it is not a disease in the classic sense and is amenable to psychological understanding and treatment.
7.4 R.D. Laing: A Radical Return to Psychiatry’s Roots
7.3 Alienation Is a Negation [I]t is not accidental that aliené, in French, and alienado, in Spanish, are older words for the psychotic, and the English “alienist” refers to a doctor who cares for the insane, the absolutely alienated person. – Erich Fromm (1962, p. 41)
Living and fighting in wartime Martinique and Europe, training in medicine and psychiatry in France and then practicing in France and Algeria, Frantz Fanon confronted even more complex instances of negation. In the context of colonialism, there was a double alienation where the alienation of the psychiatric patient was compounded by the alienation of colonization. It is fascinating to note that alienation takes on both a psychiatric and a political dimension and we find in all European languages the alienation of social and political theory along with the mental alienation treated by alienists, an older term for psychiatrists.12 And just as we can invert psychiatric alienation as a kind of separation from a “sane” (i.e., authentic and healthy) way of living, whereby it can be understood as an understandable response to an alienating environment, so too we confront the topsy-turvy logic of colonization imposing foreign medical and social categories of living to pronounce on the alienation of the locals perceived by aliens (foreigners) and alienists (psychiatrists). Fanon dissects these forms of alienation with clinical precision, examining first how the native patients respond to the clinical situation with a negation of their inmost selves – wearing, in the arresting image of his first book – “white masks” over their “black skins” (Fanon 2008). Fanon then examines with growing political awareness how the alienists themselves are separated from their patients in spite of their medical tasks which are at odds with local culture, including and perhaps most painfully in the case of the alienist who comes from the same culture and, by dint of his training in European medicine and psychiatry, comes to attend to his countrymen, a situation creating a negation (the native co-opted by colonizer) of a negation (European colonization) of a negation (psychiatric alienation).
7.4 R.D. Laing: A Radical Return to Psychiatry’s Roots Scotsman Ronald David Laing (1927–1989) was a radical psychiatrist- psychoanalyst, returning psychiatry to its clinical roots, with his trenchant critiques of Ludwig Binswanger’s existential analysis and psychiatric practice generally, calling for social phenomenology, negating the mystification of mental illness by placing the suffering of the self in social, family, and political context.
Psychiatrists are among the severest critics of psychiatry. – R.D. Laing (1983, p. 45)
Cf. Littlewood and Lipsedge (1997). Joaquim Maria Machado de Assis, a Brazilian mulatto and son of freed slaves, wrote a famous novella about an alienist who applies his ever-growing criteria for mental maladies to more and more of the population until he ends up admitted himself in his own asylum, The Alienist (2012).
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While his writings are sprinkled with comments critical of orthodox psychiatry, Ronald Laing was always looking for openings within that tradition: One movement within orthodox institutional psychiatry in the direction of trying to restore, at least theoretically, the humanity of the person lost in psychiatric theory and practice has been existential psychiatry (Laing 1983, p. 45).
Laing negated Ludwig Binswanger’s phenomenology in his reading of the case of Ellen West (See: Binswanger 1958; Laing 1983, pp. 53–62; Di Nicola 2011). More importantly, he negated anti-psychiatry, calling himself a “conservative revolutionary.” In my reading of psychiatric and psychoanalytic history, Laing was not a revolutionary. By negating, he affirmed the tradition of clinical psychiatry in the mold of Karl Jaspers and psychodynamic psychiatry as practiced at the Tavistock Institute and Clinic in London, with clinically based arguments for understanding the modern version of madness – the “schizoid and schizophrenic” patients he described in The Divided Self (Laing 1965). (See Excursus: Schizophrenia: “The Sublime Object of Psychiatry.”) Against Binswanger’s existential analysis based on Jaspers’ phenomenology, Laing proposed social phenomenology inspired by his reading of Jean-Paul Sartre (Laing and Cooper 1964; see Collier 1977).
Excursus: Schizophrenia: “The Sublime Object of Psychiatry” (Woods 2011; Szasz 1988; Laing 1965; Beveridge 2011; Itten and Young 2012; Collier 1977) For more than a century, from Emil Kraepelin (psychiatry’s Linnaeus) and Eugen Bleuler (who coined the term schizophrenia) to Kurt Schneider (who tried unsuccessfully to establish “pathognomonic” signs and symptoms that separate schizophrenia from other diseases or disorders), and then onto to the APA’s DSM project, especially after DSM-III (1980), defining schizophrenia has defined psychiatry. The tension is not just in the nomenclature and the issue of what is normal and what is pathological but also whether the experience of psychosis is alienating for the patient and for the psychiatrist. That is to say, is the psychotic experience part of a range of normative, widely shared experiences and therefore amenable to explanation, or is it a cut, a separator, or a chasm between normal and abnormal, as Karl Jaspers established with his hugely influential phenomenological approach to psychiatry? Now, the biologically oriented psychiatrists have tended toward seeing psychosis in the guise of schizophrenia as the modern madness, abnormal, and unintelligible. In spite of Jaspers, many phenomenological and humanist psychiatrists and those following the psychoanalytic movement have tended to see psychosis and schizophrenia as accessible and treatable predicaments. The latter include Silvano Arieti, R.D. Laing, and Jacques Lacan as psychoanalytic psychiatrists and a host of other approaches in anthropology, family therapy, and sociology.
7.5 Jacques Lacan: Psychoanalytic Subversive, Psychiatric Rebel
And yet, as Angela Woods concludes, we have already moved into another era (Woods 2011, pp. 220–224). The subject of “madness” and debates in the academy between clinical and cultural theorists no longer move the public or remain priorities for research funding. Just as Laing was responding to the notion of schizophrenia after several generations of efforts to grapple with it, the traumatized and displaced populations resulting from world wars, global conflicts, and terrorism became the emblematic social and psychiatric predicament of the latter third of the twentieth century, a period I have dubbed the “Age of Trauma” (Di Nicola 2012b). Yet, more disquieting still is the genuine possibility that in its pursuit of positivist science and its rewards, psychiatry has all but abandoned such debates and simply moved on to understanding the brain through neuroscience and genetics. Consciousness, language, and their vicissitudes have already been ceded to cognitive psychology, while therapy has been subcontracted to psychologists who administer cognitive behavior therapy (CBT) and family therapists and social workers who attend to the family and social aspects of mental illness. Accordingly, anthropologists, historians, and philosophers have shifted their investigations to these latter domains, as witnessed by the contemporary work of Patricia Churchland13 and Catherine Malabou (2012).
7.5 J acques Lacan: Psychoanalytic Subversive, Psychiatric Rebel The French Jacques Lacan (1901–1981) was both a subversive psychoanalyst and a psychiatric rebel, affirming the centrality of Freud in his construction of psychoanalysis while rebelling against both the psychoanalytic and psychiatric establishment, negating the institutionalization of psychoanalytic practice, whether in the academy or in psychoanalytic institutes. Man’s being cannot be understood without reference to madness, nor would he be man without carrying madness within as the limit of his freedom. – Jacques Lacan (1966, p. 176)
In her informative essay on French anti-psychiatry, Turkle (1981) points out differences between psychoanalysis in the USA where it was not generally employed for social criticism and in France where it became subservice, especially in the hands of Jacques Lacan. Much of Freud’s work positions psychoanalysis as a radical doctrine, but in the USA, medical professionalization defused what was radical in his
Patricia Smith Churchland (1986, 2013). See the review of the latter book by Colin McGuin (2014) and the exchange between Churchland and McGuin (2014).
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vision. Starting with a decision to limit the practice of psychoanalysis to physicians in 1927, American psychoanalysis joined American psychiatry in a “marriage of convenience” – American psychiatry was looking for a new paradigm, and psychoanalysts yearned for legitimacy. This privileged the development of psychoanalytic ego psychology that Turkle characterizes as “socialized” or even “domesticated” by American institutions and values “in the service of a better adaptation to reality.” As a result of this American marriage of convenience, anti-psychiatry has also meant anti-psychoanalysis in the USA. In France, on the contrary, psychoanalysis had early support in the artistic community, especially the Surrealists, and remained a stigmatized outsider in the medical and psychiatric establishment, positioning it strategically with the post-war anti-psychiatry movement. With the seismic cultural and political events of May 1968 in Paris pitted against all institutions, psychoanalysis was recruited to save psychiatry by offering psychiatric therapy out of the psychiatric institutions and into the community. This effort was led by medically oriented psychiatrists who were psychoanalytic but anti-Lacanian, recruiting psychoanalysis to improve psychiatry, much as in the USA. Yet the French psychoanalytic movement, especially the Lacanians, was attached to politics than to psychiatry. Who is this Lacan and what was his impact on anti-psychiatry? Jacques Lacan was a French psychiatrist and psychoanalyst. In Turkle’s reading, Lacan’s mantra of a “return to Freud” echoed and amplified the most subversive aspects of Freudian thought against the pejorative psychiatric concept of madness as a lack of rationality. Hence Lacan’s famous quote that man cannot be understood without madness. In fact, this draws the most important fault line in modern psychiatric thought: can madness be understood, is it subject to reason? This fault line allows us to draw a different cartography of psychiatry and anti-psychiatry than the usual histories have offered. On one side are the two founders of modern psychiatry – Emil Kraepelin (the Linnaeus of psychiatric classification) and Karl Jaspers (who introduced phenomenology into psychiatry); what they have in common is imposing order on psychiatry, one by an (attempted) objective nosography and the other by understanding the subjective experience of psychiatric patients. But Jaspers introduced a phenomenological worm in psychiatry’s apple by insisting that there is a chasm between the psychiatrist and the psychotic patient (the modern term for madness). On the other side are two other major influences in psychiatric theory and practice in the last century or so – Eugen Bleuler, the psychiatrist who coined the term schizophrenia and was influenced by Freud, and of course Freud himself, the neuropathologist who created the psychoanalytic movement. These two represent a more profound understanding of the mind based on introspective methods and unconscious processes. The Freudian-Bleulerian approach does not dismiss the possibility of understanding psychosis and with variations is the approach of those who have wish to treat psychiatric phenomena including psychosis and schizophrenia psychologically rather than biologically. This cartography is
7.6 “Psychoanalysis as Subversion”
instructive: we can draw a clear line from Kraepelin to the American Psychiatric Association’s DSM project (since DSM-III in 1980) and now to the model of psychiatry as a neuroscience championed by the US National Institute of Mental Health. Another lineage can be traced from Bleuler and Freud (often also influenced by subjective phenomenology) to anti-psychiatrists Lacan and Laing who are dedicated to understanding madness as a human phenomenon with personal, familial, social, and political dimensions. Of the anti-psychiatrists described here, these two, Lacan and Laing, have the most in common, revisioning the definitions of self, mind, and relation. Both would agree with Laing’s description of the “divided self.” Whereas Laing moves out to “self and other,” exploring the “politics of the family” and “reason and violence,” Lacan locates his theorizing in a kind of theatre of the mind, with his tripartite division of the self into “real, symbolic, and imaginary.” At different times and in different places in the last century and more, we can see the relative dominance of one or the other of these approaches, with variations; and this, always imbricated with the models of mind and the politics that obtain.
7.6 “Psychoanalysis as Subversion”14 So what was so subversive about Lacan? In fact, I see three different trends in his work. His “return to Freud” was conservative, yet his approach to mainstream psychoanalysis was subversive, and he used psychoanalysis to rebel against psychiatry. Raised in a bourgeois Catholic family, Lacan was socially conservative but forcefully independent-minded which allowed him to champion the father figure Freud while railing against all institutional orthodoxy (Badiou and Roudinesco 2014). Lacan brushed aside all institutional requirements for psychoanalysis. Whether about training or the practice of psychoanalysis, as Turkle says, “the only rule is that there should be no rules.”15 In terms of his theorizing, Lacan is anti-biological, returning to the Freud of The Interpretation of Dreams (1900), locating sexuality on a symbolic level, not anatomy (as in Freud’s later maxim, “Anatomy is destiny”). Lacan was an anti-philosopher, sparring with Louis Althusser about the primacy of philosophy over psychoanalysis. As did Freud, Lacan held that psychoanalysis negated philosophy.16 We can say, paraphrasing Freud, that the royal road to truth
Sherry Turkle’s description from (1981), pp. 156–60 Badiou and Roudinesco (2014), p. 157, emphasis added 16 See Badiou and Roudinesco (2014) and Tauber (2010). 14 15
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lies in psychoanalysis which analyzed our irrational minds, not in philosophy which proposes the discourse of reason. Excursus: “The Cut” Cut, scission, splintering … rupture, interruption … enigma interpretation, neologisms, silence: these are some of the terms that describe the technique, the theory and the repercussions of the movement that Lacan inspired. One of his most controversial innovations was Lacan’s “cut” – how and when to end the analytic session, as opposed to the fixed time of the classical 50-minute hour. In an article on Winnicott and Lacan (Luepnitz 2009, p. 966), two of the most influential psychoanalysts of the twentieth century, Lacan’s cut or scansion is described as a process whereby “the analyst cuts the session off at a propitious moment” and “keeps the analysand working actively in between sessions.” This cut thus locates “the cure” outside of the session, beyond the session and not in a corrective emotional experience with the person of the analyst. The implications are spelled out by Lacan’s epigone: “The age of interpretation is behind us,” declares Jacques-Alain Miller (2007, p. 3) and this “post-interpretative world … takes its bearings on the cut” (Miller 2007, p. 8). Although this generated much debate and is cited as the reason that Lacan was asked to leave the International Psychoanalytical Association, Gilbert Diatkine sums up nine arguments of Lacan’s apology for the short session (Diatkine 2007).
7.7 F ranco Basaglia: Reforming Psychiatry by Transforming the Asylum Italian psychiatrist Franco Basaglia (1924–1980) was a reformer who instigated psychiatric deinstitutionalization around the world with his key text, L’Istituzione negata (“The Institution Negated,” 1968; L’Institution en négation, 1970, in French) and by joining the Radical Party in the Italian Parliament that reformed Italy’s mental health legislation. Basic to the psychiatrist’s traditional role, and obscured by the aura of scientific objectivity, was the task of isolating and containing social problems and conflicts. – Franco Basaglia (1981, p. 185)
Franco Basaglia negated institutional psychiatry which in the Italy of his era largely meant the public or state asylum. His key work is in fact entitled in Italian, L’Istituzione Negata, and L’Institution en negation in French translation, meaning The Institution Negated (Basaglia 1968). It was an undoing of the European asylum logic and tradition. Canadian-American sociologist Erving Goffman described the
7.7 Franco Basaglia: Reforming Psychiatry by Transforming the Asylum
asylum as a “total institution” that maintains the functions and roles of “guard and captor” (Goffman 1961). Such total institutions have their origins in Jeremy Bentham’s nineteenth-century carceral Panopticon, a kind of ever-present, all- seeing eye directed on prisoners, as documented by Michel Foucault (1977). This was not in itself a revolution but a reform of institutional psychiatry. Basaglia was a mainstream academic psychiatrist, trained in a traditional faculty, publishing in respectable psychiatric journals. He was the administrator of a major psychiatric institution and an institutional reformer. In the end, Basaglia’s reforms were more important for their consequences than for their proposals, leading to the creation of general hospital psychiatry, community psychiatry, and the family therapy movement in Italy. Being closely involved with the latter as an Italian family therapist, I can attest to its continued vigor and vitality. Luigi Boscolo and Gianfranco Cecchin, two members of the pioneering Milan Team of Systemic Family Therapy, described their first trainees in 1977 as “very knowledgeable” about psychiatry and psychoanalysis and “very sophisticated” and in the forefront of the anti-psychiatry movement (Boscolo et al. 1987). They were Marxists for whom everything was political. They came for training because they were part of a “social revolution,” rejecting psychoanalysis as bourgeois and searching for new tools to treat patients who did not get better. Yet, they thought in binary terms – either you were Marxist or bourgeois. “The point is that,” Cecchin wrote, “slowly, they found we offered a third solution: through technique, you reach epistemology, you learn to think” (Boscolo et al. 1987, p. 220). Boscolo added that, “they didn’t believe in individual psychotherapy. They too thought in terms of ‘systems,’ and family therapy seemed to be congruent with their philosophy.” Boscolo who had trained in the USA as a psychiatrist and psychoanalyst realized when he returned to this cultural climate in Italy that he was trained to think in terms of dyads: the therapist and the patient. “In Italy, it became a triad: family, therapist and society; and the therapist was at the interface of the family and society.” Grasping the dilemma for the therapist, Boscolo saw that the therapist, often not conscious of what she is doing, “may introduce societal norms to the patient, or ally with society against the patient, or ally with the patient against society” (Boscolo et al. 1987, p. 221). And their Marxist students were clearly aware of these possibilities. Having trained with the Milan Team, I would say that they also learned from their anti-psychiatric Marxist students who pushed them to brilliant new insights and techniques for working with families (Cf. Selvini 1988). Basaglia was a modern Pinel, not a Kraepelin with a new nosography or a Jaspers with a fresh philosophical basis for psychiatry. Where Pinel supposedly unlocked the chains of the Bicêtre to render confinement more “humane,” Basaglia went further, unlocking the doors and letting the patients go. Whereas Foucault documented the birth of the asylum in his Madness and Civilization, Basaglia signed its death warrant. Yet, the foundational story of Pinel unchaining the aliénés of the asylum as part of the French revolution was in fact a myth (as psychoanalytic historian Elisabeth Roudinesco demonstrates) whose purpose was to hide the fact that the
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Fig. 7.1 An illustration from the French alienist J.E.D. Esquirol (1838) showing a patient in a mechanical restraint
coercive measures continued, notably under Esquirol who replaced the chains with mechanical constraints17 (See Fig. 7.1). Curiously, not all of the institutionalized patients wanted to leave the institutions in the many Western countries where deinstitutionalization took hold. They were socialized into passivity and dependence on the institution, with limited independent living skills. This paradox was the heart of the message in two counterculture films. In Milos Furman’s film of Ken Kesey’s One Flew Over the Cuckoo’s Nest, the rebellious protagonist is shocked to learn that he is one of the few patients committed against his will. Most of the patients could leave if they were prepared for life outside the institution. There is a poignant scene in the antiwar film, King of Hearts, set in the First World War, when the patients are freed from the asylum because of
Roudinesco (2008), p. 70: “Pinel was a pure myth, and everyone knew that the myth had been invented by Étienne Esquirol during the Restoration solely in order to remake the founding hero into an anti-Jacobin humanitarian and so bury the fact that he had been appointed to the hospital at Bicêtre by a decree of the Montagnard Convention on 11 September 1793. The myth of the unsullied and irreproachable hero had then been handed down from generation to generation in a canonical form that no longer bore any relation to historical reality. But like all myths, it had become truer than reality.” 17
7.8 Italy: “Jesters and Madmen” – Anti-Psychiatry as a Cultural Revolution
the war and then, seeing two opposing armies kill each other off, decide to return to the safety and sanity of the asylum (Forman 1975; de Broca 1966). This is not the place to take stock of the impact of deinstitutionalization or make judgments about it. For Italians, this was an issue of public policy, rights, and morality. What was at stake was a democratic vision of society, irreducible to medical claims and evidence-based “outcome studies.” In my discussions with psychiatrists around the world, few grasp this essential element, always returning to the reductive questions of costs and control. To leave the asylum behind completely … is not a matter of simply updating the old form of management, or extending it into the community; rather, to take this step is to unmask the system which carefully allocates a measured dose of sanction to each particular case, and to throw into crisis the whole apparatus of social control. (Basaglia 1981, p. 192)
Excursus: Deinstitutionalization Influenced by phenomenological psychiatry and taking cognizance of humanistic trends, Franco Basaglia was one of the founders of the deinstitutionalization of psychiatric patients. This has roots and offshoots in the entire history of psychiatry. As the course summary of Foucault’s Collège de France lectures on Psychiatric Power notes, “the whole of modern psychiatry is permeated by antipsychiatry” (Foucault 2008a, p. 342). Interesting to note that in French, dépsychiatrisation is defined as the set of processes of deinstitutionalization of the mentally ill and their reinsertion into their social milieu and the tendency to avoid the abusive psychiatrization of social cases, deviants, and the elderly that society too easily gave to the care of psychiatrists often with the complicity of psychiatrists themselves (Postel 1998, p. 140). In Psychiatric Power, Foucault expands this definition greatly by tracing depsychiatrization back to nineteenth-century neurology, notably to Babinski. This movement brought madness away from psychiatry and back to medicine; psychosurgery and psychopharmacology are two “notable forms” of this, according to Foucault. Against this movement, anti-psychiatry’s demedicalization of madness is “correlative with this fundamental questioning of power” (Foucault 2008a, p. 346). In Foucault’s archaeology of psychiatry, he contraposes depsychiatrization to demedicalization, with psychopharmacology emanating from the former and anti-psychiatry championing the latter.
7.8 I taly: “Jesters and Madmen” – Anti-Psychiatry as a Cultural Revolution Basaglia was a reformer as part of a larger social revolution. More than in any other country, Italians made anti-psychiatry a political cause where deinstitutionalization was a moral question that became a cultural phenomenon. Dario Fo, Italy’s irascible social satirist and 1997 Nobelist in Literature, is a descendent of the jesters of the
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Middle Ages and a contemporary practitioner of the commedia dell’arte. As a friend of Basaglia, Fo performed in all the hospitals where he worked, observing that Basaglia “always attempted to keep a dialogue alive inside these jails, to involve people in the problem and to ensure it was a question for all society and not an inconvenient problem left to a few doctors transformed into jailers” (Fo 1991, p. 131). Fo tells the story of his performance in “The Fifteen,” an institution in Turin for the “untreatable cases” who were usually tied to their beds or in chairs. Released from this “modern version of the pillory,” these supposedly mad patients relaxed and enjoyed themselves, “laughing at the right times” and made “some quite witty remarks, considering that they were supposed to be a bunch of dangerous madmen.” There was a moment in the course of the dialogue between the drunk and the angel, which is part of Mistero Buffo, when a woman got to her feet to start shouting. She was getting annoyed with the angel who would not let the drunk get on with his story, and yelled: ‘Let him talk you bastard! Otherwise, I’ll come up there and give you a kick in the halo.’ The amazing thing was that she was raging at the character whom I had sketched out in the air; she was pointing at the spot where I had left him. Another patient got up and shouted out: ‘Nurse, will you stop it?’ The angel had been transformed into the day-to-day authority they had to deal with. (Fo 1991, p. 131)
It is remarkable that without fanfare or pretense Fo grasps the meaning of the patient’s substitution “angel/nurse.” This could be interpreted using classical psychiatric semiology (a symptom of psychosis), Jasper’s phenomenological approach (a communicative chasm, indicative of psychosis), or psychoanalysis (displacement, projection), but Fo just accepts it as a straightforward communication. It is similar to how Laing worked with schizophrenic patients, getting to the core of their “ontological insecurity,” and Bateson’s notion of “metaphors that are meant,” again speaking directly to their daily predicaments and paradoxes. Fo continues: There was a debate afterwards, or more precisely, an inquiry by me and the doctors. The medical people were taken aback by one totally unexpected fact: all the inmates spoke. Indeed, they pressed insistently to be allowed to speak, and at one point all shouted together. It required a lot of patience to persuade them to speak one at a time. Most of them recounted the effect that those tales had on them, and almost all of them had experienced the desire to get up on the stage and perform on their own behalf. What would the subject have been? Their own lives, or rather tragedies and bizarre episodes in their lives. We made some of them recount these episodes. They were weird stories, with certain lucid passages, which then trailed off into the impossible. A row broke out between two patients. One accused the other of having stolen his story (copyright does not exist inside an asylum). Several told of their lives inside ‘The Fifteen’, of the violence, the criminal treatment, the monstrosities they had endured. (Fo 1991, pp. 131–132)
Referring to the Ship of Fools in the Hanseatics during the Middle Ages, when madmen were left adrift in rudderless boats and exposed to the elements, Fo provocatively asks if they were not more honest and courageous compared to the asylums of Italy, “where there has been a return to segregation, to the total annulment of the patient and to the administration of drugs that tranquillise and kill.” Fo concludes with resignation that, “All the labours of Franco Basaglia for a more humane and civil school of psychiatry have been for naught” (Fo 1991, p. 132).
7.9 The Myth of Thomas S. Szasz: Psychiatry in Reaction
Now, before moving on to Frantz Fanon, whom I consider a true psychiatric revolutionary, and Michel Foucault, the prime archaeologist of madness and unreason, I would like to consider a reactionary in academic psychiatry – Thomas Szasz.18
7.9 The Myth of Thomas S. Szasz: Psychiatry in Reaction Hungarian-American Thomas S. Szasz (1920–2012) was a reactionary psychiatrist in the guise of a progressive who negated the reality of psychiatric disorders. Szasz trivialized mental and relational suffering as mere “problems in living,” arguing against the majority of psychiatric disorders having biomedical origins, thus promoting the medical model in its most reductive form. In contrast with the other anti-psychiatrists, Szasz’s negation was destructive, leading the way to greater stigmatization of mental illness and diminished resources and services.
The strange part of the story … is that though they ascribe moral defects to the effect of misfortune either in character or surroundings, they will not listen to the plea of misfortune in cases that in England meet with sympathy and commiseration only. Ill luck of any kind, or even ill treatment at the hands of others, is considered an offence against society, inasmuch as it makes people uncomfortable to hear of it. – Samuel Butler (1985, p. 64)
The myth of Szasz is that he was a progressive psychiatrist who championed humanistic values in medicine and psychiatry. This is a myth and a toxic one! He belongs in this discussion insofar as he is an anti-psychiatrist. Szasz was a destructive force in academic psychiatry; he wanted to confirm the most reductive practices of the disputed medical model. What is at the heart of his critique, popularized in The Myth of Mental Illness?19 He rejected the contemporary definition of mental illness on the grounds that it was not based on brain pathology. In effect, he was critical of American psychiatry’s expansion beyond what he considered a truly medical psychiatry to define social, familial, and existential suffering as part of psychiatry. A latter-day version of this critique is Allen Frances’ strenuous objections to DSM-5 on the basis of inflation and overreach. While I agree that this question is valid and critical (overreach having achieved bulimic proportions in the bloated DSM-5 which has now swollen to some 1000 pages, from the small pamphlet that was the first iteration of DSM), a more disquieting impact of Szasz that is truly reactionary is the trivialization and stigmatization of mental illness, which I would qualify simply as mental (or personal) and relational distress (cf. adversity and stress studies).
For a detailed comparison, see Bracken and Thomas (2010). See Szasz (1961, 2011); and reply by medical historian Shorter (2011). On Szasz’s faulty understanding of the medical model, see Kendall (2004). 18 19
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Thanks to Szasz, whom many patients and ex-patients consider a hero, tough- minded American biological psychiatrists were emboldened to trivialize the family, social, and cultural contexts of mental suffering and to denigrate psychotherapy as “rent-a-friend” for the “worried well.” In devaluing the notion of mental illness in institutional and academic psychiatry, Szasz is directly responsible for the critique and withdrawal of psychotherapy for the interventions sanctioned by psychiatry and the US health-care system hand in hand with the promotion of biological treatments such as psychopharmacology, neuro-stimulation, and electroshock. More disquieting is the transfer to the US penal system of millions of people caught up in a “perfect storm” of personal and social problems, diminished resources, and unsympathetic societal attitudes. In arguing that madness is manufactured in another of his polemics, Szasz also conflated mad with bad, such that people with drug dependency, for example, ended up being criminalized instead of being treated (Szasz 1997). Excursus: Antinomies of Crime and Disease Samuel Butler wrote a brilliant satire called Erewhon, an anagram for “nowhere,” an upside-down world where Erewhonians declared disease a crime for which the sick were imprisoned and crime was called a disease for which criminals were hospitalized. Whereas Butler inverted the nineteenth- century logic of crime and disease as antinomies for satiric purposes, Szasz upends crime and disease all too literally. When it comes to crime, Szasz was a latter-day Cesare Lombroso, the founder of criminal anthropology and positivist psychiatrist, seeing crime as disease. In seeing psychiatric disease as a myth, sometimes in the service of crime or moral failing, Szasz sounds like a moralist, a latter-day Samuel Butler without the satire.20
Social workers, psychologists, and the various schools of psychotherapy have taken up the slack left by psychiatrists. In the interdisciplinary approach of my child psychiatry clinic, this work is often more important than the narrowly defined psychiatric disorders that are treated with medications. “Mental illness” in the impoverished imagination of the likes of Thomas Szasz may be a myth, but the suffering it indicates is all too real. For these reasons, Szasz is a reactionary anti-psychiatrist, not a progressive one. In denying mental illness, he entrenched the most reductive aspects of the biomedical model of psychiatry and trivialized the truly human context of existence and its vicissitudes. If mental and relational problems are a myth in psychiatry, to whom will people turn in their predicaments of suffering and distress? We already know part of the answer: families in difficulty turn to family therapists like Boscolo and Cecchin of the Milan Team (discussed above), who have – in the wake of the reform
20 Butler (1872). Deleuze and Guattari (1977) drew on Butler’s ideas in their work, Anti-Oedipus, and elsewhere.
7.10 Frantz Fanon: The Unfinished Revolution of Psychiatry
and radical rereading of psychiatry by the likes of Basaglia and Laing – created a vibrant and growing movement around the world.21
7.10 Frantz Fanon: The Unfinished Revolution of Psychiatry As a psychiatrist, philosopher, and revolutionary, Martinican Frantz Fanon (1925–1961) negated nothing less than the claim of European psychiatry to universalism in his radical critiques of the psychology of colonization and identity formation, offering a more humane psychology on which to found psychiatry in a revolutionary program for a new society. Fanon’s critiques were far more trenchant than other anti-psychiatrists, with far-reaching impacts on critical theory, postcolonial studies, and Marxist political theory, yet his project remained unfulfilled when he died all-too-young, bequeathing us psychiatry’s unfinished revolution.
The colonized people as a whole … will react in a harsh, undifferentiated, categorical way before the dominant group’s activity. It is not unusual to hear such extreme observations as this: “Nobody asked you for anything; who invited you to come? Take your hospitals and your port facilities and go home.” – Frantz Fanon (1965, p. 122)
Fanon negated nothing less than the Eurocentric basis of academic psychiatry; in addressing the particularities of a Caribbean identity, he held up a harsh mirror to psychiatry’s self-concept, shattering its pretensions to an unquestioned universalism, providing a new vision for a psychology of human being subtending the clinical work of psychiatry. In critiquing the limits of psychiatry, in opening a dialogue about a new vision of persons (what I call psychology), in calling for a radical society of equality and social justice incarnated in the Algerian revolution of which he became an inspiring leader, Frantz Fanon is the most revolutionary and radical psychiatrist of the twentieth century. More than other anti-psychiatrists, Fanon negated the very basis for academic psychiatry. To extend the metaphor that Sartre offered in his celebrated preface to Fanon’s text, Fanon held a sword that cut down the dead wood of psychiatry. As Sartre would have it, [V]iolence, like Achilles’ lance, can heal the wounds that it has inflicted…. Every day we retreat in front of the battle, but you may be sure that we will not avoid it; the killers need it; they’ll go for us and hit out blindly to left and right…. you will have to fight, or rot in concentration camps…. when your back is to the wall, you will let loose at last that new violence which is raised up in you by old, oft-repeated crimes. (Fanon 1968, pp. 30–31) This search for the alleviation of suffering is repeated across the many avatars of psychotherapy triggered by the psychoanalytic movement, not to mention competing models based on behavioral and cognitive psychology.
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The sword Fanon wielded was double-edged, Sartre declared – it wounded and it healed. I contest this possibility because it sanctions violence not only in the academy but in politics. Violence is the tragic repetition of trauma and cannot open new possibilities; violence cannot herald the event. Fanon was the anti-psychiatrist who more than any of the others opens a new horizon for psychiatry: a more embracing and inclusive psychology that opens vistas for identity and belonging, a radical critique of psychiatric practice, and a more humane vision of society through a revolutionary politics. Without endorsing the violence that both Fanon and Sartre sanctioned to achieve such a revolution, this remains the unfinished promise of Fanon’s revolutionary antipsychiatry. For such a revolution to occur, it will be necessary not only to negate but to affirm; for its practitioners to be faithful to its founding vision, it will be necessary not only to witness an event – the birth of the new – but to heal the trauma of the old so that the pain of the past does not drown out the fresh waters of a possible present. Fanon rejected the notion that “underdeveloped people” have superstitions that thwart their ability to adapt to new practices and solutions: Once the body of the nation begins to live again in a coherent and dynamic way, everything becomes possible.… The people who take their destiny into their own hands assimilate the most modern forms of technology at an extraordinary rate. (Fanon 1965, pp. 144–145)
On the other hand, Fanon was against the imitation of Europe, sending back a “reflection of their society and their thought,” exhorting Africa and the Americas to invent and make discoveries: For Europe, for ourselves, and for humanity, comrades, we must turn over a new leaf, we must work out new concepts, and try to set afoot a new man. (Fanon 1968, p. 316)
7.11 M ichel Foucault: Reordering Medical Perception and Psychiatric Thought The work of French psychologist and philosopher Michel Foucault (1926–1984) overshadows the entire discourse of anti-psychiatry, just as he informs and impels us to reorder medical perceptions, psychiatric thought, and the very “order of things.” Foucault’s negation was the most disturbing to established psychiatric thought because he questioned the very basis for imagining madness and reason/unreason.
There is a very good reason why psychology can never master madness; it is because psychology became possible in our world only when madness had already been mastered and excluded from the drama. – Michel Foucault (2011, p. 143) Before the end of the eighteenth century, man did not exist.… As the archaeology of our thought easily shows, man is an invention of recent date. And one perhaps nearing its end. – Michel Foucault (1994, pp. 336, 422)
7.11 Michel Foucault: Reordering Medical Perception and Psychiatric Thought
More than simply recording the history of psychiatry (in the guise of a history of madness), Foucault reordered the ways in which madness had been imagined and tamed by society in general and medicine and psychiatry in particular. These two epigraphs from Foucault show that he found both psychology and its ostensible subject – man – to be historical artifacts. This is his famous gloss on Kant: not an absolute a priori (knowledge before experience) but a historically situated one (knowledge in the light of experience). Foucault’s “historical a priori” is the order subtending any given culture at any given time. As outlined above, Badiou’s schema to make sense of the mission of great thinkers as philosophers and anti-philosophers has resonance both in philosophy (akin to Richard Rorty’s “systematic” versus “edifying philosophers” Rorty 1979) and in science (cf. Kandel’s “disciplines and subdisciplines” Kandel 1979). Yet, I think that Foucault does not fit neatly into this system of thought. I discern a third group of thinkers that I call methodologists who provide tools for thought. Think of Ockham’s razor, Hume’s fork, or Wittgenstein’s ladder. Foucault provides a rich set of analytical tools to unearth the established order of things, medical perception, and the logic of the penal system – with his concepts épistème (akin to paradigm) and dispositif (apparatus). This is just how Foucault offered his own work: “I want my books to be a sort of toolbox that people can rummage through to find a tool they can use however they want in their own domain.”22 Gutting reads three different historical methodologies in Foucault’s work – genealogy, archaeology, and problematization (Gutting 2005, p. 104). Paul Rabinow and Nikolas Rose add subjectification, as both inquiry and method, which is extremely relevant to the subject of psychiatry (Rabinow and Rose 2003). Foucault does not provide a philosophy or even an anti-philosophy that sharpens the analytic powers of philosophy proper through probing questions. Rather, he reads and reorders the history of thought in a kind of epistemology of suspicion (a gloss on Paul Ricoeur’s famous “hermeneutics of suspicion”), to be able to ask how thought comes to the point where we look at things in a particular way.23 In The Order of Things, in outlining his concept of the episteme, Foucault refers to the “point of heresy” on several occasions (Foucault 1994). The “point of heresy” was elucidated by Étienne Balibar as the opposing disciplines within an episteme or paradigm: It determines and fine-tunes the method that Foucault employs to analyze the discursive spaces he calls “epistemes” for each of the epochs he describes and, within each episteme, the kind of structured opposition found within each discipline between the discourses or scientific works that opt for one of two contrary terms, one of two possibilities that in each instance are available for elaborating a rational program to advance the discipline. The best example – and I believe that in this case he uses the term itself–is the opposition between Linnaeus’ and Buffon’s approach to nature from within the classical episteme. One sees – this was Foucault at his most structuralist – that, in using the term, he systematically sought parallels between the various disciplines comprising each episteme. (Duvoux and Sévérac 2012)
Cited by Gutting (2005), p. 112 The formulation of an epistemology of suspicion is from Gutting (2005), p. 126.
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So, if we adopt Foucault to examine anti-psychiatry, we would explore various anti- psychiatric arguments as points of heresy to analyze the discursive spaces of the episteme of psychiatry. What I have called the “standard model” of late twentieth- century psychiatry is an episteme and the points of heresy at contention in the standard model concern measurement (reliability of psychiatric diagnosis, to some extent the related question of predictability or prognosis) versus meaning (starting with validity, that is, whether the name truly represents the thing, and ending with hermeneutics or interpretation and making meaning, i.e., making sense of and giving meaning to lived experience). What the anti-psychiatrist must do is to negate some feature that undermines the episteme and separate it from psychiatry, employing a dispositif or apparatus I call Badiou’s scythe (Di Nicola 2012b). What the critical psychiatrist, provoked by the anti-psychiatrist’s negation, must do is to follow it with an affirmation of the task of psychiatry by radically reconstituting both theory and practice. Excursus: Madness Versus Reason/Unreason It is instructive that the English translation of Foucault’s most famous work, Madness and Civilization (1973),24 highlights madness versus reason (civilization). In French, the original title was Folie et Déraison, or Madness and Unreason (1961). As Ian Hacking points out in his Foreword to the complete English translation of the French text (Foucault 2006) and elaborated in his essay, “Déraison” (Hacking 2014, pp. 38–51), Foucault agreed with the English title and collaborated in the editing of the first English edition which differed significantly from the original French. This maps a dance of thought, a complex archaeology between reason and unreason in the establishment of mental illness. “The language of psychiatry,” Foucault argued, “is a monologue of reason about madness” – revealing “a broken dialogue” that has fallen silent, a rupture that was forgotten. Foucault’s work, he insisted, is neither a history of psychiatry nor an archaeology of psychiatric discourse “but rather the archaeology of that silence” (Foucault 1973, pp. x–xii). The major English translations of this Foucauldian archaeology include Madness: The Invention of an Idea, his introduction to Binswanger’s Dream and Existence (Foucault and Binswanger 1993), Madness and Civilization (abridged version) and History of Madness (complete version), Abnormal (Foucault 2003b), Psychiatric Power (Foucault 2008a), and his essay on “Madness and Society” (Foucault 2003a, pp. 370–376). Edgardo Castro’s lexicon of the Foucauldian oeuvre covers abnormal, antipsychiatry, apparatus, asylum, madness, medicine, normal, power, psychoanalysis, psychology, psychiatry, subject, and subjectivation (Castro 2004).
Foucault (1973); intriguingly, no translator is named.
7.11 Michel Foucault: Reordering Medical Perception and Psychiatric Thought
While he is often cited by those who are critical of psychiatry, I do not read Foucault as simplistically anti-psychiatry. And I have this on his own authority: “I am not trying to deny the validity of psychiatry, but this medicalization of the madman … for economic and social reasons.”25 He was concerned with formulating the question of “psychiatric power,” the theme of his lectures at the Collège de France in 1973–1974 (Foucault 2008a). In response to these critiques, he said, “the importance of anti-psychiatry is that it challenges the doctor’s power to decide on an individual’s state of mental health” (Foucault 2008a, p. 353). He adds in these lectures that when he wrote Histoire de la folie, he was “very ignorant of antipsychiatry and especially of the psycho-sociology of the time” (Foucault 2008a, pp. 13–14). What then was anti-psychiatry for Foucault? Here is the definition he offered at a colloquium in Montreal: I call antipsychiatry everything which challenges and calls into question the role of a psychiatrist formerly called upon to produce the truth of the illness in the hospital space.26
As such, Foucault asserts that “we could speak of antipsychiatries that have permeated the history of psychiatry.”27 And he discerns two distinct processes (see Excursus on Deinstitutionalization). The first is depsychiatrization which preserves medical power and is opposed by anti-psychiatry. Foucault cites Basaglia as a psychiatrist negating the use of power: The doctor’s power increases as vertiginously as the patient’s power diminishes; the latter, simply by virtue of being confined, becomes a citizen without rights, handed over to the arbitrariness of the doctor and nurses, who can do with him what they like without the possibility of appeal. (Foucault 2008a, pp. 344–45)
Anti-psychiatry opposes depsychiatrization due to its medicalization of madness. The second distinct process is the demedicalization of madness. Anti-psychiatry analyses the use of power in psychiatric practice and, in order to free madness from this power, proposes its demedicalization. A recent French revue describes him as “against the system” and a “rebel in the heart of the system.”28 What Foucault and those who follow in his footsteps do is to ask how a given state of affairs comes to be. Foucault offers a method, not a platform. Furthermore, his work is not a history of madness nor a proper history of psychiatry. It is rather a reordering of our ways of thinking about madness and the ways that European civilization created discourses of reason about unreason, a field entirely conceived by himself and plowed by few others.
Castro (2004), emphasis added Michel Foucault, “Histoire de la folie et antipsychiatrie” [The history of madness and anti-psychiatry], at the colloquium organized by Henri F. Ellenberger at the University of Montreal in May 1973, “Faut-il interner les psychiatres?” [Should we commit the psychiatrists?] Cited in Foucault (2008a), Note, p. 264. 27 Foucault (2008a), p. 342; emphasis added; note the plural, antipsychiatries. 28 “Michel Foucault: L’anti-système,” Le Point, Juin-Juillet, Numéro 16 (2014) 25 26
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As opposed to the history of how madness was conceived and the practices that emerged to deal with it, the history of madness per se is an altogether different subject, which Roy Porter, Andrew Scull, and others attempt in their work as historians.29 The history of psychiatry as such is vast and detailed even for the critical energies of a Foucault; in any case, it needs to be written in each time and placed by those who know the subject intimately, and only then can we compare those texts with each other and against Foucault’s larger archaeological project. Noted psychoanalytic historian Elisabeth Roudinesco offers a condensed but spirited review of the controversies engendered by Foucault’s history, locating him faithfully in debates with both unsympathetic historians and somewhat more sympathetic psychiatric leaders such as Henri Ellenberger and Henri Ey (Roudinesco 2008). Foucault’s own definition of his work on the order of things, on medical perception, and on the European discourse about madness is summed in the title he chose for his chair at the Collège de France: The History of Systems of Thought (Foucault 2008b, p. ix). In this, he is in the anti-philosophical tradition of Nietzsche and Freud, tearing down the curtains of civilization and civility to unmask our pretensions and precious illusions. Foucault’s reordering was the most disturbing to established psychiatric thought because he questioned the very basis for imagining madness and reason/unreason. This is not anti-psychiatry because his goal was not to reform or radicalize psychiatry in order to reforge its practice. What distinguishes anti-psychiatry, like Badiou’s antiphilosophy, is that it compels the main discipline – psychiatry or philosophy – to actualize itself, becoming more contemporary and more responsive to human needs.
7.12 The Ship of Fools Of all the images that Foucault summons, the Panopticon and the Ship of Fools are the two that persist in my memory (See Fig. 7.2). These images are particularly salient for psychiatry. German history reveals that the Narrenschiff, the Stultifera Navis in the Latin texts of the late Middle Ages and early Renaissance, the Ship of Fools, contained an ambivalence that only grew across the centuries, where the mad were sent off on a voyage – to be healed or to be discarded? Later in European history, the Panopticon, the all-seeing eye, created the intrusiveness of the state into private life as part of the institutionalization and categorization of all experience. In Europe’s Middle Ages, the Narrenschiff were boats that: conveyed their insane cargo from town to town. Madmen led an easy wandering existence. The towns drove them outside their limits; they were allowed to wander in the open countryside, when not entrusted to a group of merchants and pilgrims (Foucault 1973, p. 8).
29 See Roy Porter, The History of Madness; Andrew Scull, Museums of Madness; and The Discovery of the Art of the Insane.
7.12 The Ship of Fools
Fig. 7.2 Stultifera Navis (Latin), Das Narrenschiff (Modern German), the Ship of Fools by Sebastian Brant (1494) is a satirical allegory about the role of fools in the late Middle Ages and early Renaissance
Allowing that it is not easy to uncover their meaning, Foucault considers numerous hypotheses followed by contrary evidence: One might suppose it was a general means of extradition by which municipalities sent wandering madmen out of their own jurisdiction … One might then speculate only foreigners were driven away … It is possible that these ships of fools, which haunted the imagination of the entire early Renaissance, were pilgrimage boats, highly symbolic cargoes of madmen in search of their reason. (Foucault 1973, p. 9) … We may suppose that in certain important cities—centers of travel and markets—madmen had been brought in considerable numbers by merchants and mariners and lost there, thus ridding their cities of their presence. It may have happened that these places of “counterpilgrimage” have become confused with the places where … the insane were taken as pilgrims. (Foucault 1973, p. 10)
Articulating the interpenetration of antinomies that is a hallmark of his entire oeuvre, Foucault describes “the madman’s liminal position on the horizon of medieval concern” (Foucault 1973, p. 11) as both a passage and a division: a position symbolized and made real at the same time by the madmen’s privilege of being confined within the city’s gate: his exclusion must enclose him; if he cannot and must not have another prison than the threshold itself, he is kept at the point of passage. He is put in the interior of the exterior, and inversely. (Foucault 1973, p. 11)
Foucault calls these madmen the “free slaves of the ship of fools” (Foucault 1973, p. 35).
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Is this not another instance of the state of exception that Giorgio Agamben describes when governments arrogate to more power in times of crisis, impinging on constitutional rights, only to extend these powers beyond the crisis, whereby the exception becomes the rule? (Agamben 2005). Agamben traces the origin to Roman law whereby a citizen could be banned but not killed, exiled but not protected. In medieval Europe, churches denied access to madmen, but ecclesiastical law could not refuse them the sacraments. Cities wanted to expel them, while other places collected more than their share and become safe havens or places of confinement. The madmen on the Narrenschiff were liminal people, neither in nor out, imprisoned at the threshold of cities – in a veritable state of exception. This echoes down the centuries and could be a page in Victor Turner’s anthropology of liminal people and transitional states, “betwixt and between” (Turner 1969). Turner’s liminalitas is the thread that links Foucault’s mediaeval madman to Agamben’s state of exception (Turner 1969; Agamben 2005). Yet, the meaning of liminality has shifted, from potenza in Agamben’s formulation or exception in Badiou’s, both suggesting a radical opening and the possibility of event, to the dark side of rupture that our age calls trauma and which I define as the closing of possibilities.30 The modern industrial world deals with madness and other exceptions very differently than by performing cultural rituals (Turner) or symbolic watery voyages (Foucault) as witnessed in Agamben’s paradigm of the state of exception. From Auschwitz and Guantánamo to the refugees and migrants dying on the new ships of fools at the ports of entry to today’s Europe, we have constructed quite another kind of threshold, as we enter a persistent state of exception. It is instructive that Foucault starts his history of madness with this allegory of the Ship of Fools, followed by a series of other stories and metaphors for madness, from the “Great Confinement” to the “Birth of the Asylum.” The entire work may be read as a loss of our capacity to live with madness. As Foucault had declared in an early work, up to about 1650, “madness was allowed free reign” in a culture that was “strangely hospitable to these forms of experience” (Foucault 2011, p. 112). Foucault ends Madness and Civilization with reflections on madness and art: “The madness of Tasso, the melancholy of Swift, the delirium of Rousseau belong to their works, just as these works belong to their authors” (Foucault 1973, p. 285). The works and the madness were intermingled in their lives. By the end of the nineteenth century, the two can no longer cohabit: “Madness is no longer the space of indecision through which it was possible to glimpse the original truth of the work of art” (Foucault 1973, p. 287). This is followed by what is in my reading the most compelling pensée that Foucault penned on the meaning of madness for us: It is of little importance on exactly which day in the autumn of 1888 Nietzsche went mad for good, and after which his texts no longer afford philosophy but psychiatry: all of them,
The radical disjunction between trauma and event is the essential thesis of Trauma and Event (Di Nicola 2012b).
including the postcard to Strindberg, belong to Nietzsche, and all are related to The Birth of Tragedy. But we must not think of this continuity in terms of a system, of a thematics, or even of an existence: Nietzsche’s madness – that is, the dissolution of his thought – is that by which his thought opens out onto the modern world. What made it impossible makes it immediate for us; what took it from Nietzsche offers it to us. (Foucault 1973, pp. 287–88)
Badiou understood this as Foucault’s legacy: Foucault “annexed for philosophy, for pure thought, objects and texts that had been divorced from it” (Badiou 2009, p. 122). The rupture that produced the silence that followed the “broken dialogue” about madness is what Foucault’s archaeology reveals. Only in a world where philosophy and psychiatry are so radically separated could there be such a thing as anti-psychiatry; only in such a world would psychiatry need anti-psychiatry – its negative afterimage – in order to reopen the discourse of reason/unreason. What does this mean? It means that the radical psychiatrist-psychoanalyst Laing, wielding Badiou’s scythe in the “weed garden” of psychiatry, tried to cut it free from Jaspers’ phenomenology (positing a chasm between psychiatrist and psychotic) which denied that we can talk to psychotic patients and understand their madness.31 It means that the psychiatric reformer Basaglia employed Badiou’s scissors to cut psychiatric patients free to be citizens again through the legislation of the Radical Party in the Italian Parliament to close the asylums and reform the Italian system of mental health care. It means that Lacan who was a psychoanalytic subversive and psychiatric rebel placed madness at the core of his theorizing, using Badiou’s shears with linguistic subtlety and a clinical intervention called “the cut” to separate Freudian thought from all biologism and psychoanalysis from all orthodoxy, rejecting the rationalities of the ego and ego psychology. Finally, it means that the psychiatric and political revolutionary Fanon, working as an alienist in the French colonies of Martinique and Algeria, first skillfully handled Badiou’s scalpel to execute refined clinical dissections to negate the European colonization of the mind; and in a more violent gesture, brandished Badiou’s sickle to separate the European cuttings from the native roots to allow the newly independent citizens of Algeria to claim their own psychology and forge their own destiny.
7.13 Envoi médico. “Yo quisiero un Dios para curarlos, o ser el hombre de la calle que sigue de largo … Y no puedo ser ni una ni otra cosa …” (Raúl E. Baethgen, El error del professor Bodhel). – Leo Maslíah (2014, p. 138)
Under the entry “physician,” Leo Maslíah cites a Uruguayan novel where a doctor confesses that “I wanted to be a god that cures them or the man in the street that accompanies them. And I can be neither one nor the other.” The realities of medical
31 This is a reference to Laing’s notable account of a patient’s story – “the ghost of the weed garden,” in her own words – in Laing (1965).
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practice reveal that neither medical hubris (the fantasy of cure) nor social solidarity (being a man of the street) is an enduring solution. Slavoj Žižek is fond of using jokes to illustrate complex philosophical ideas, especially when they reveal inversions of logic and negations. One of my favorites about psychiatry is the joke concerning: a conscript who tries to evade military service by pretending to be mad. His symptom is that he compulsively checks all the pieces of paper he can lay his hands on, constantly repeating: “That is not it!” He is sent to the military psychiatrist, in whose office he also examines all the papers around, including those in the wastepaper basket, repeating all the time: “That is not it!” The psychiatrist, finally convinced that he really is mad, gives him a written warrant releasing him from military service. The conscript casts a look at it and says cheerfully: “That is it!”.32
The history of psychiatry (not the history of madness or society’s attempts to understand it more broadly, but the history of the profession) is encapsulated in this joke of the conscript feigning madness to avoid military service. His compulsion, as Žižek tells it, is to check all the pieces of paper, looking for the relief that comes as the punch line. But there is something wrong with Žižek’s analysis: obsessionals and compulsives do not have such clear and comforting goals. Unlike the conscript who is merely feigning mental illness, no amount of checking or verifying will bring relief to the obsessive-compulsive. Any such relief is always short-lived, without therapy at least, damning the sufferer to endless repetitions. Žižek argues that, “the paradox … is that process of searching itself produces the object which causes it” (Žižek 2014, p. 160). Here, he confounds things to say the least, concluding that, “The error of all the people around the conscript, the psychiatrist included, is that they overlook the way they are already part of the ‘mad’ conscript’s game” (Žižek 2014, p. 161). In the joke, the conscript manages to produce the result he seeks, a warrant to avoid military service. In reality, such a feint would not produce the conscript’s desired result. As the soldiers who wanted to leave the war discover in Joseph Heller’s antiwar novel, Catch-22, wishing to leave the battlefield to be safe is a sign of normalcy, not insanity, and backfires. This is the same error as the originators of the “double-bind theory of schizophrenia” made, thinking that the logic of jokes describes or predicts human behavior (Bateson 1972). That theory states that if people are put into impossible-to-resolve “double-binds” and have no power to contest them, they will become mad, as in the joke about the boy who receives two T-shirts for his birthday and when he appears with one of them, the mother asks him why he didn’t like the other one. Damned if you do, damned if you don’t. Although this is frustrating, in fact, most people respond with humor or shrug it off as absurd. They may even respond with irritation or aggression if it persists, but madness? Unlikely.
Žižek (1989); cited in Žižek’s Jokes (2014, p. 125)
Will anti-psychiatry through its negations that trigger reform and revolution in psychiatry ever find that warrant? No, because like the true obsessive-compulsive, psychiatry/anti-psychiatry is a ceaseless dialectic of opposition since each generation disseminates, iterates, and repeats its symptoms anew. Anti-psychiatry is always looking for that piece of paper that will serve as warrant, give respite, and end the game. I am sympathetic to that. But defeating the military game or serving the interests of the feigned mad conscript is a mere palliative: the military machine goes on. Reforming psychiatry as a result of Basaglia’s negation of the institution is in this sense a palliative. It laudably undoes the logic of the asylum, but does it address the complex determinants of mental illness? Ultimately, the joke reflects a fanciful, idealistic view of madness and of anti- psychiatry. If only we could get some misunderstanding of the mind out of the way, or neutralize the toxic effects of psychiatry, the symptom will dissipate. That is the social solidarity that the Uruguayan doctor wanted to offer. Nothing in my experience as a social scientist, psychiatrist, or philosopher gives credence to such beliefs. We may indeed correct this or that misunderstanding and improve one or another of our practices, but that was not the origin of the symptom to start with. Believing that is medical hubris, which is untenable, as the Uruguayan doctor discovered. In the joke’s frame of reference, let us not confound the military psychiatrist with military service or the military itself. I would not work in that capacity, even in the service of undermining a war I did not agree with, precisely because I refuse that conflation. Not only would I refuse to play “the ‘mad’ conscript’s game”; I would refuse to play the military’s game. If the state wants to judge who is or isn’t a fit person to serve in the military or enter as a refugee or immigrant (e.g., with PTSD), I refuse to make this a medical matter. There is a strange twist there: in the case of military service, one has to be of sound mind, whereas in the case of refugee claimants, one has to be traumatized. So you have to be sane to serve in the army but disturbed to qualify for sanctuary. As a psychiatrist, I want nothing to do with it. These are not medical questions but socio-political ones.33 The dialectic psychiatry/anti-psychiatry is the engine of negation compelling change in my field, but it is not in itself a theory of psychopathology, nor a map for a new vision of the person, mind and relation, and their vicissitudes. That is the subject of another discussion about evental psychiatry. Psychiatry and anti- psychiatry are part of what I call trauma psychiatry, addressing only trauma and the closing down of possibilities. A psychiatry of the event which poses a new theory of the subject and of the event opens up new possibilities for psychiatry.
See Fassin and d’Halluin (2007). I have steadfastly refused to work for the courts, even in the “best interests of the child,” and hold that those who do so are in an ethical, moral, and legal conflict of interest. An example of how to deal with such demands is documented with verbatim transcripts; see Vincenzo Di Nicola (1997b).
7 The End of Psychiatry
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Renewal in Psychiatry Vincenzo Di Nicola with Drozdstoj Stoyanov
Man is unique not because he does science, and he is unique not because he does art, but because science and art equally are expressions of his marvelous plasticity of mind.—Jacob Bronowski, The Ascent of Man (1973, p. 412)
In the third part of this book, we want to conclude by clarifying three final matters: cleaning the house of psychiatry (a necessary periodic task in every discipline), reframing psychiatry (by posing the right questions), and creating a new synthesis (new realities require new vocabularies).
Reference Bronowski, J. (1973). The ascent of man (p. 412). Boston/Toronto: Little, Brown and Company.
Cleaning the House of Psychiatry
Trivial Pursuits When I was a graduate student of psychology in the 1970s in London, I read a brilliant takedown of “assertiveness training,” very much in vogue at the time as a skill-based approach to dealing with social interactions – If life is this simple, what were Dostoyevsky and Freud writing about? This represents the problem in dealing with trivial versus more complex matters. Assertiveness training was just the beginning of today’s self-help techniques. These approaches seize on one narrow aspect of human psychology and through their popular success, overstate their importance by greatly simplifying or even distorting human behavior. Assertiveness morphed into “empowerment,” bringing together a common concern about the social presentation of self with the analysis of power as the key dynamic in society (we can thank Foucault for that) and a culture of victimology, what I call “the age of trauma” (Di Nicola 2012, 2018b). Multiple Models More worrisome still, it was not only popular psychology that responds to the public’s understandable search for solving life’s workaday problems, but academic psychology lurching from one new theory to another, often changing the very definition of what psychology is. Here is Clifford Geertz (1997, p. 22, emphasis added), a preeminent cultural anthropologist, reading psychology and allied disciplines: What does one say when one says “psychology”…? Since it got truly launched as a discipline and a profession in the last half of the nineteenth century, … the self-proclaimed “science of the mind” has not just been troubled with a proliferation of theories, methods, arguments, and techniques. That was only to be expected. It has also been driven in wildly different directions by wildly different notions of what it is, as we say, “about”—what sort of knowledge, of what sort of reality, to what sort of end, it is supposed to produce. From the outside, at least, it does not look like a single field, divided into schools and specialties in the usual way. It looks like an assortment of disparate and disconnected inquiries classed together because they all make reference in some way or other to something or other called “mental functioning.” Dozens of characters in search of a play.… The wide swings between behaviorist, psychometric, cognitivist, depth psychological, topological, developmentalist, neurological, evolutionist, and culturalist conceptions of the © Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_8
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subject have made being a psychologist an unsettled occupation, subject not only to fashion, as are all the human sciences, but also to sudden and frequent reversals of course. Paradigms, wholly new ways of going about things, come along not by the century but by the decade; sometimes, it almost seems, by the month. It takes either a preternaturally focused, dogmatical person, who can shut out any ideas but his or her own, or a mercurial, hopelessly inquisitive one, who can keep dozens of them in play at once, to remain upright amid this tumble of programs, promises, and proclamations.
Psychiatry has hardly fared better. More clearly focused on our patients, psychiatry continually seeks out new theories or models in order to make a clinical difference and promptly declares revolutions. Change comes under different names in different domains: science has its paradigms, psychology its theories, psychiatry its revolutions. Binary oppositions and false dichotomies A book edited by John Brockman (2015) who dreamed up “the third culture” as a bridge between arts and science is entitled This Idea Must Die: Scientific Theories That Are Blocking Progress. Many of the entries deal with unproductive binary oppositions and false dichotomies as part of our western/northern historical legacy, but we need our own version for a spring cleaning in the house of psychiatry. Among the concepts that bedevil us in psychiatry and block our progress are (Di Nicola 2019): • Nature versus nurture and its iterations in psychiatry (endogenous vs. exogenous factors, inherited vs. acquired traits) • Individual versus collective (individual versus group therapy, individual versus family therapy, clinical psychiatry versus community psychiatry) • Subjectivity versus objectivity • Social versus biological
8.1 Psychiatry, Fast and Slow If we cannot defeat binary thinking, let us at least put it to good use as a metaphor. Adapting Nobel-winning psychologist Daniel Kahneman’s (2011) approach to thinking, fast and slow, and my own investigations on slow thinking and slow psychiatry (Di Nicola 2017a, 2017b), we can imagine two poles of psychiatry as it is currently constructed: fast psychiatry and slow psychiatry. This way of looking at modes of thinking and styles of investigation cuts across many disciplines, as in the celebrated essay by Isaiah Berlin (1978) contrasting Russian thinkers Dostoyevsky and Tolstoy, characterized as the deeply burrowing hedgehog and the wide-ranging fox (Table 8.1). Anthropologist Claude Lévi-Strauss (1966) called them engineers versus bricoleurs and psychologist Jerome Kagan (2006) called them hunters versus butterfly chasers, while I have named therapists technocrats or phenomenologists according to their temperament (Di Nicola 1990c, 1997, 2011). Fast psychiatry yields William James’ tough-minded empiricism (James 1995) converging on solutions (2000), using technocratic algorithms for pragmatic ends
8.1 Psychiatry, Fast and Slow Table 8.1 Fast psychiatry and slow psychiatry
127 Fast psychiatry Keywords The wide-ranging fox Empirical Convergent Technocratic Etic, experience-distant Thin descriptions Algorithm Pragmatic impact Rapidity Mastery Paradigm/uniform Research
Slow psychiatry Keywords The deeply burrowing hedgehog Rational Divergent Phenomenological Emic, experience-near Thick descriptions Heuristic Knowledge accumulation Slowness/incrementalism Comprehension Syntagm/pluralistic Investigation
Adapted from Di Nicola (2017a, 2018a, 2019)
(Di Nicola 2011) deploying etic or experience-distant approaches with “thin” descriptions (Geertz 1973), focused on rapid change to gain mastery within a definitive, uniform research paradigm. We may call them engineers, hunters, or technocrats. Keywords: wide-ranging fox, empirical, convergent, technocratic, algorithmic, pragmatic impact, rapidity, mastery, paradigmatic/uniform, research. Examples of fast psychiatry include behavior therapy, cognitive-behavior therapy, brief therapies, solution-focused therapy, psychiatric pharmacotherapy, clinical trials, aspects of psychiatric genetics, and the reductive use of biological psychiatry and neuroscience. Slow psychiatry offers James’ tender-minded rationalism (James 1995), pursuing divergent questions (Kagan 2000), deploying phenomenological heuristics to pursue knowledge (Di Nicola 2011), using emic or experience-near approaches, incrementally aiming at comprehensive “thick” descriptions (Geertz 1973), and understanding in a syntagmatic (pluralistic) approach to investigations. They may be called bricoleurs, butterfly chasers, or phenomenologists. Keywords: deeply burrowing hedgehog, rationalistic, divergent, phenomenological, emic/experience- near, heuristic, knowledge accumulation, slowness/incrementalism, comprehension, syntagm/pluralistic, investigation. Slow psychiatry includes psychoanalysis and its derivations; aspects of systemic family therapy (on the more phenomenological side; Di Nicola 1997, 2011); the “narrative turn” in therapy; dialogical methods (Bakhtin 1981; Salgado and Gonçalves 2007) transcultural psychiatry (both in its original “classical” version at McGill University (Prince 1972; Murphy 1982) and the “new cross-cultural psychiatry” at Harvard, even more clearly focused on emic, experience-near approaches (Kleinman 1977); epidemiological studies (Marmot 2015); social determinants of health (CSDH 2008; Satcher et al. 2012; Silverstein et al. 2019) the human genome project; social neuroscience (Cacioppo 2002; Cacioppo and Berntson 2005) and mirror neurons (Gallese 2008, 2014) to investigate all forms of imitation from empathy to learning to social skills; and, finally, social psychiatry.
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8.2 Centrifugal Versus Centripetal In medicine, there is a distinction between “lumpers and splitters” – those who see clinical similarities and “lump” them together in one group versus those who see nuances and “split” them into different groups (e.g., McKusick 1969). Lumpers are convergent in my schema; splitters are divergent. Another way to capture psychiatric approaches is to contrast their impacts: centrifugal versus centripetal. In a centrifugal approach, the operative element is analysis, producing multiplicity. The dispersion leads to fragmentation, dissent, and incoherence. It reflects a technocratic temperament and may use convergent methods to create or conform with a paradigm, but in the end it disperses knowledge. By contrast, in a centripetal approach, the operative element is synthesis, seeking uniformity. The goal of integration leads to building bridges, consensus, and both theoretical and clinical coherence. Temperamentally, it is more allied with the phenomenological temperament and may be divergent in its methods, while converging toward a holistic, unified view of the field, a movement that E.O. Wilson (1998) described as consilience (cf. Henriques 2003). Complexity Now, between oppositions and dichotomies, fast psychiatry and slow psychiatry, technocratic and phenomenological temperaments, centrifugal and centripetal approaches, is there a middle ground, either as hybrid or compromise? Glenn Gabbard (2007), a leader of psychodynamic psychiatry in the USA, offers thoughts on complexity and reductionism. He argues that “pluralism is the hallmark of 21st century psychoanalytic discourse” with a “by-product of retreating into orthodoxy.” Nonetheless, Gabbard sees “genuine psychoanalytic thinking” as non- reductionistic, returning to Freud’s core notion of overdetermination which favors complexity, opening “‘infinite space’ of meaning, motive, and causation” in psychoanalytic work, characterized as a complex practice. Gregg Henriques in US psychology similarly addresses the complexity of constructing a unified general model (Henriques 2003). Is the lack of consensus a sign of a discipline’s immaturity or an acknowledgement of its growing complexity? In a key paper on the dangers of imposing a single theoretical model, Vivian Rakoff (1984) argued for the necessity of multiple models in family therapy, whose pioneers and leaders were often part of the community psychiatry movement. For our purposes, is the declaration of psychiatry as a branch of medicine (Guze 1992) an affirmation of our medical roots and identity (Sartorius 2019; Schwenk 2020) or a simplification and reduction of all that is mental and psychiatric into biological reductionism?
8.3 Reductionism in Medicine and Psychiatry In this section, we will cover several examples of how reductionism in medicine and psychiatry distorts our understanding and blocks true progress: (1) depression and the “chemical imbalance theory,” (2) simplistic biological models for the
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schizophrenias, and (3) eating disorders and the search for medical explanations over broader social psychiatric ones. First, let us examine how the intersection of the powerful laboratory tools of genetics and consumer culture is distorting the public discourse about disease, risk, identity, and culture. Today’s major cultural meme about identity is provided by the personal genomics or consumer genetics industry by companies such as “23andMe” and “Ancestry.com.”
Excursus: “I Traded My Lederhosen for a Kilt” or “Reinventing Ancestry” “Ancestry” and “23andMe” are direct to consumer genetic testing companies. Such companies make two pitches to the public – genetic testing for health and disease on one hand and ancestry and cultural heritage on the other. The first claim is exaggerated; the second one is distorted and absurd! The Ancestry ads typically show a situation where someone has a cultural identity based on their family history. After genetic testing, they discover some previously unknown genetic link to another cultural group, and suddenly their understanding of themselves (e.g., habits, interests, tastes) is discredited, and they quickly adopt a new cultural identity. Katherine confesses in an Ancestry ad: “I thought I married an Italian,” but Ancestry shows that Eric is “only 16% Italian” and “34% Eastern European”! In another Ancestry ad, Kyle testifies: “Growing up, we were German. We danced in a German dance group, I wore lederhosen.” Then he did his ancestry testing and found that, “52% of my DNA comes from Scotland and Ireland, so I traded in my lederhosen for a kilt.” In each case, the expressed identity is a caricature of national character and identity. As their commercial ironically asserts, 23andMe is “reinventing ancestry.” The announcer promises that, “You’ll learn about your ancestry through your 23 pairs of chromosomes that make you who you are.” This is false, tragically false! As the great developmental biologist C.H. Waddington demonstrated 50 years ago in his metaphor of the epigenetic landscape, nature carves out the channels where marbles will roll on a hill with “valleys” and “forks,” but as they roll they also adapt biologically, at the cellular level (Noble 2015). Since then, social and cultural studies of nurture in child psychology, psychiatry, and their allied fields have amply demonstrated that our lives are also shaped by the history of our attachments and the adaptations of our cultures, the memory of our personal and collective histories, and the uniquely human counterfactual capacity to imagine and build different futures that will impel us beyond all possible biologies and imagined limits of the human imagination. See https://www.youtube.com/watch?v=tJcODboSSEg accessed March 1, 2020.
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This is precisely our concern with such technological reductionism. This translation of technology into practice is misapplied and misguided. The curiosity to “know yourself” is understandable, but personal, family, cultural, and religious identities are complex and based on shared experiences and values over a lifetime, over generations in fact, and not narrowly determined by genes. While the family stories are portrayed positively (although there is no statement as to whether they are true or not), they are a caricature of belonging and identity, culture and history. Furthermore, it’s a short step to crude biological identifications and all that goes by the name of “nativism” and “racism” in the current cultural climate. Since biologists and population geneticists have demonstrated that “race” is a myth (Cavalli- Sforza et al. 1996), we should reject these terms and affirm that belonging and identity are historical and cultural constructs, not biological givens that can be understood under the rubric of “race.” When I was in medical school, one of my professors used to joke that, When evolution is complete, we’ll all be Irish. The race myth smacks more than a little of the notion of evolution understood as “progress,” with its attendant hierarchies and implied “superiority.” Nonetheless, while biologically speaking race is a myth, its deployment as an apparatus for prejudice and discrimination is a tragic social reality. Now, what does this have to do with psychiatry and our current crisis? Everything! If we want to understand the pathologies that psychiatry studies, we have to resist the reduction of mind to brain and ancestry merely to genes. Let me express this personally. I was born in Italy of Italian parents. When I was a child, my maternal family moved to Canada where I was raised in English and now practice in French in Montreal. Does my family background make me less of a Canadian or a Quebecker? Even more tellingly, I did not meet my father before my 40s, limiting his influence on me to genetics and family stories. Am I my father’s son? Biologically, yes, but culturally, psychologically, only partially, and that by choice. I chose to visit Brazil where he lived and to learn Portuguese, developing a secondary career there, and to marry a Brazilian psychologist. But these are choices that have little to do with DNA and much to do with how families construct myth and meaning out of the virtues and vicissitudes of our lives. Finally, many theorists are reluctant to argue against reductionism for fear of being called dualists or believing in ghosts (cf. Ryle’s “ghost in the machine”). There are many ways to construe the “brain” and “mind” without resorting to dualism or indeed any other philosophical commitment to explain them. They are separate domains. Just as the brain does not explain mind, neither does the mind explain all relational patterns in culture and society. Critics of psychiatry often criticize the “medical model” as reductionistic. This is a gross simplification: misconstruals of the medical model – and I give three examples from psychiatry below – do not disqualify its value properly understood. In arguing against reductionism, I am not against the medical model of psychiatry but for an enlarged, broadened medical model that includes the brain, mind, society, and culture (cf. Gardner and Kleinman 2019). 1. Depression and the “chemical imbalance” myth. For decades, both the profession and public have been believed in the biological story that depression reflects
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a chemical imbalance in the brain. They were misled. The original catecholamine hypothesis of mood disorders was carefully qualified by its originators in the 1960s, recognized as significantly flawed and inadequate, and significantly modified to reflect more complex biological mechanisms in major mood disorders (Frances et al. 2007; Pies 2019). Besides mischaracterizing the neurochemistry associated with mood disorders, the “chemical imbalance” myth gave false hope to patients about the promise of antidepressant drugs and vastly underplayed the impact of psychological, interpersonal, and social factors and their role in preventing and treating mood disorders. Reductionism in psychiatry is not mere oversimplification; it misdirects investigations and undermines effective treatments. 2. Schizophrenias and their reductions. Robin Murray (2017), a distinguished British researcher in the area of the schizophrenias, acknowledged the role of social factors in the etiology of psychoses late in his career: “The truth was that my preconceptions,” Murray now admits about the neurodevelopmental hypothesis, “had made me blind to the influence of the social environment.” No less an authority than Manfred Bleuler, the son of Eugen Bleuler the psychiatrist who named the schizophrenias as a psychiatric disease, clearly identified family and psychosocial factors as major factors in every stage of this potentially devastating groups of illnesses. And this was published in Murray’s own department in London where it was no doubt ignored because Michael Shepherd (1982) was a professor of social psychiatry. The larger lesson here is that the complexity of disorders like the psychoses makes them fertile ground for attenuating family and social risk factors or amplifying biological ones. Biological psychiatrists severely criticized family observations about the schizophrenias, such as the now discredited “schizophrenogenic mother” (cf. Seeman 2016), although the Expressed Emotion (EE) paradigm confirmed suspicions that negative family environments play a crucial role in triggering relapses or worsening outcomes in these illnesses (Butzlaff and Hooley 1998; Di Nicola 1988). The complex interplay of biological, psychological, family, and social factors in the psychoses is amply confirmed by the research in Murray’s own department that developed the EE paradigm as well as the pioneering research by British psychologist Richard Bentall (2004). In psychiatry as in medicine, complexity is rarely served by simplistic reductions. 3. “Anorexia multiforme”: A cultural chameleon. The history of eating disorders and their sociocultural distribution (Di Nicola 1990a, 1990b, 2021) show that after anorexia nervosa was first described in London and Paris in the latter part of the nineteenth century, very little progress was made in understanding and treating this social psychiatric illness. What slowed it down was the discovery of Simmonds Disease in 1914 and Sheehan’s Syndrome in 1939 – both related to the pituitary gland with clinical manifestations that have little to do with anorexia nervosa except for weight loss. Lesson: when a medical explanation is available no matter how imperfect the fit with clinical reality, it is preferred over social, relational, or psychological explanations, to the detriment of genuine understanding and effective treatment. Anorexia nervosa has severe medical conse-
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quences, while the causation is not only multifactorial, but the sociocultural aspects are far more salient for its treatment. Another lesson here is that the nature of anorexia nervosa is that it has no “nature” in two senses of the word: it is not inherently genetic or biological with a fixed phenotype (or clinical manifestations) and is thus best understood as a “cultural chameleon,” responding fluidly to individual, interpersonal, and sociocultural sensitivities in an exquisite interplay across place and time. That is why I characterize it as “anorexia multiforme.” “Bracket creep” versus slim promises The criticism of Allen Frances, past chairman of the DSM-IV, is that the APA’s DSM project suffers from diagnostic “bracket creep,” meaning that it has become overly inclusive, allowing the criteria “bracketing” the categories of psychiatric disorders to balloon to bulimic proportions. From the slim pages of the initial DSM in 1952 to the expansive 1000 plus pages in small type of DSM-5 in 2013, something has gone awry. If DSM’s nosology has become bulimic, then NIMH’s Research Domain Criteria (RDoC) is positively anorexic! It is instructive to read the humanities. The twentieth century produced two great Irish writers who straddle extremes. Joyce was a synthesizer who “worked with all knowing, with putting everything in,” whereas Beckett was an analyzer who “worked … by taking everything out” (Knowlson 2006). DSM-5 puts in, as much possible as possible, a veritable encyclopedia of psychopathology, to compensate for its lack of a theory of human psychology. And under Insel, NIMH’s project, dismissing the previous DSM lexicon and nosology as a “mere dictionary,” takes clinical descriptions out in favor of mechanisms in the brain. After the “decade of the brain” and much fanfare, it makes for a very meager understanding of the brain, much less of the mind. In the final analysis, whether by adding or removing too much, both approaches reduce human psychology to an atheoretical manual of psychopathology, based either on clinical descriptions or brain mechanisms. Neither approach has integrated a general psychology of human beings into its understanding of psychopathology. Bulimic diagnostic “bracket creep” (DSM) versus the slim promises of brain science (NIMH). See Paris and Phillips (2013) for a nuanced critical overview of the making of DSM-5. Bread and Words A final rejoinder from the humanities to reductionists of all stripes, whether biomedical, psychosocial, or ecocultural. Psychologist Abraham Maslow (1954) proposed a hierarchy of human needs that is often invoked as if it is a law of nature. It is not. Meaning trumps nutrition, even security, even in extremis. Think of Bobby Sands, an IRA political prisoner, starving himself to death on a hunger strike in a British prison in Northern Ireland. Osip Mandelstam, writing from Stalin’s Gulag where he nourished his fellow prisoners with the hope of poetry, knew that the people need poetry not less than they need bread (Mandelstam 1973). “Poetry is like bread” (Russian poet Mandelstam, French mystic Simone Weil) that we cling to like a “redemptive handrail” (Polish Nobel laureate for poetry, Wisława Szymborska), “opening a window” (Brazilian gaúcho poet Mario Quintana) in the prisons we live in, some imposed, some chosen through misguided ideologies.
None of the reductionistic approaches to our work, from behaviorism to neuroscience, can make sense of the power of poetry. Skinner’s (1971) apologia for behaviorism was severely criticized by linguist Chomsky (1972) for its explanatory and creative poverty. Kandel’s (2012) neuroaesthetics attempting to understand “art, mind, and brain” through neurobiology was similarly found wanting by noted literary critic Adam Kirsch (2015). Only a human science that acknowledges that mind evolves in the context of a healthy brain bathed in a supportive social context nourished by attachment and belonging can have a dialogue about bread and words (Centeno Hintz and Godoy Santos Rosa, 2013; Di Nicola 2019).
References Bakhtin, M. M. (1981). The dialogic imagination: Four essays by M.M. Bakhtin, (ed. by Michael Holquist, trans: Caryl Emerson and Michael Holquist). Austin, Texas: University of Texas Press. Bentall, R. (2004). Madness explained: Psychosis and human nature. Foreword by Aaron T. Beck. London: Penguin Books. Berlin, I. (1978). The hedgehog and the fox. In Russian thinkers (Ed. by Henry Hardy & Aileen Kelly with an Introduction by Aileen Kelly) (pp. 22–81)). New York: The Viking Press. Brockman, J. (2015). This idea must die: Scientific theories that are blocking progress. New York: HarperCollins. Butzlaff, R. L., & Hooley, J. M. (1998). Expressed emotion and psychiatric relapse: A meta-analysis. Archives of General Psychiatry, 55(6), 547–552. https://doi.org/10.1001/archpsyc.55.6.547. Cacioppo, J. T. (2002). Social neuroscience: Understanding the pieces fosters understanding the whole and vice versa. American Psychologist., 57(11), 819–831. Cacioppo, J. T., & Berntson, G. (2005). Social neuroscience: Key readings. New York: Psychology Press. Cavalli-Sforza, L. L., Menozzi, P., & Piazza, A. (1996). The history and geography of human genes, Abridged edition. Princeton: Princeton University Press. Centeno Hintz, H., & Godoy Santos Rosa, M. I. (2013). “Pão e palavras”: Um diálogo relacional com Prof. Doutor Vincenzo Di Nicola, MD, PhD/“Bread and words”: A relational dialogue with Prof. Vincenzo Di Nicola, MD, PhD. Revista Pensando Famílias, 17(2), 3-34. Chomsky, N. (1972). Psychology and ideology. Cognition, 1(1), 11–46. CSDH. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. In Final report of the commission on social determinants of health. Geneva: World Health Organization. Di Nicola, V. (1988). Expressed emotion and schizophrenia in North India: An essay-review. Transcultural Psychiatric Research Review, 25(3), 205–217. Di Nicola, V. F. (1990a). Overview: Anorexia multiforme: Self-starvation in historical and cultural context. I: Self-starvation as a historical chameleon. Transcultural Psychiatric Research Review, 27(3), 165–196. Di Nicola, V. F. (1990b). Overview: Anorexia multiforme: Self-starvation in historical and cultural context. II: Anorexia nervosa as a culture-reactive syndrome. Transcultural Psychiatric Research Review, 27(4), 245–286. Di Nicola, V. F. (1990c). Contrasting visions from Milan: Family typology vs. systemic epistemology. Journal of Systemic & Strategic Therapies, 9(2), 19–30. Di Nicola, V. (1997). A stranger in the family: Culture, families and therapy. New York: W.W. Norton & Co. Di Nicola, V. (2011). Letters to a young therapist: Relational practices for the coming community. Foreword by M Andolfi, MD. New York & Dresden: Atropos Press.
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Di Nicola, V. (2012). Trauma and event: A philosophical archaeology. PhD dissertation in philosophy, psychiatry and psychoanalysis. Europäische Universität für Interdisziplinäre Studien— European Graduate School, Saas-Fee, Valais, Switzerland. Di Nicola, V. (2017a). Badiou, the event, and psychiatry, part 1: Trauma and event. Online blog of the American Philosophical Association, November 23, 2017. https://blog.apaonline. org/2017/11/23/badiou-the-event-and-psychiatry-part-1-trauma-and-event/. Di Nicola, V. (2017b). Badiou, the event, and psychiatry, part 2: Psychiatry of the event. Online blog of the American Philosophical Association, November 30, 2017. https://blog.apaonline. org/2017/11/30/badiou-the-event-and-psychiatry-part-2-psychiatry-of-the-event/. Di Nicola, V. (2018a). Take your time: The seven pillars of a slow thought manifesto. Aeon Magazine [internet]. 2018 Feb 27 [cited 2020 Mar 1]. Available from: https://aeon.co/essays/ take-your-time-the-seven-pillars-of-a-slow-thought-manifesto. Di Nicola, V. (2018b). Two trauma communities: A philosophical archaeology of cultural and clinical trauma theories. In P. T. Capretto & E. Boynton (Eds.), Trauma and transcendence: Limits in theory and prospects in thinking (pp. 17–52). New York: Fordham University Press. Di Nicola, V. (2019). Review article—“A person is a person through other persons”: A social psychiatry manifesto for the 21st century. World Social Psychiatry, 1(1), 8–21. Di Nicola, V. (2021). Antonella—“A stranger in the family”: A case study of eating disorders across cultures. In: D. S. Stoyanov, C. W. Van Staden, G. Stanghellini, M. Wong, & K. W. M. Fulford (Eds.), International perspectives in values-based mental health practice: Case studies and commentaries (pp. 27–30). New York: Springer International. https://doi. org/10.1007/978-3-030-47852-0_3. Frances, C. M., Lysaker, P. H., & Robinson, R. P. (2007). The “chemical imbalance” explanation for depression: Origins, lay endorsement, and clinical implications. Professional Psychology: Research and Practice, 38, 411–420. Gabbard, G. O. (2007). ‘Bound in a nutshell’: Thoughts on complexity, reductionism, and ‘infinite space. International Journal of Psychoanalysis, 88(3), 559–574. Gallese, V. (2008). Mirror neurons and the social nature of language: The neural exploitation hypothesis. Social Neuroscience, 3, 317–333. Gallese, V. (2014). Bodily selves in relation: Embodied simulation as second-person perspective on intersubjectivity. Philosophical Transactions of the Royal Society of London. Series B, 369(1644), 20130177. Gardner, C., & Kleinman, A. (2019). (2019). Medicine and the mind—The consequences of psychiatry’s identity crisis. The New England Journal of Medicine, 381, 1697–1699. Geertz, C. Review: Learning with Bruner—The culture of education by Jerome Bruner. New York Review of Books, April 10, 1997, 44(6):22–24. Geertz, C. (1973). Thick description: Toward an interpretive theory of culture. In The interpretation of cultures: Selected essays (pp. 3–30). New York: Basic Books. Guze, S. (1992). Why psychiatry is a branch of medicine. Oxford, UK: Oxford University Press. Henriques, G. (2003). The tree of knowledge system and the theoretical unification of psychology. Review of General Psychology, 7(2), 150–182. James, W. (1995). Pragmatism. New York: Dover. Kagan, J. (2009). The three cultures: Natural sciences, social sciences, and the humanities in the 21st century. Revisiting C.P. Snow. Cambridge: Cambridge University Press. Kagan, J. (2006). An argument for mind. New Haven: Yale University Press. Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux. Kandel, E. R. (2012). The age of insight: The quest to understand the unconscious in art, mind, and brain, from Vienna 1900 to the present. New York: Random House. Kirsch, A. (2015). Art over biology. In Rocket and lightship: Essays on literature and ideas (pp. 3–21). New York & London: W.W. Norton & Co. Kleinman, A. M. (1977). Depression, somatization and the “new cross-cultural psychiatry”. Social Science & Medicine, 11(1), 3–10.
Knowlson, J. (2006). Beckett and his biographer: An interview with James Knowlson. The European English Messenger, 15(2), 58–63. Lévi-Strauss, C. (1966). The savage mind. Chicago: The University of Chicago Press. Lombrozo, T. (2015). The mind is just the brain. In J. Brockman (Ed.), This idea must die: Scientific theories that are blocking Progress (pp. 271–273). New York: HarperCollins. Mandelstam, O. (1973). Selected Poems. (trans: Clarence Brown and W.S. Merwin). London: Oxford University Press. Marmot, M. (2015). The health gap: The challenge of an unequal world. The Lancet., 386(10011), 2442–2444. Maslow, A. (1954). Motivation and personality. New York: Harper. McKusick, V. A. (1969). On lumpers and splitters, or the nosology of genetic disease. Perspectives in Biology and Medicine, 12(2), 298–312. Murphy, H. B. M. (1982). Comparative psychiatry: The international and intercultural distribution of mental illness. Berlin & Heidelberg: Springer-Verlag. Murray, R. (2017). Mistakes I have made in my research career. Schizophrenia Bulletin, 43(2), 253–256. Noble, D. (2015). Classics—Conrad Waddington and the origin of epigenetics. The Journal of Experimental Biology, 218, 816–818. https://doi.org/10.1242/jeb.120071. http://jeb.biologists. org/content/jexbio/218/6/816.full.pdf. Accessed 1 Mar 2020. Paris, J., & Phillips, J. (Eds.). (2013). Making the DSM-5: Concepts and controversies. New York: Springer. Pies, R. W. Debunking the two chemical imbalance myths, again. Psychiatric Times, August 2, 2019, 36(8). https://www.psychiatrictimes.com/depression/debunking-two-chemical- imbalance-myths-again. Accessed 2 Feb 2020. Prince, R. (1972). Mental health workers should be trained at home: Some implications of transcultural psychiatric research. African Journal of Psychiatry, 2, 277-282. Rakoff, V. (1984). The necessity for multiple models in family therapy. Journal of Family Therapy, 6, 199–210. Salgado J., & Gonçalves, M. (2007). The dialogical self: social, personal, and (un)conscious. In J. Vaalsiner, & A. Rosa (Eds), The Cambridge handbook of sociocultural psychology (pp. 608–621). Cambridge: Cambridge University Press. Sartorius, N. (2019). Medicine is medicine through its disciplines. World Social Psychiatry, 1, 22. Satcher, D., Okafor, M., & Nottingham, J. H. (2012). The social determinants of mental health. In E. Sorel (Ed.), 21st century global mental health (pp. 73–94). Burlington: Jones and Bartlett Learning. Schwenk, T. L. (2020). What does it mean to be a physician? Journal of the American Medical Association. https://doi.org/10.1001/jama.2020.0146. Seeman, M. V. (2016). Schizophrenogenic mother. In J. Lebow, A. Chambers, & D. Breunlin (Eds.), Encyclopedia of couple and family therapy. Cham: Springer. https://link.springer.com/ referenceworkentry/10.1007%2F978-3-319-15877-8_482-1. Shepherd, M. (1982). In M. Bleuler (Ed.), Psychiatrists on psychiatry (pp. 1–13). Cambridge: Cambridge University Press. Silverstein, M., Hsu, H. E., & Bell, A. (2019). Addressing social determinants to improve population health: The balance between clinical care and public health. Journal of the American Medical Association, 322, 2379–2380. Skinner, B. F. (1971). Beyond freedom and dignity. New York: Knopf. Wilson, E. O. (1998). Consilience: The unity of knowledge. New York: Alfred A. Knopf.
Reframing Psychiatry: Posing the Right Questions
In our opening Prospectus and Leitmotifs, we raised questions that arise from both epistemological and ontological considerations. Here, I will elaborate what I consider psychiatry’s core problem, the ontological issues that create its existential crisis.
9.1 The Crisis of Psychiatry Is a Crisis of Being In an early form of empiricism, Protagoras proclaimed that, “Man is the measure of all things,” essentially placing human experience at the center of the human world. Plato criticized this as relativism and contemporary versions of Protagoras’ thought include constructivism and phenomenalism. Where Protagoras grounded his epistemology in a subjective sense-based empiricism, Plato appealed to the knowledge of objective and transcendent realities, beyond the individual’s experience and construction. With modernity at war with subjectivity (Postman 1993), science in the guise and pursuit of objectivity has now become the all-purpose measure that evolutionary biologist Stephen Jay Gould (1996) characterized as “the mismeasure of man” (cf. Kendell and Jablensky 2003), documenting misguided attempts to objectify human experience and qualities. Why in human psychology and psychiatry has science become the measure of all things? Why have we reduced our fields of knowledge to scientism and methodolatry, where only what is objectively measurable and quantifiable is valued? (Di Nicola 2017). My colleague Stoyanov argues that these are epistemological questions, that is to say questions about knowledge, and that the crisis of psychiatry is a crisis of knowledge (Stoyanov and Di Nicola 2017). While I agree that such issues are pressing and relevant, I believe that they are secondary considerations and that psychiatry is in crisis precisely because it lacks a core notion of what being human means and thus allows itself to be sutured or yoked to its shifting methods. As a result, psychiatry’s © Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_9
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identity crisis is not a result of the difficulties of taxonomy and nomenclature but their cause. Psychiatry’s crisis is a crisis of being. Our lack of clarity about the mission of psychiatry obscures three critical gaps: 1. The lack of a consensual psychology (or theory of persons) 2. The lack of an organizing consensual model of psychiatry (or theory of psychopathology that many call the phenomenology of psychiatry) 3. The lack of a consensual theory of change (as opposed to mere descriptions of change related to a given model) We must avoid suturing or yoking psychiatry to any given subdiscipline, but that is not enough. In order to create the coherence in the field that we currently lack, we must first radically rethink how theories are built in our field. That is precisely what psychiatry cannot do for itself and why we need philosophy and its two fundamental branches – ontology and epistemology. One of the founders of modern psychiatry, psychiatrist and philosopher Karl Jaspers (1997, p. 7700) anticipated this a century ago: If anyone thinks he can exclude philosophy and leave it aside as useless he will be eventually defeated by it in some obscure form or other.
Three possibilities for a philosophy of psychiatry may be construed: Declare psychiatry’s crisis as a “pseudo-problem” (Wittgenstein) We can give up trying to create a foundation for psychiatry and dismiss psychiatry’s difficulties as “pseudo-problems” (like Wittgenstein 1922, 1953) and simply continue with descriptive projects like the DSM-5 (APA 2013) that NIMH’s former director Thomas Insel (2013) dismissed as a mere “dictionary.” This is the major approach taken in twentieth-century academic philosophy, psychology, and psychiatry in the Anglo-American sphere led by Gilbert Ryle’s (1966) ordinary language philosophy at Oxford, John Watson, B.F. Skinner, and Hans Eysenck in behavioral psychology in the USA and the UK, and the neo-Kraepelinian project of American empirical psychiatry (Guze 1992). Opt for “weak thought” (Vattimo) We can argue that foundational theories of the mind are “weak” (Italian philosopher Gianni Vattimo 2012; Vattimo and Rovatti 2012), meaning that they are doomed to be pluralistic and incomplete. Vattimo’s (2012) philosophical argument hinges on the categories of totality and adequation which are comparable to Kurt Gödel’s concepts of completeness and coherence. For the nonspecialist in philosophy of mathematics and science, Gödel’s incompleteness theorems demonstrate the inherent limitations of every formal axiomatic system. The implication for our purposes is that we cannot expect psychiatry to achieve a complete and unitary theory. At best, we can reach for something like the vaunted but now much-criticized eclectic biopsychosocial model (propounded by American psychiatrist George Engel 1977, 1980) which lacks specificity and coherence (see Nassir Ghaemi 2010).
9.2 Di Nicola’s Frame Shift: Re-visioning Phenomenology – D Stoyanov
A defense of weak thought in psychiatry comes from a critique of the field yearning for “foundations” or the “true” nature of psychiatry but ends up falling into a series of what German psychiatrist and historian Paul Hoff calls “single method mythologies” (Fulford et al. 2013). Nonetheless, without a unifying theory, weak thought has made psychiatry centrifugal – dispersed and incoherent. This ironically describes the state of psychiatry today: strong on pluralism and diversity, weak on conceptual coherence and completeness. Refound psychiatry on being (Badiou) Finally, we can reach for a new foundation for psychiatry based not on what sorts of questions we have the tools to sort out, using computational models, genetics, or neuroscience, but on the very nature of human being. That means ontology, the study of being, and French philosopher Alain Badiou offers just such a foundation for psychiatry, with a theory of the subject (Badiou 2009b), the nature of being (Badiou 2005, 2009a), and with the Event, a theory of change (Badiou 2005, 2009a; Badiou and Tarby 2013). This speaks to contemporary psychiatry’s three critical conceptual gaps, noted above. The most beautiful lives are, in my opinion, those which conform to the common measure, human and ordinate, without miracles or extravagance. – Michel de Montaigne (2003, p. 1269)
In conclusion, a psychiatry founded on ontology is an antidote to the vacuity of dismissing mind as a pseudo-problem (in Anglo-American philosophy) or psychiatry dissipated by weak thought (in continental philosophy). Gathering in the dispersion of weak thought (meaning psychiatry distributed incoherently across such domains as mind, brain, and behavior) in a centripetal movement toward conceptual coherence and completeness, a psychiatry of being is a potent counterforce to the vacuity of mindlessness and the centrifugal dispersion of weak theory (not to mention giving up on theory altogether as in DSM-III’s claim to be “atheoretical”). As distinguished American cultural anthropologist Clifford Geertz (2010) affirmed, echoing Alexander Pope’s celebrated affirmation, “the proper study of Mankind is still Man.” Accordingly, let’s focus psychiatry on what makes humans human and our all-too-human vicissitudes. Psychiatry itself must now be measured by that task. By revisioning phenomenology, psychiatry can turn again to being as the measure of humanity, not merely behavior, cognition, or emotion and neither like a computer nor a neural network genetically wired by evolution but being in its full complement of human qualities situated historically, socially, and culturally.
9.2 D i Nicola’s Frame Shift: Re-visioning Phenomenology – D Stoyanov My colleague Di Nicola delineates the crisis in psychiatry as a crisis of being by bringing forward three major critical gaps. Those are concerns about lack of unitary theory of the normal psyche (or normal person), lack of consensual theory of
9 Reframing Psychiatry: Posing the Right Questions
psychopathology beyond conventional descriptions, and lack of consensual theory of change. By following the philosophical agenda of his mentor Alain Badiou, Di Nicola forecasts revisioning phenomenology as a potential source to overcome the current crisis by means of non-foundational and foundational (or metaphysical) approaches. My intuition in this respect is that two fundamental issues are entailed in this frame shift. On one hand, it remains purely epistemological as it addresses our disciplinary structure and the need to formulate a unitary theory of knowledge. It may be seen equally as a crisis of disciplinary identity. On the other hand, it penetrates more profoundly an essential problem for the entire field of medicine and health care, and that is the estrangement of technocratic medicine from the person. Although other disciplines in medicine demonstrate conceptually different foundations with unitary theories to consolidate normal and abnormal based on strict, quantitative definitions of their own, other medical specialties actually have one greater caveat. They are no longer concerned with the person behind the illness and are alienated from suffering articulated on an intersubjective level. What is Di Nicola’s view on that perspective? And what is the potential remedy if we consider the entire field of medicine in crisis, instead of just psychiatry being fatally separated from the rest of medical knowledge?
9.3 T ypes of Thinkers: Systematic, Edifying, and Methodological My answer to Stoyanov is to acknowledge his caveat as deeply relevant and that the problems of psychiatry are only a specific instance of a more general crisis not only in medicine but in science. Here, I mean “medicine” in its entirety as a profession and a biomedical science and “science” strictly as a methodology as opposed to its applications. As a method of inquiry, all the sciences have been in crisis since the advent of modernity. Edmund Husserl’s great work, after all, was entitled The Crisis of European Sciences and Transcendental Phenomenology (Husserl 1970, 1936), followed by such grand theorizing as philosopher and sociologist Jürgen Habermas’ On the Logic of the Social Sciences (Habermas 1989) and jurist and sociologist Boaventura de Sousa Santos’ Um Discurso Sobre as Ciências (Discourse on the Sciences) (de Sousa Santos 1987). Furthermore, we are living in the age of a replicability (or replication) crisis in research (Fidler and Wilcox 2018). This started in experimental psychology and other social sciences and has spread to medicine and related domains of research, notably the pharmaceutical industry. The replicability crisis goes to the heart of the scientific method to the point that it creates in the sciences what Habermas (1975) calls a legitimation crisis in the domain of politics and I call a credibility crisis for biomedical and social sciences. A critical analysis demonstrates that science’s methodological problems may be better understood through metascience (defined as “the scientific study of science
9.3 Types of Thinkers: Systematic, Edifying, and Methodological
itself” but which I see as a rebottling of philosophy of science). A deeper reflection by Muthukrishna and Henrich (2019) in fact suggests it is precisely theory that is lacking in the conduct of science, not merely methodological rigor. They argue that the larger part of the replication crisis is the lack of a cumulative theoretical framework: “Without an overarching theoretical framework that generates hypotheses across diverse domains, empirical programs spawn and grow from personal intuitions and culturally biased folk theories” (Muthukrishna and Henrich 2019, p. 221). I suspect that the “estrangement of medicine” arises precisely from the confusion between the physician’s commitment to healing, an eternal value of medicine, against the deployment of science as a method of inquiry, which is not only constantly shifting but whose authority is in question. Stoyanov bemoans the “estrangement of technocratic medicine from the person.” I call it the “eclipse of the person” in behavioral psychology (which was my first training; see Excursus: The Eclipse of the Person, the Empire of Reason, below). Now, if medicine has forgotten it, psychiatry’s first task must then be to restore the person as the focus of our work, both as the category of the person (in the classical Aristotelian sense) and in our subjective and intersubjective experiences (in the modern phenomenological sense). In the following, I break down the sources of what attracts thoughtful, intelligent investigators to the kinds of work they do. This may explain the temptations toward reductionism that has culminated in the erasure of “mind” from our field to create what philosopher Giorgio Agamben (1998) calls “bare life” and I decry as the evacuation of the human in the figure of the zombie (Di Nicola 2011b). As Agamben (personal communication, European Graduate School, 2010) said in reaction to my presentation on zombies at his seminar on Homo sacer, “Perhaps we are all zombies now.” Geertz (1997) observed that in the light of constantly shifting paradigms that “come along not by the century, but by the decade; sometimes, it almost seems, by the month”: It takes either a preternaturally focused, dogmatical person, who can shut out any ideas but his or her own, or a mercurial, hopelessly inquisitive one, who can keep dozens of them in play at once, to remain upright amid this tumble of programs, promises, and proclamations. There are, in psychology, a great many more of the resolved and implacable, esprit de système types (Pavlov, Freud, Skinner, Piaget, Chomsky) than there are of the agile and adaptable, esprit de finesse ones (James, Bateson, Sacks).
Systematic versus edifying thinkers This bifurcated view of thinkers in psychology and related fields is remarkably similar to how some contemporary philosophers and scientists see their work and reflects my distinction of fast psychiatry versus slow psychiatry (see above). Alain Badiou (2011b) distinguishes anti- philosophers from the true philosopher. Richard Rorty (1979, 1989) discerned edifying thinkers from systematic philosophers, just as neuroscientist Eric Kandel (2005) separated “disciplines and subdisciplines.” The true philosopher (Badiou) or systematic philosopher (Rorty) builds systems of thought, while Badiou’s
9 Reframing Psychiatry: Posing the Right Questions
a nti-philosopher undermines established thought, undermining the very possibility of philosophy, or simply pursues edifying questions (Rorty) rather than foundational ones. Plato, Aristotle, and Kant are philosophers, while Nietzsche, Freud, Wittgenstein, and Lacan are anti-philosophers, according to Badiou. Just as I argued in Part II that antipsychiatry is better understood as “psychiatry against itself,” negating some critical feature of psychiatry, anti-philosophy is the critique of some core features of philosophy to the extent that some, like Rorty and Vattimo, doubt the very possibility of ontology and become anti-foundational thinkers. Rorty eventually called himself a humanist rather than a philosopher. Geertz rightly points out that many “resolved and implacable” thinkers in psychology-related fields created systems of thought. Each of the people he named founded schools and a cottage industry of work followed them. These would be Rorty’s systematic thinkers. The others Geertz identifies as the rarer “agile and adaptable” thinkers of a refined and subtle spirit who are influencers rather than founders, and Rorty’s edifying thinkers. Methodologists I distinguish another group among all these schemes that I call methodologists – thinkers who provide tools for thought (Di Nicola 2012; 2018). This group is intermediate, overlapping, or orthogonal to the other two types. Classically, these were the rhetoricians and logicians who, by defining the shape and form of philosophical argumentation, established the canons of Western thought. Examples include the notions: a priori, a posteriori, a fortiori, induction, and deduction. In contemporary thought, there are methodologists who believe that there are tools of thought or methods of experimentation that will resolve philosophical aporias in epistemology and ontology. A striking example is cognitive psychologist Stephen Kosslyn (personal communication, Harvard University Dept. of Psychology, 1977) who argued that cognitive psychology now has the experimental means “to resolve questions that were hopelessly metaphysical” in the past. Not only is this not possible, but the experimental method only trivializes metaphysical questions. Earlier, in his work on psychology, Ludwig Wittgenstein (1953, p. 232) wrote: The existence of the experimental method makes us think we have the means of resolving the problems that trouble us; though problem and method pass one another other by.
This is a critique of methodolatry, reflecting an attachment not to truth but to the methods, apparatus, and techniques of empirical investigations. Methodolatry obtains when methodology becomes ideology. Alasdair MacIntyre (1998) warns about this in an essay on social science methodology as ideology, notably when deployed by bureaucrats for policy purposes. “Still metaphysical after all these years” Returning to Kosslyn and Wittgenstein, the sorts of questions that are addressed by these experiments do not address the sorts of questions that philosophers ask. The most important philosophical questions cannot be resolved empirically. Empirical observations of nature can add significant information but won’t resolve the fact-value distinction. EBM (“facts”)
9.4 Ideology and Temperament
cannot replace clinical reasoning and judgment (ultimately based on “values,” Fulford 2008; Stoyanov et al. 2020). As physician-philosopher Karl Jaspers said, any physician that believes he can avoid philosophical questions will find that they come back to defeat him in one form or another. And philosopher and novelist Rebecca Newberger Goldstein (2015) disputes the notion that science would make philosophy obsolete. After elaborating a version of Jaspers’ thought, arguing that most of the defenses of science employ philosophical ideas such as Karl Popper’s falsifiability criterion, Newberger Goldstein goes further, concluding that “we should retire the idea of ‘science’ itself … in favor of the more inclusive ‘knowledge’” (p. 131). In other words, in spite of Kosslyn’s assertion, to paraphrase Paul Simon, things are still “hopelessly metaphysical” after all these years! How does this apply to psychiatry? In psychiatry too, there are systematizers, the chief example of which is Emil Kraepelin and his followers in what we could call the neo-Kraepelinian project of classification with the DSM (APA 2013). Anti- psychiatrists, such as Franco Basaglia, Frantz Fanon, R.D. Laing, and Jacques Lacan (discussed at length in Part II on Critical Psychiatry), are better understood as “critical psychiatrists” on one hand, with an “edifying” discourse about the social and political nature of psychiatric disorders on the other (which is a major reason for their appeal). The methodologists are the EBM group who espouse the experimental method over theory, although their methods always reflect underlying theoretical assumptions.
9.4 Ideology and Temperament “What wound was I seeking to heal, what thorn was I seeking to draw from the flesh of existence when I became what is called ‘a philosopher’?” It may be that, as Bergson maintained, a philosopher only ever develops one idea. In any case, there is no doubt that the philosopher is born of a single question, the question which arises at the intersection of thought and life at a given moment in the philosopher’s youth: the question which one must at all costs find a way to answer. – Alain Badiou, Preface to Quentin Meillassoux’s After Finitude (2008, p. vi) Ideologia, eu quero uma pra viver Ideology—I want one to live. –Brazilian rocker, Cazuza, “Ideologia” (1988)
What determines how a psychiatrist becomes a given type of thinker, clinician, and investigator? To paraphrase German philosopher Johann Gottlieb Fichte, the psychiatry one chooses depends on the kind of person one is. What guides us to “the question which one must at all costs find a way to answer”? In a nutshell: ideology and temperament (Di Nicola 1990, 2011). Of the two, temperament is more durable than ideology.
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9.5 Ideology Imagine that you are a young investigator and casting about for a way to pursue your interests in the workings of the mind. You read an article, hear a talk by a visiting lecturer, or listen to your professor of anthropology, biology, linguistics, or psychology enthuse about some perspective on mind and culture, social relations, or the biology of the brain. You start reading everything you can about that perspective and start looking at the world around you in that light. In my generation, that would have been anthropologists Claude Lévi-Strauss or Clifford Geertz, biologists Jacques Monod or René Dubos, and linguistics theorist Noam Chomsky or behavioral psychologist B.F. Skinner. Monod’s book on Chance and Necessity (Monod 1971) was particularly important for me as a counterbalance to another Frenchman Pierre Teilhard de Chardin who proposed a kind of spiritual progress of the universe in The Human Phenomenon (Teilhard de Chardin 1999). We have to fight the notion of teleology and vitalism because there is still more than a whiff of this among biologically oriented students of mind, brain, and behavior who talk of human evolution as progress. These folks often see themselves as “progressives” and are at war with others who look at the same questions without sharing their values. An example is the controversy over IQ and race, forcefully countered by Stephen Jay Gould (1996) in his seminal polemic, The Mismeasure of Man. Now, suppose you have read one of these thinkers and start examining things from their perspective. You adopt their theory and try to explain as much as possible from that perspective. At the beginning, you are impressed by the power of the idea and how much more you seem to understand. Your analysis is marked by a beginner’s enthusiasm and clumsiness. After a while, you get more practiced in your arguments and expand the examples you examine with more success. Eventually, though, you face difficulties, and your now cherished perspective hits a wall: those aspects of human behavior that you cannot explain. Now you have a choice: to become ever more selective in your arguments, eliminating those situations that disconfirm your perspective, or examine the limits of your perspective more critically. This is ideology at work. That is the way knowledge, or science as we call it today, proceeds: you try something on for size, see how far you can take it, confront its limits, and then look for a better fit, something that takes you further along. “Wittgenstein’s ladder” is based on the philosopher’s notion that ideas are something we use to scramble up and then discard. Don Hebb, my first professor of psychology at McGill, had a provocative way of putting that: A theory makes a good mistress but a poor wife. If we remove the old-fashioned sexism from this maxim, there is still a nugget of truth there: theories need to be tried and tested, not taken on faith. Most of our ideas and perspectives are at best hypotheses, sometimes theories, and only after much trial and error do we call them laws. Psychology has very few laws; one of them is Thorndike’s Law of Effect, stating that a response followed by pleasure (“a satisfying state of affairs”) will encourage that response, while a
9.6 Psychiatric Temperaments
response followed by discomfort (“an annoying state of affairs”) will discourage its repetition. The Law of Effect can be traced back to philosopher John Locke’s associationism (recast by Thorndike as connectionism) as a principle of behavioral conditioning. It is compatible with the basic tenets of evolutionary theory and anticipated B.F. Skinner’s operant conditioning. It is also remarkably similar to one of Benedict Spinoza’s (1976, p. 53) proposition in his Ethics: If a man has been affected pleasurably or painfully by anyone of a class or nation different from his own, and if the pleasure or pain has been accompanied by the idea of the said stranger as cause, under the general category of the class or nation: the man will feel love or hatred, not only for the individual stranger, but also to the whole class or nation whereto he belongs.
Psychiatry has many theories, but unlike science and medicine (see Mukherjee’s “laws of medicine,” below), no laws so far.
9.6 Psychiatric Temperaments There is a second reason, deeper than ideology for our choices in psychiatry: temperament. Congruent with the notions of a fast psychiatry and a slow one, lumpers and splitters in medicine, centrifugal versus centripetal approaches in psychiatry, and systematic versus edifying philosophies, are my work on psychiatric or therapeutic temperaments (Di Nicola 1990, 1997, 2011a). I recognize two temperaments among therapists and psychiatrists: a more humanistic, phenomenological temperament centered around the experience of the other, the face-to-face therapeutic encounter (Levinas 1988), the course of the illness and the process of therapy, and a more scientific, technocratic temperament focused on intervention techniques and skills and their outcome. More than ideology, temperament guides our attraction to explanatory models of our work; ideology more easily follows. As philosophers Badiou and Bergson suggest, the formation of temperament occurs early in life when such crucial questions arise. Someone who is a lumper, looking for unifying approaches and coherence – in short, a phenomenological temperament – will be drawn to the kind of work in psychiatry that she will find edifying, such as psychotherapy with humanistic values, person-centered psychiatry, and Values-Based Practice (see Section III, below). Someone with a technocratic temperament, on the other hand, will more naturally be attracted to evidence-based practice and investigation. Here is a clue: in psychology and psychiatry, the technocrats define themselves by their method – so they call themselves behavior therapists, cognitive therapists, or psychotherapists. Earlier, we asked the question, Why has science become the measure of all things? More of the answer is revealed by temperament. Temperament guides the sorts of questions we ask in our youth and the methods and ideologies that follow coherently from them. We are more likely to adopt new methods and theories than to undergo temperamental change. That’s why temperament trumps ideology.
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People can adopt new ideologies (Badiou’s philosophy of the Event makes just such a claim), but changing your temperament is much harder (although psychoanalysis and some meditative practices make that claim). Nonetheless, our era is a technocratic one, oriented to STEM disciplines – science, technology, engineering, and mathematics – and rewards them more favorably.
9.7 Qualities of the Psychiatrist What are the qualities necessary to be a good psychiatrist? Nietzsche, who knew something about physicians and madness as he struggled with his own, recommended that the psychiatrist needs to be methodologically up- to-date, a good communicator, attentive and empathic, and a role model (Jaspers 1997, Vol II, pp. 808–809). Furthermore, while he must acquire the skills of “every other profession,” as Nietzsche puts it, something stands apart from the requirements and skills, and that is the core of psychiatry. For Jaspers (1997, p. 808), that was a combination of “scientific attitudes of the sceptic with a powerful personality and a profound existential faith.” Another physician-philosopher, William James (1890), referred to a similar duality of tough-minded empiricism and tender-minded rationalism. Medicine adopted the notion of sophrosyne from Greek philosophy (see Excursus on sophrosyne). Excursus: Sophrosyne (from the Greek σωφροσύνη) Whereas “philosophy is either reckless or it is nothing” (Badiou 2011a, p. 71) and science seeks the certainty of truth (Wilson 2013), psychiatry must be balanced. The ancient Greeks called this quality sophrosyne (Greek: σωφροσύνη), a wise, judicious balance, similar to sattva (Sanskrit: सत्त्व) in Indian thought. Each approach represents a very different path to the truth and each path defines and reaches for the truth in its own way. And each path has its zenith and its nadir. What we admire in philosophers is boldness, even recklessness which breeds resistance; what we demand of scientists is objectivity which breeds arrogance and contempt, what we cherish in physicians is what William Osler (1932) called aequanimitas – an even temper with balanced judgment, which breeds indifference and callousness.
9.8 Asymptote: The Law of Diminishing Returns In psychiatry, both phenomenology (ontology) and classification (epistemology) have reached an asymptote in terms of understanding and explaining. The academic leaders of psychiatry have found neuroscience wanting (e.g., Kingdon 2020), and philosophy has declared the end of subjective phenomenology (Badiou 2005, 2009a;
Sparrow 2014). Sparrow asserts that phenomenology has become too vague or generic a rubric that could mean anything or nothing. I am a keen student of phenomenology both in philosophy and psychiatry (Di Nicola 2012; Broome et al. 2012), but it has not lived up to its promise of a century ago. If it was going to spark a revolution in either field, it would have happened by now. In fact, we have moved far beyond “appearances” and “describing things as they are,” to other questions. “Part II: Psychiatry in Crisis as a Human & Social Science” of this volume documents the death, with the assisted suicide of Ellen West, of Binswanger’s Daseinsanalyse. Its canonical case, “Der Fall Ellen West” (Binswanger 1958), in German literally “the case of Ellen West” but metaphorically her “fall,” also declares the fall of existential analysis and of phenomenological psychiatry. Psychiatrists and scholars in the humanities continue to write thoughtful works, mostly historical, that simply rehash what we have already learned. Like the movie “Groundhog Day,” the same approach is repeated over and over again in psychiatry. My colleagues who do basic science research in psychiatric genetics or neuroscience always say the same thing: We are advancing and a breakthrough is just around the corner. But here’s the rub: as we get closer and closer, we reach an asymptote, a kind of bottleneck that slows down progress. “The law of diminishing returns” means that more research, understanding, and illumination will require ever more time and energy (resources) while advancing ever more slowly to an elusive goal. Clinical judgment remains an opinion, no matter how well informed, understood, and rendered conscious. As for EBM, no matter how much data is brought to bear, the clinician is still faced with a clinical judgment in the final instance. And this is now represented by such approaches as Person-Centered Medicine and Values- Based Practice (Fulford 2008; Stoyanov et al. 2020). Clinical judgment itself can be investigated by psychological methods, but that is more sophisticated than what people usually invoke by EBM. While these studies can illuminate the cognitive processes that are at stake, they cannot determine them or bridge the gap between the scientific evidence and the human values when real solutions are required. At best, cognitive science can identify typical trends, casts of thoughts as the research by Kahneman and Tversky has brilliantly demonstrated (Kahneman 2011). In my reading, it elucidates the parameters of clinical reasoning and may explain its pitfalls, but the issue for the psychiatrist is not only epistemological (how to know one’s own and other minds) but ontological (what is human nature?) and clinical (how to help the patient). And this is very important: if the wrong approach or procedure is chosen, the asymptote will defeat us. This is inevitable and unchangeable until we change approaches, redefine our terms, and reframe the questions.
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Badiou, A. (2005). Being and event (trans: Oliver Feltham). London: Continuum. Badiou, A. (2008). Preface. In: Q. Meillassoux (Ed.) After finitude: An essay on the necessity of contingency (pp. vi–viii) (trans: Ray Brassier, Preface by Alain Badiou). London: Continuum. Badiou, A. (2009a). Logics of worlds, being and event II (trans: Alberto Toscano). London: Continuum. Badiou, A. (2009b). Theory of the subject (trans: and with an introduction, by Bruno Bosteels). London: Continuum. Badiou, A. (2011a). Second manifesto for philosophy (trans: Louise Burchill). Cambridge, UK: Polity Press. Badiou, A. (2011b). Wittgenstein’s antiphilosophy (trans: with an Introduction by Bruno Bosteels). London: Verso. Badiou, A., & Tarby, F. (2013). Philosophy and the event (trans: Louise Burchill). Cambridge, UK: Polity Press. Binswanger, L. (1958). The case of Ellen west: An anthropological-clinical study (trans: Werner M. Mendel & Joseph Lyons). In: M. Rollo, A. Ernest, & H. F. Ellenberger (Eds.) Existence: A new dimension in psychiatry and psychology (pp. 237–364; 293–294). New York: Basic Books. Broome, M. R., Harland, R., Owen, G. S., & Stringeris, A. (Eds.). (2012). The Maudsley readers in phenomenological psychiatry. Cambridge: Cambridge University Press. de Montaigne, M. (2003). The complete essays (trans: M. A. Screech). London: Penguin. de Sousa Santos, B. (1987). Um Discurso Sobre as Ciências [A Discourse on the Sciences]. Porto: Edições Afrontamento. Di Nicola, V. (1990). Contrasting visions from Milan: Family typology vs. systemic epistemology. Journal of Systemic & Strategic Therapies, 9(2), 19–30. Di Nicola, V. (1997). A stranger in the family: Culture, families and therapy. New York: W.W. Norton & Co. Di Nicola, V. (2011a). Letters to a young therapist: Relational practices for the coming community. New York & Dresden: Atropos Press. Di Nicola, V. (2011b). States of exception, states of dissociation: Cyranoids, zombies and liminal people. An essay on the threshold between the human and the inhuman. In Letters to a young therapist: Relational practices for the coming community (pp. 149–162). Foreword by M Andolfi, MD. New York & Dresden: Atropos Press. Di Nicola, V. (2012). Trauma and event: A philosophical archaeology. PhD dissertation in philosophy, psychiatry and psychoanalysis. Europäische Universität für Interdisziplinäre Studien— European Graduate School, Saas-Fee, Valais, Switzerland. Di Nicola, V. (2017). Badiou, the event, and psychiatry, part 1: Trauma and event. Online blog of the American Philosophical Association, November 23, 2017. https://blog.apaonline. org/2017/11/23/badiou-the-event-and-psychiatry-part-1-trauma-and-event/. Engel, G. L. (1977). The need for a new medical model: a challenge for biomedicine. Science, 196(4286), 129-136. Engel, G. L. (1980). The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137, 535-544. Fidler, F., & Wilcox, J. (2018). “Reproducibility of scientific results”. The Stanford encyclopedia of philosophy (Winter 2018 Edition), Edward N. Zalta (ed.). https://plato.stanford.edu/ archives/win2018/entries/scientific-reproducibility/ Fulford, K. W. M. (2008). Values-based practice: A new partner to evidence-based practice and a first for psychiatry? Mens Sana Monographs, 6, 10–21. Fulford, K. W. M., Davies, M., Gipps, R. G. T., Graham, G., Sadler, J. Z., Stanghellini, G., & Thornton, T. (Eds.). (2013). The Oxford handbook of philosophy and psychiatry. Oxford, UK: Oxford University Press. Geertz, C. (1997). Review: Learning with Bruner—The culture of education by Jerome Bruner. New York Review of Books, April 10, 1997, 44(6), 22–24. Geertz, C. (2010). Life among the anthros and other essays, ed. with an introduction by Inglis, F. Princeton: Princeton University Press.
Ghaemi, S. N. (2010). The rise and fall of the biopsychosocial model: Reconciling art and science in psychiatry. Baltimore: The John Hopkins University Press. Gould, S. J. (1996). The mismeasure of man. New York: W.W. Norton & Co. Guze, S. (1992). Why psychiatry is a branch of medicine. Oxford: Oxford University Press. Habermas, J. (1975). Legitimation crisis (trans. and introduced by Thomas McCarthy). Boston: Beacon Press. Habermas, J. (1989). On the logic of the social sciences (trans: Shierry Weber Nicholson and Jerry A. Stark). Cambridge, MA: MIT Press. Husserl, E. (1970). The crisis of European sciences and transcendental phenomenology (trans. with an introduction by David Carr). Evanston: Northwestern University Press. Original published in German in 1936. Insel, T. (2013). Transforming diagnosis. National Institute of Mental Health. April 29, 2013 [Online]. Available at: https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/ transforming-diagnosis.shtml. Accessed 25 Jan 2020. James, W. (1890). Principles of psychology. New York: Holt. Jaspers, K. (1997). General psychopathology, Vols. I and II (trans: Hoenig, J. and Hamilton, M.W., with a new forward by McHugh, P.R.) Baltimore & London: The Johns Hopkins University Press. (Original in German, 1913). Kahneman, D. (2011). Thinking, fast and slow. New York: Farrar, Straus and Giroux. Kandel, E. R. (2005). Psychiatry, psychoanalysis, and the new biology of mind. Washington, DC: American Psychiatric Publishing. Kendell, R., & Jablensky, A. (2003). Distinguishing between the validity and utility of psychiatric diagnoses. American Journal of Psychiatry, 160, 1, 4-12. Kingdon, D. (2020). Why hasn’t neuroscience delivered for psychiatry? BJPsych Bulletin, 44, 1–3. https://doi.org/10.1192/bjb.2019.87. Levinas, E. (1988). Entre Nous: Thinking-of-the-other (trans: Michael B. Smith and Barbara Harshav). New York: Columbia University Press. MacIntyre, A. (1998). Social science methodology as the ideology of bureaucratic authority. In K. Knight (Ed.), The MacIntyre reader (pp. 53–68). Cambridge: Polity Press. Monod, J. (1971). Chance and necessity: An essay on the natural philosophy of modern biology (trans: by Austryn Wainhouse). New York: Alfred A. Knopf. Muthukrishna, M., & Henrich, J. (2019). A problem in theory. Nature Human Behaviour, 3, 221–229. Newberger, G. R. (2015). Science makes philosophy obsolete. In J. Brockman (Ed.), This idea must die: Scientific theories that are blocking Progress (pp. 129–131). New York: HarperCollins. Osler, W. (1932). Aequanimitas, with other addresses to medical students, nurses and practitioners of medicine. New York: McGraw-Hill. Postman, N. (1993). Technopoly: The surrender of culture to technology. New York: Vintage Books/Random House. Rorty, R. (1979). Philosophy and the mirror of nature. Princeton: Princeton University Press. Rorty, R. (1989). Contingency, irony, solidarity. Cambridge: Cambridge University Press. Ryle, G. (1966). The concept of mind. New York: Viking Penguin. Sparrow, T. (2014). The end of phenomenology: Metaphysics and the new realism. Edinburgh: Edinburgh University Press. Spinoza, B. (1976). In D. D. Runes (Ed.), Ethics: The road to inner freedom. Secaucus: The Citadel Press. Stoyanov, D. S, & Di Nicola, V. (2017). Psychiatry in crisis: Epistemological and ontological concerns. American Journal of Psychiatry and Neuroscience, November, 5 (6-1), 6. Stoyanov, D. S., Van Staden, C. W., Stanghellini, G., Wong, M., & Fulford, K. W. M. (Eds.). (2020). International perspectives in values-based mental health practice: Case studies and commentaries. New York: Springer International.
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Teilhard de Chardin, P. (1999). The human phenomenon (trans: Sarah Appleton-Weber). Eastbourne: Sussex Academic Press. Vattimo, G. The responsibility of the philosopher, edited with an Introduction by Franca D’Agostini (trans: William McCuaig). New York: Columbia university Press, 2012. Vattimo, G., & Rovatti, P.A. (Eds.) (2012). Weak thought (trans: and with an introduction by Carravetta, P.) Albany: State University of New York Press. Wilson, E. O. (2013). Letters to a young scientist. New York & London: W.W. Norton & Company/ Livewright. Wittgenstein, L. (1922). Tractatus logico-philosophicus (trans: by C.K. Ogden, Introduction by Bertrand Russell). London: Routledge & Kegan Paul. Wittgenstein, L. (1953). Philosophical investigations (trans: G.E.M. Anscombe). London: MacMillan Publishing.
Renewal in Psychiatry
In documenting psychiatry’s crisis, are we calling for renewal in psychiatry? Yes, but in what form? And to what extent? Anecdote – From tune-up to overhaul A colleague who is an anthropologist and a family therapist told me she and her partner went to a couples retreat with a noted American couple therapist. After the weekend, her husband said, “I thought we went in for a tune-up, but we came out with a new transmission.” Almost everyone admits in moments of self-inquiry and openness that we could use some “retuning,” but it is harder to see from the outset that a more radical “overhaul” (not to mention replacement) may be necessary.
10.1 Philosophy as Therapy First, with Nietzsche, philosophy’s most famous patient, later with Wittgenstein, now with Vattimo and Sloterdijk, philosophy is offered as a kind of therapy. So, if philosophy cannot explain psychiatry’s problems away, perhaps it may cure them. Nietzsche gave us “the philosopher as the physician of culture” (Sloterdijk 2013, p. 4). Wittgenstein described “philosophical treatment” with this simile: “The philosopher’s treatment of a question is like the treatment of an illness” (Wittgenstein 1953, § 255, p. 91). Vattimo (2012) prescribes philosophy as a “convalescence” or “recovery” (German, Verwindung) from the “metaphysical malady.” If we can’t cure ourselves of metaphysics, he reasons, at least we can try to recover from it like the Alcoholics Anonymous approach which holds that addictions are lifelong afflictions. In an interview, Sloterdijk (2016, p. 25) was asked if he concurred with the American trend of clinical philosophy with the slogan, “Fire your shrink, hire a philosopher.” He demurred, “Philosophers can’t heal anything, not even themselves.” Another interviewer observed that, “You have always been a therapist for our time, a diagnostician for our times.” And that his work was “the summing-up of © Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7_10
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our age,” to which he replied that it was more of a “philosophical retuning” (Sloterdijk 2016, p. 35). None of the problems noted in this book about the crisis of psychiatry are amenable to retuning but require rather a radical revisioning. “Part II: Psychiatry in Crisis as a Human & Social Science” is a “philosophical archaeology” of the promise (with Karl Jaspers) and failure (with Ludwig Binswanger) of subjective phenomenology in psychiatry. Are there other possibilities? In fact, when it comes to thinking about psychiatry, contemporary philosophy often comes up short by addressing epistemology instead of ontology. Both Anglo-American analytical philosophy, with its dismissal of “pseudo-problems” and its “language therapy” (Wittgenstein, Ryle), and the continental tradition of critical theory (the Frankfurt School) followed by deconstruction (Derrida), genealogy (Nietzsche, Foucault) and archaeology (Foucault, Agamben), are just ways of “retuning.” They analyze psychiatry’s problems without advancing them in any significant way, let alone solving them. If we see them differently, problems will just disappear, Wittgenstein says. Show the fly out of the fly bottle, climb up the ladder to get out of the muddle, and then throw it away! Derridean deconstruction is often brilliant, as in his deconstructive reading of “Plato’s pharmacy” (Derrida 1981) that uncovers heretofore hidden meanings and latent possibilities of what Leo Strauss calls hermetic texts (Strauss 1952). This method sees texts as endlessly recursive, leaving traces, disseminating, propelling meanings, a kind of centrifuge separating nuances, what Agamben following Foucault and others calls “philosophical archaeology” (Agamben 2009). Agamben uses this method as a kind of philosophical spade. We’re in the ruins of a beautiful garden, and we take up gardening tools to uncover texts like urns and their traces like broken pottery to reconstruct them and render them contemporary. Derrida’s deconstruction is like the yad in Jewish rituals, a pointer named for the letter yad in Hebrew which is used to indicate your place on the sacred text. A yad, which is shaped like a finger, points to the text, but you may never touch it. This is both literal and a metaphor. The text is treated like an untouchable sacred object (the Torah is like a bride, with adornments like a breastplate, and the admonition is to build a fence around the Torah to protect it from defilement), and the word revealed by the text is never exhausted (Di Nicola 2012). But after all is done and said – from Nietzsche’s physician of culture or Wittgenstein’s therapy and Vattimo’s convalescence to Sloterdijk’s retuning, deploying Wittgenstein’s bottle or his ladder, deconstructing with a Derridean centrifuge or a yad, digging in the philosophical ruins with Agamben’s spade, or wielding Badiou’s shears (see Part II) – where are we?
10.2 The Need to Create a New Synthesis There are many thinkers who seek a rapprochement between the art and science of psychiatric medicine, such as David Brendel (2006) and Nassir Ghaemi (2010) as well as Brockman’s “third culture” (Brockman 1995) bridging the arts and sciences
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overall. Scholars in numerous fields are using neuroscience to understand broader aspects of human being, including aesthetics. And what if this doesn’t occur? What if we don’t find a rallying cry that brings together these disparate strands under the two-century-old project called psychiatry (Marneros 2008)? Very probably, we will lose a degree of public credibility and the professional respectability we have among our colleagues in medicine and the academy in general. Leon Eisenberg (1986), American psychiatry’s éminence grise, bemoaned mindlessness (implying that mental disorders are nothing but brain disorders) versus brainlessness (psychological theories that discounted neuroscience) in psychiatry. The diversity of psychiatry, which may be seen as a strength, may also work like a centrifuge, creating dispersion and division. The gap that Eisenberg described decades ago has become a chasm. As a result, I see the profession splitting into three distinct yet overlapping branches that are already separate provinces that, failing a new consensus, would eventually declare independence: 1. Psychotherapy with Humanistic Values. The therapists who, across many other differences, hold humanistic values dear to their project: therapy as a human encounter, interpersonal in nature, ethical in its concerns, respecting both the uniqueness and individuality of each person and their complex, multiple and competing personal attachments, social belongings, and value commitments. This branch is congruent with two emerging movements – Person-Centered Psychiatry (Mezzich et al. 2016) and Values-Based Practice in Health and Social Care (Fulford 2008; Di Nicola 2020; Stoyanov et al. 2020) – and would include many forms of relational therapy, such as couples therapy and family therapy. In terms of psychiatric temperament, I see this group as phenomenological.
Excursus: The Eclipse of the Person, the Empire of Reason This group of humanistic psychotherapists probably would not include such psychological therapies as behavior therapy and its derivations such as cognitive-behavioral therapy, the current “gold standard” of treatment in psychology and psychiatry, allied with EBM and managed care. Behavioral and cognitive therapies either reduce the person to behaviors (and skills sets) or to cognitive schemas (or maps in the mind). Behaviorism reduces the person to an agent controlled by antecedents and consequences; in the behavioral triad, ABC – antecedent, behavior, and consequence – there is an eclipse of the person. There are neither persons nor personalities in behaviorism and behavior therapy. It was constructed during the war in early modern psychology against the introspective method and, later, as a cudgel against psychoanalysis (“Insight does not equal behavior change”). Cognitive therapy is a way to redraw the person as controlled by cognitive schemas or maps in the mind of the self and the world. How such maps or schemas come about is unclear in this model. At least cognitive therapy
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reintroduced mind, yet in concentrating on cognition or thinking, it plays to the preferences of Western society, privileging certain kinds of thinking and verbal expression over other experiences, what I have decried as “elitist cognitivism” (Di Nicola 1990). This approach conflates thinking with emotions and reduces persons to rational actors with little room for values and experiences that are not based on a narrow, utilitarian view of reason. Psychopathology here becomes “unreason,” just as irrational thoughts are “cognitive distortions.” The empire of reason leaves out aesthetics, ethics, and morality, not to mention free will and political resistance.
2. Evidence-Based Clinical Neuroscience. The researchers who hold by EBM and psychiatry as clinical neuroscience. Formerly biological psychiatrists, they now rally under the mantra, “mind equals brain,” whose gold standard is “the evidence base.” As cognitive scientist Marvin Minsky put it, “Minds are simply what brains do.” Over a century ago, Ambrose Bierce satirically defined mind in The Devil’s Dictionary (Bierce 1911) as “a mysterious form of matter secreted by the brain.” This is the Mind/Brain Identity Theory in philosophical terms, pioneered by U.T. Place and Herbert Feigl. The subtext boldly exposed by Neil Postman in his Technopoly (Postman 1993, p. 158), is a war against subjectivity: “Diversity, complexity, and ambiguity of judgment are enemies of technique.” In terms of psychiatric temperament, I consider this group technocratic. A paramount example of this approach is the recent research by Stoyanov and associates (Stoyanov et al. 2019) into discovering brain signatures of functional magnetic resonance imaging patterns corresponding to self-evaluation reports on clinical scales. Three brain signatures were discovered from the entire dataset by means of multivariate linear method, a highly sophisticated machine learning technique. Based on them, the investigators were able to achieve statistical differentiation of the two diagnoses – schizophrenia and depression with a high accuracy level (90%). The apparent risks here are reductionism expressed as scientism and methodolatry, where robust statistical procedures, machine learning, and neuroimaging fingerprints tend to displace meaningful clinical subjective experience (Stoyanov 2020). Excursus: The Third Culture and Human Nature The Third Culture. Many psychiatrists in the neuroscience group would no doubt identify with John Brockman’s “third culture” (Brockman 1995), bringing scientific thinking to a broader public in an effort to bridge the chasm of C.P. Snow’s so-called two cultures (Snow 1963) of the sciences and the humanities. A critic noted that this new third culture is “an offspring of science … a pop culture based in technology” where “technology itself is the
10.2 The Need to Create a New Synthesis
star, as it is in many special-effects movies” (Kelly 1998, p. 992). “Cultural centers radiate new language; technology is a supernova of slang and idioms swelling the English language” (Kelly, 1998, p. 992). Unlike science which pursues the truth and the arts which describe the human condition, this “cultural realignment” pursues novelty. Human Nature. This group values progress and reason, imposing a technocratic view of human nature on the biomedical, social, and human sciences. One need only contrast cognitive scientist Steven Pinker’s view of human nature in How the Mind Works (Pinker 1997) and Enlightenment Now (Pinker 2018) with philosopher Roger Scruton’s On Human Nature (Scruton 2017). Other essays on human nature range from B.F. Skinner’s Beyond Freedom and Dignity (Skinner 1971), whose subtitle could aptly be “on human nature,” to E.O. Wilson’s sociobiological synthesis, also called On Human Nature (Wilson 1978), and bioethicist Peter Singer’s A Darwinian Left (Singer 1999), where he argues that the left must revise its outdated view of human nature to include Darwinian evolution. Together, they offer a broad range of views, from behaviorism (Skinner) to neo-Darwinian sociobiology (Wilson) to Darwinian politics (Singer) to evolutionary psychology (Pinker) and, finally, to a more embracing philosophical defense of human beings as persons (Scruton). The history of psychology and psychiatry is in part a history of the impoverishment of “human nature.” Human nature is precisely in question but in an expanded, enlarged sense that includes society and culture. Brain science cannot and will not replace psychology and psychiatry, animated by the questions that philosophy has posed for millennia. On the other hand, philosophy must take stock of how human nature is defined by various human, social, and life sciences with such compelling new paradigms as mimetic theory in anthropology (René Girard 1996) or mirror neurons in neuroscience (Vittorio Gallese 2008, 2014). The study of human nature was invented in the Enlightenment. Giambattista Vico, Benedict Spinoza, and Immanuel Kant launched visions that triggered battles over how to understand and define human nature with the likes of John Locke, Thomas Hobbes, David Hume, and Jean-Jacques Rousseau. Most contemporary sciences have taken a stab at defining human nature. Having dedicated his work to eliminating everything we think of as human from behaviorism, B.F. Skinner surprisingly concludes his philosophical summa, Beyond Freedom and Dignity (Skinner 1971) with this declaration: “We have not yet seen what man can make of man.” Psychologist-philosopher-historian Michel Foucault declared the Enlightenment notion of “Man” dead, let alone human nature. They are both radical departures from the renaissance and humanist projects defining humanity and human nature across the biological, social, and human sciences.
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With his insights into the nature and function of memoria, Giordano Bruno can become the contemporary of those who today huddle around the brain as if it were the locus of the riddle of the universe. – Peter Sloterdijk (2013, p. 26).
This is prescient and precise. These investigators claim that the brain is the most complicated thing in the universe. Closer to psychiatry’s vision, they hold that understanding consciousness is the Holy Grail of the human sciences. Intriguingly, Freud approached this mystery negatively, through the discovery of the unconscious (cf., Ellenberger 1970; Makari 2015). But let’s not mince words; “consciousness” is mind, pure and simple, narrowly redefined in cognitive terms. The simple rejoinder to Minsky’s notion of mind as a function of the brain is that a full account of the brain will not be a complete account of the mind (Kagan 2006). But we still have to combat reductionism in the form of scientism and methodolatry in general and “Darwinitis and Neuromania” specifically (Tallis 2011). 3. Psychiatry as an Integrative Synthesis. Finally, there are those brave souls who still hold out for a grand synthesis of these competing strands. This could be called a “third culture” or “third way” – but those terms have been appropriated by technology culture and as a description of the political hybrid between neoliberalism and social democracy (See Excursus: The Third Culture. As such, the term third culture is more congruent with the second group of EBM technocrats.) This synthesis would complement EBM with Values-Based Practice (Fulford 2008; Stoyanov et al. 2020); the impersonal approach of psychiatric epidemiology’s populational research (now morphed into the global mental health movement) with Person-Centered Medicine in psychiatry (Mezzich et al. 2016); and quantitative research with qualitative approaches including narrative and experiential witnessing. Temperamentally, this synthesis would attract psychiatrists who combine both phenomenological, humanistic tendencies with a technocratic, scientific framework. Syntheses make for odd pairs and false friends, as they say in language translation. With the potential synergies touted by Stein and associates (Stein et al. 2015) in their proposed synthesis of global mental health (a populational approach) and neuroscience (an experimental one), the clinical relevance and implications are as yet unclear. Psychiatry tried to adopt psychology’s model of the clinical scientist. Yet, among clinical psychiatrists, those who can dedicate an important amount of time to research are very limited for both practical reasons and for reasons of temperament. Imposing the ideal of each practitioner becoming a clinical neuroscientist will fail
10.2 The Need to Create a New Synthesis
Excursus: Psychology’s Two Communities of Practice Clinical psychology has long acknowledged these differing temperaments, separating academic investigators from applied clinicians. Yet, in spite of the “scientist-practitioner model” (Boulder Conference in 1949), the practitioner- scholar model (Vail Conference, 1973), and today’s “clinical scientist” movement, the vast majority of people attracted to psychology are interested in human models of human beings, not animal, computer, AI, or biological models. In response, some psychologists have tried to create a unified theory in psychology (Henriques 2011) with an integrated identity for the profession transcending the distinctions of clinician or practitioner and scholar or scientist into “a holistic view of a mental health profession” (Henriques 2014). Henriques argues that, “the practice of psychology cannot be fully reduced to the science” (Henriques 2014). From a research perspective, developmental psychologist Jerome Kagan (2006) saw academic psychology differentiating into two broad fields. One group, with a narrower focus, “will study the biological foundations of sensation, perception, the establishment of conditioned associations, registration and retrieval of information and motor performance.” Advances in genetics, neuroscience, and molecular biology will attract scientists who seek crisp and clear answers, those whom Kagan calls “hunters,” anthropologist Claude Lévi-Strauss (1966) calls “engineers” and whom I call “technocrats” in my view of therapeutic temperaments (Di Nicola 2011). The complementary group has a wider focus that “will probe human behaviors, emotions and beliefs, will explicitly acknowledge the contribution of history and culture and will include psychologists, sociologists, anthropologists, and a few historians and economists.” These are “butterfly chasers” according to Kagan, “bricoleurs” in Lévi-Strauss’ typology, and “phenomenologists” in my view. “Variation in the tolerance for ambiguity separates hunters from butterfly chasers,” asserts Kagan knowingly, from an accomplished life in psychological research (emphasis added). Kagan separates the two groups largely because of different methods which produce different evidence and “evidence gives meaning to concepts.” miserably and will lead those who can’t or won’t follow this model to secede into the branches outlined here or some variation thereof. And indeed, one sees these tensions everywhere – in departmental meetings, in psychiatric publications, and at conferences at every level. Indeed, the higher one goes, the more authority and experience that psychiatrists have, the more likely are they to reveal their admonitions and concerns: • Cultural psychiatrist-anthropologist Arthur Kleinman (1991, 2012): Rethinking Psychiatry and his editorial on rebalancing academic psychiatry • Psychiatrist-philosopher Nassir Ghaemi (2010, 2017): Critique of the BPS model and his pessimistic letter to a medical student
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• Psychiatrist-psychologist and Past Director of WHO Division of Mental Health Norman Sartorius (1994, 2017, 2019): The need for a common language in psychiatry, multiple futures for psychiatry, and the difficulties of global mental health versus the need for social psychiatry As noted above, Jerome Kagan acknowledged that the field of psychology has already separated into two branches based not on the kinds of questions people pursue but on their temperaments and methodologies. In psychiatry, Eric Kandel has effectively argued in his analysis of the disciplines and subdisciplines of scientific research that identities, methodologies, and what is foreground and background shift according to the problem at hand, with very convincing examples from biomedical research. I do not see such an easy rapprochement possible under one tent called psychiatry. The experiment with the BPS model demonstrated clearly that the second group (evidence-based neuroscience, formerly biological psychiatry) only mouths a commitment to methodological diversity and plurality and that, indeed, Allen Frances was right in affirming the reality that “BPS became bio-bio-bio.” It’s also true that whoever has hegemony risks doing the same so that in mid-twentieth century American academic psychiatry, psychodynamic psychiatry held sway, countered by the community mental revolution of the 1970s on the heels of the anti-psychiatry movement of the 1960s. The two grand movements in academic psychiatry now are global mental health (GMH) and neuroscience twinned with psychiatric genetics. Despite Di Nicola’s involvement with GMH and Stoyanov’s research in neuroscience, both models are very distant from clinical practice, and neither is likely to rally the field into a consensus. Evental Psychiatry We can never foresee an event that may change everything. Yet, we can perceive that we are, in the ontological language of philosopher Alain Badiou, in an evental site: a place and time where an event could come about. It is radically contingent, but once it occurs, people change in important ways, name the experience, and live and work faithfully in the light of such an illuminating event. For example, the field of psychology, if we can still call it that, changes its name, its focus, and its practices according to its prevailing theory and methods. Psychologists as different as Carl Rogers, B.F. Skinner, and Steven Pinker have an internally coherent theory and a practice that follows from an event to the extent that they engendered a name change for the field – humanistic psychology (Rogers), behavioral psychology (Skinner), and evolutionary psychology (Pinker). In Pinker’s case, beyond evolution and neuroscience, the event of his life is evidently his conviction about progress and reason, expressed in his summa, Enlightenment Now (2018). Closer to home in academic psychiatry, Eric Kandel (2005, 2006, 2018), a psychiatrist who won the Nobel Prize in Physiology or Medicine in 2000 for his research on memory, sees the future of psychiatry in neuroscience, along with many others who see syntheses between neuroscience and everything from anthropology (Domínguez et al. 2010) to aesthetics (Gallese and Gattara 2015; Kandel 2012), global mental health (Stein et al. 2015), language (Gallese 2008), philosophy (Gallese 2014), psychoanalysis and psychotherapy (Blinder 2003, 2007; Kandel 2005, 2006, 2012;
10.3 The Long Habit
Novac et al. 2019), and social science (social neuroscience, Cacioppo 2002; Cacioppo and Berntson 2005). The crisis of psychiatry demands an acknowledgement of these competing visions, a historically informed reading of how we got here, and a capacity to criticize ideologies of all stripes. At this point, any declaration of consensus is an aspiration, not a reality.
10.3 The Long Habit The long habit of living indisposeth us for dying. – Thomas Browne, Hydriotaphia, Urn Burial (1658; cited by Lewis Thomas 1974, p. 47)
When I was well advanced in my doctoral investigations in the philosophy of psychiatry, French philosopher Alain Badiou posed a critical question (Di Nicola 2012): You are at a crossroads where you will either declare the end of psychiatry as such, or declare a new psychiatry, perhaps an “evental psychiatry.”
This question prolonged my investigations for another year when I defended my doctoral thesis in a jury presided by Badiou and which included the founder of the school, Wolfgang Schirmacher, and the inimitable Slavoj Žižek, “the most dangerous philosopher in the West.” At the conclusion of my defense, Badiou declared that my thesis “opens a broad new horizon for psychiatry and philosophy” (Di Nicola 2012). The heart of my concerns is sketched out in “Part II: Psychiatry in Crisis as a Human & Social Science,” a necessary prologue to a new, evental psychiatry (Di Nicola 2017a, 2017b). More than a century ago, Canadian physician William Osler (original 1899) gave medicine a unified vision in The Principles and Practice of Medicine, American physician-philosopher William James (original 1890) effectively founded modern psychology with his Principles of Psychology, and modern psychiatry was established with the twin conceptual bases of Emil Kraepelin’s classification (1893) and Karl Jaspers’ application of phenomenology in his General Psychopathology (1968, 1997; original 1913). Both psychiatric founders were steeped in the medicine of their times and boldly expanded it with their transdisciplinary investigations. Kraepelin effectively founded “comparative psychiatry,” the roots of today’s transcultural psychiatry and global mental health (see Jilek 1995). And Jaspers, having made the most important translation in history of philosophy into medical psychiatric theory and practice, later left the field to become a significant (if now neglected) European philosopher (see Part II for an extended discussion of phenomenology in psychiatry). Now, medicine has articulated many links to the human and social sciences (e.g., Thomas 1974; Kleinman 1991; Pellegrino 2008), along with its powerful research paradigms and affirmation of its social context through the social determinants of health (CSDH 2008; Satcher et al. 2012; Silverstein et al. 2019). And yet
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psychology is still struggling with an overarching philosophy (Henriques 2003, 2011, 2014), having split into two rather different enterprises (Kagan 2006) – basic research, where cognitive neuroscience and evolutionary psychology dominate, and clinical psychology, as diverse and pluralistic as clinical psychiatry, with deep tensions among psychoanalytic, relational, and cognitive-behavioral approaches. Mario Bunge (2012), whose authority as a philosopher of science came from being a dual philosopher-physicist, outlined a contentious, typically reductionistic and highly selective philosophy of medicine, unencumbered by any experiential knowledge of medical practice or biomedical sciences. Contrast the view of physicians as “wise healers” in the informed work of another philosopher, Jacob Needleman (1992), in deep conversation with physicians. A telling section in Bunge’s chapter, Medicina moderna, resumes perfectly the progressivist view of philosophers of science: De mito a ciencia – From myth to science, as if all previous epochs were “dogmatic” and benighted, given to “myths” and irrationality, and now, with the magical incantation of “science,” physicians are enlightened and all is well. In his Cierre – Closing, Bunge notes that medicine has already had its Galileo: Claude Bernard (the great French physiologist, called the father of experimental medicine), then asks: ¿Cuando aparecerà el Newton de la medicina? When will the Newton of medicine appear? In the English version, Bunge (2013) omits this question, closing with the observation that “medicine is chock-full of philosophy” (true), while complaining that, “physicians and philosophers have always ignored each other.” (This is not quite true as classical physicians from Hippocrates to Maimonides have also been great philosophers, not to mention the intimate dialogue between philosophy and psychiatry since Jaspers and continuing today, documented in “Part II: Psychiatry in Crisis as a Human & Social Science”). Bunge ends by citing Osler: Nec timeas recte philosophando—Fear not, as long as you philosophize rightly. Physicians themselves offer more trenchant and relevant reflections. French physician and philosopher Georges Canguilhem (1991) addressed epistemological questions in biology and medicine (unlike the Anglo-American concentration on the physical sciences), with a study of normality versus pathology. Noted physician and bioethicist Edmund Pellegrino (2008, p. 36), both medical practitioner and academic, asserts that, “The philosophy of medicine consists in a critical reflection on the matter of medicine—on the content, method, concepts, and presuppositions peculiar to medicine as medicine.” Pellegrino (2008, p. 37) explains this practically: Medicine qua medicine comes into existence in the clinical encounter or in public health when the knowledge of the sciences basic to medicine is employed for a specific end, i.e. for the cure, containment, amelioration, or prevention of human illness in individuals and societies. Medicine qua medicine, therefore, is shaped not just by the ends and purposes of the sciences. Medicine uses scientific knowledge for its own specific ends, which are healing, helping, curing, and preventing illness and disease and promoting health.
Brazilian physician and clinical philosopher, Ildo Meyer (2016) presents the case for integrating clinical philosophy with medical practice under the ironic title, Visita de médico. In Brazil, this expression, literally “the doctor’s visit,” signifies a quick, obligatory visit, “on the clock,” contrary to the “slow medicine” movement emerging there (cf. Di Nicola 2018). Meyer asks how the medical consultation came to be
10.3 The Long Habit
a metaphor for haste and how to recapture a more engaged face to face medical encounter with attentive listening. American cancer physician and researcher, Siddhartha Mukherjee (2015, p. 7, emphasis added) offers his more ambitious, “laws of medicine,” as he describes them, which “are really laws of uncertainty, imprecision, and incompleteness. They apply equally to all disciplines of knowledge where these forces come into play. They are laws of imperfection.” They are worth citing here in the light of psychiatric practice: Law One: A strong intuition is much more powerful than a weak test. This is about chance and probability. Tests can only be interpreted responsibly – Mukherjee says “sanely” – in the light of clinical probabilities. In other words, technology (and that includes everything from lab tests to rating scales, from the Rorschach to the Child Behavior Checklist) is a tool, not a theory or clinical hypothesis. We don’t just hand out rating scales or do lab tests for every possible medical or psychiatric condition. Aside from unacceptable costs and wasting time, such a strategy encounters false-positive and false-negative rates. We need clinical reasoning that directs our investigations. Those who temperamentally cannot live with balancing probabilities will not be satisfied with a career in medicine, much less in psychiatry. Hence, the famous dictum that psychiatric practice requires tolerance for ambiguity. Law Two: “Normals” teach us rules; “outliers” teach us laws. The psychiatric example Mukherjee gives is that a century ago, children who were withdrawn, self-absorbed, and uncommunicative were considered to have a variant of schizophrenia. But the clinical reality did not fit that diagnosis. Later, they were called autistic from the Greek word for “self.” By taking these “outliers” seriously, despite many blind alleys from icy “refrigerator moms” to hallucinogenic drugs to “warm up” the child, we now have more a more sophisticated epigenetic and neurodevelopmental model of autistic spectrum disorders that teach us a lot about nature and nurture. Law Three: For every perfect medical experiment, there is a perfect human bias. Human decision-making, Mukherjee asserts, especially faced with “uncertain, inaccurate, and imperfect information, remains absolutely vital to the life of medicine. There is no way around it” (p. 69). Where I teach medicine, we call that clinical reasoning, which cannot be adequately reduced to an algorithm or taught with the reductive notion of EBM. Echoing Gil Scott-Heron’s “The [political] revolution with not be televised,” Mukherjee asserts, “the medical revolution will not be algorithmized.” In psychiatry, the foundations established by Kraepelin’s classification (epistemology) and Jaspers’ subjective phenomenology (ontology) are both stymied at an asymptote and need to be radically redefined, not retuned yet again. Those foundations are crumbling precisely because they are mutually incoherent and incompatible. What we need is a new ontological foundation (an objective phenomenology, Badiou 2005, 2009; Di Nicola 2012, 2017a, 2017b), accompanied by a new epistemology (based not on classification but a new human science of personal and social
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being, which is my definition of psychology) that follows coherently from its ontology. To sum up and synthesize We need an enlarged view of medicine – not simply as science, although it is informed by the spirit of science and its methods – and the medical model is still the basis for psychiatry. Medicine includes clinical judgment and the full panoply of the medical encounter, face to face, informed by ethics, guided by social responsibility, and committed to lifelong follow-through care. Psychiatry is a branch of medicine, deeply reflected and broadly conceived, informed by biomedical, human, and social sciences. It is governed by medicine’s laws of imperfection – uncertainty, imprecision, and incompleteness. What we need – pace Bunge – are not Galileo and Newton, patrons of cosmology and physics, but a new philosophy of psychiatry, to follow our own 5000-year-old medical path on a new footing that I, with Alain Badiou, call an event. Will a new Osler in medicine, a new James in psychology, or a new Jaspers in philosophical psychiatry appear to announce such an event for the field that we still call out of long habit and ambivalent attachment – if not conviction – psychiatry?
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Jaspers, K. (1997). General psychopathology, Vols. I and II (trans: Hoenig, J. and Hamilton, M.W., with a new forward by McHugh, P.R.) Baltimore and London: The Johns Hopkins University Press. (Original in German, 1913). Jaspers, K. (1968). The phenomenological approach to psychopathology. British Journal of Psychiatry, 114, 1313–1323. (Original in German, 1912). Jilek, W. G. (1995). Emil Kraepelin and comparative sociocultural psychiatry. European Archives of Psychiatry and Clinical Neuroscience, 245(4–5), 231–238. Kagan, J. (2006). An argument for mind. New Haven: Yale University Press. Kandel, E. R. (2005). Psychiatry, psychoanalysis, and the new biology of mind. Washington, D.C.: American Psychiatric Publishing. Kandel, E. R. (2006). Biology and the renaissance of psychoanalytic thought. In In search of memory: The emergence of a new science of mind (pp. 363–375). New York and London: W.W. Norton & Co. Kandel, E. R. (2012). The age of insight: The quest to understand the unconscious in art, mind, and brain, from Vienna 1900 to the present. New York: Random House. Kandel, E. R. (2018). The disordered mind: What unusual brains tell us about ourselves. New York: Farrar Straus and Giroux. Kelly, K. (1998). The third culture. Science, 279(5353), 992–993. Kleinman, A. (1991). Rethinking psychiatry: From cultural category to personal experience. New York: Free Press. Kleinman, A. (2012). Editorial—Rebalancing academic psychiatry: Why it needs to happen–and soon. British Journal of Psychiatry, 201, 421–422. Kraepelin, E. (1893). Psychiatrie—Ein kurzes Lehrbuch fuer Studirende und Aerzte (4th ed.). Leipzig: Abel (Meiner). Lévi-Strauss, C. (1966). The savage mind. Chicago: The University of Chicago Press. Makari, G. (2015). Soul machine: The invention of the modern mind. New York and London: W.W. Norton & Company. Marneros, A. (2008). Psychiatry’s 200th birthday. British Journal of Psychiatry, 193(1), 1–3. Meyer, I. (2016). Visita de médico: Uma aproximação entre filosofia clínica e medicina [The doctor’s visit: A rapprochement between clinical philosophy and medicine]. Petrópolis: Editora Vozes. Mezzich, J., Botbol, M., Christodoulou, G., Cloninger, N. R., & Salloum, I. (Eds.). (2016). Person centered psychiatry. New York: Springer. Mukherjee, S. (2015). The Laws of medicine: Field notes from an uncertain science. New York: TED Books/Simon & Schuster. Needleman, J. (1992). The way of the physician. London: Penguin Books/Arkana. Novac, A., Tuttle, M. C., & Blinder, B. J. (2019). Identity narrative and its role in biological survival: Implications for child and adolescent psychotherapy. Journal of Infant, Child, and Adolescent Psychotherapy, 18(2), 155–184. Osler, W. (1899). The principles and practice of medicine: Designed for the use of practitioners and students of medicine. New York: Appleton and Company. Pellegrino, E. D. (2008.). The philosophy of medicine reborn: A Pellegrino reader (Ed. by H. Tristram Engelhardt, Jr., and Fabrice Jotterand). Notre Dame: University of Notre Dame Press Pinker, S. (1997). How the mind works. New York and London: W.W. Norton & Company. Pinker, S. (2018). Enlightenment now: The case for reason, science, humanism, and Progress. New York: Viking. Postman, N. (1993). Technopoly: The surrender of culture to technology. New York: Vintage Books/Random House. Sartorius, N. (1994). Challenges to psychiatry of the next century. Social Psychiatry, 1, 30–32. Sartorius, N. (2017). More than one scenario exists for the future of psychiatry. Lancet Psychiatry, 4, 738–739. Sartorius, N. (2019). Medicine is medicine through its disciplines. World Social Psychiatry, 1, 22.
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Satcher, D., Okafor, M., & Nottingham, J. H. (2012). The social determinants of mental health. In E. Sorel (Ed.), 21st century global mental health (pp. 73–94). Burlington: Jones and Bartlett Learning. Scruton, R. (2017). On human nature. Princeton: Princeton University Press. Silverstein, M., Hsu, H. E., & Bell, A. (2019). Addressing social determinants to improve population health: The balance between clinical care and public health. Journal of the American Medical Association, 322, 2379–2380. Singer, P. (1999). A Darwinian left: Politics, evolution and cooperation. New Haven & London: Yale University Press. Skinner, B. F. (1971). Beyond freedom and dignity. New York: Knopf. Sloterdijk, P. Philosophical temperaments from Plato to Foucault (trans: Thomas Dunlap, Foreword by Creston Davis). New York: Columbia University Press, 2013. Snow, C. P. (1963). The two cultures: And a second look: An expanded version of the two cultures and the scientific revolution. Cambridge: Cambridge University Press. Stein, D. J., He, Y., Phillips, A., Sahakian, B. J., Williams, J., & Patel, V. (2015). Global mental health and neuroscience: Potential synergies. Lancet Psychiatry, 2(2), 178–185. Stoyanov, D. (2020). The reification of diagnosis in psychiatry. Neurotoxicity Research, 37(3), 772–774. https://doi.org/10.1007/s12640-019-00139-2. Stoyanov, D., Kandilarova, S., Paunova, R., Barranco Garcia, J., Latypova, A., & Kherif, F. (2019). Cross-validation of functional MRI and paranoid-depressive scale: Results from multivariate analysis. Frontiers in Psychiatry, 10, 869. https://doi.org/10.3389/fpsyt.2019.00869. Stoyanov, D. S., Van Staden, C. W., Stanghellini, G., Wong, M., & Fulford, K. W. M. (Eds.). (2020). International perspectives in values-based mental health practice: Case studies and commentaries. New York: Springer International. Strauss, L. (1952). Persecution and the art of writing. New York: The Free Press. Tallis, R. (2011). Aping mankind: Neuromania, Darwinitis and the misrepresentations of humanity. Durham: Acumen. Thomas, L. (1974). The long habit. In The lives of a cell: Notes of a biology watcher (pp. 47–52). New York: The Viking Press. Wilson, E. O. (1978). On human nature. Cambridge: Harvard University Press. Wittgenstein, L. (1953). Philosophical investigations (trans: G.E.M. Anscombe). London: MacMillan Publishing. Sloterdijk, P. (2016). Selected exaggerations. Conversations and interviews 1993-2012 (Ed. by Bernhard Klein, trans: Karen Margolis). Cambridge, UK: Polity Press. Vattimo, G. (2012). The responsibility of the philosopher (Ed. with an Introduction by Franca D’Agostini, trans: William McCuaig). New York: Columbia university Press.
Saving Psychiatry I chose psychiatry as a career because it best combined the ancient arts of medicine with its newly emerging science. How great to feel I could study my craft reading thinkers as diverse as Dostoevsky, Freud, Durkheim, Darwin, Pavlov, Kant, Hume, and Epictetus! My training was in psychoanalytic, behavioral, cognitive, systems theory, and pharmacological models. These models all seemed so completely complementary, it never occurred to me there would soon be bitter wars among them. But war there was. When I started my residency in 1967, most chairs of psychiatric departments were either psychoanalytically trained or at least sympathetic. By the time I finished 4 years later, the changing of the guard was well underway with most new chairs having a firmly fixed biological orientation and an enduring antagonism toward psychological and social approaches. DSM-III, published in 1980, added greatly to the changed momentum. Though atheoretical in letter, its reductionistic spirit clearly favored biological methods of research and practice. It fit in neatly with the exciting technological revolutions in brain imaging, genetics, and molecular biology. At the time, many in the field were optimistic that these powerful windows into brain and cell functioning would soon provide quick and simple answers to the mysteries of human behavior, in sickness and in health. The National Institute of Mental Health fell for the hype and bombastically declared the 1990s “The Decade of the Brain.” This entailed a radical redefining of its focus from what had been a broad-based, clinically engaged research agenda to the narrowest of neuroscience. Thirty years later, this exciting intellectual adventure has taught us a great deal about brain functioning, but sadly it hasn’t yet helped a single patient. The brain turned out to be the most complicated thing in the known universe and has revealed its secrets only in tiny and indigestible packets. Most of the many neuroscience studies never replicate and few have any clinical relevance.
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Meanwhile, changes in reimbursement radically reshaped the practice of clinical psychiatry from biopsychosocial ecumenism to rote medication prescribing. Psychiatrists now have far too little time to get to know their patients and often too little training in using the therapeutic relationship and external supports as essential aids in healing. Psychiatry had once been mostly brainless; it is now in danger of becoming mostly mindless. This book provides a wonderful corrective to the reductionisms that bedevil and divide psychiatry. It is beautifully written, well organized, deeply felt, and carefully thought out – a thinking person’s guide to combining the psychiatric arts with the psychiatric sciences. I especially like the way it digs beneath the surface to explore the epistemological foundations of the most important questions facing our field today. Will the book’s important bridge-building message have the readership and influence it deserves? I certainly hope so, but must admit to doubts. More than almost any other endeavor, psychiatry is cursed by wars among stubborn true believers – true believer medication types versus true believer anti-medication types; diagnostic enthusiasts versus diagnostic nihilists; biological reductionists versus psychosocial reductionists; as well as psychotherapists who are rigid, true believers of one particular school and implacable antagonists to all others. The people who most need this book are probably too stuck in their trenches to ever read or fully understand it. But for those of open mind and heart, the authors provide precious insights that enrich understanding and promote more effective practice. Their book is a noble effort to save psychiatry from petty dogmatisms, epistemological dead ends, tunnel vision, and warring schools. No model in psychiatry is sufficient, all are necessary and all are complementary. Duke University, Durham, NC, USA April 2020
A Academic psychiatry, 91 Academic psychology lurching, 125 Agamben, G., 76, 79, 85, 86, 152 philosophical archaeology, 86 (see also Philosophical archaeology) American Psychiatric Association (APA), xii See also Diagnostic and Statistical Manual (DSM) Anglo-American analytical philosophy, 152 Anorexia multiforme, 132 Anorexia nervosa, 131 Feminist interpretations, 68 Antinomies, 106, 113 Anti-psychiatry, 117 critiques, 85 as cultural revolution, 103, 104 dialectic psychiatry/anti-psychiatry, 117 Anti-psychiatry movement, 88 Asymptote, 147 The law of diminishing returns, 147 Attachment theory, 90 Axiomatic stability, 22 B Badiou, A., vii, 8, 9, 76, 92, 141 Badiou’s scalpel, 92, 115 Badiou’s scissors, 92, 115 Badiou’s scythe, 10, 92, 115 Badiou’s shears, 92 Badiou’s sickle, 92, 115 Badiou’s scythe, 93, 110, 115 Badiou’s shears, 115 Badiou’s sickle, 83
© Springer Nature Switzerland AG 2021 V. Di Nicola, D. Stoyanov, Psychiatry in Crisis, https://doi.org/10.1007/978-3-030-55140-7
Badiou’s theory of the subject, 69, 74, 75 Basaglia, F., 84 anti-psychiatry, 89 deinstitutionalization, 103 depsychiatrization, 111 humane confinement, 101 institutional psychiatry, 100, 101 psychiatric deinstitutionalization, 84, 100 reforms, 101 Behavior therapy, 127 Behaviorism, 59, 133, 153 Benjamin, W., 75 Binary oppositions and false dichotomies, 126 Binswanger, L., xiii, 77 about authentic, suicide, 66 Binswanger’s method, 77 existential analysis, 66 foreign psychiatrist (Alfred Erich Hoche), 71 gesture, 72 katechon, 73 prognosis, 67 The Case of Ellen West, xiii, 69 (see also West, E.) Biomarkers, 22, 23, 25, 36 Biopsychosocial (BPS) model, 5, 39, 91 Bleuler, E., 71 See also Binswanger, L.; West, E. Body, 90 Bolton, D., 60 Bracket creep, 132 Brain dysfunction, 19 Brainlessness vs. mindlessness, 153 Brain science, 155 Burt, C., 56 Bricoleurs, 127
170 C Cartesian dualism, 44, 45 Cartesian prejudice, 58 Caseness in psychiatry, 70, 78–79 Lem, S., 78, 79 Categorical diagnosis, 33 Centrifugal vs. centripetal complexity, 128 operative element is analysis, 128 Chemical imbalance theory, 129 Classical psychiatric semiology, 104 Classification, 32, 36 Classification systems, 32 Clinical assessment methods, 20, 21 Clinical judgment, 147 Clinical psychology, 157 Clinical psychology assessment, 20 Clinical reality, 38 Clinical tools, 20 Cognitive behavioral therapy (CBT), 92 Cognitive therapy, 153 EBM, 153 (see also Evidence-based medicine (EBM)) Community psychiatry movement, 128 Comparative psychiatry, 159 Confidence, 28 Consensual theory of the person, 20 See also Critical gaps of psychiatry Constructive-genetic anthropology, 58 Crick’s program, 19 Crisis of psychiatry, xi Crisis of being, vii, 7–11 Crisis of knowledge, vii, 4–7 Crossroads, xi Critical gaps of psychiatry, 7, 9 consensual general theory of clinical psychiatry (psychopathology), 9 consensual science of persons (psychology), 9 general theory of change, 9 Cultural chameleon, 132 D Decade of the Brain (1990s), 2 Degree of confidence, 27 Deinstitutionalization, 84, 88, 100, 102, 103, 111 Depersonalization, 77 Depression, 32 clinical psychology, 26 psychiatry, 26 translational procedure, 26 Derrida, J., 152 deconstruction, 152 Jewish rituals, 152 Plato’s pharmacy, 152
Descriptive psychology, 59 See also Husserl, E. Diagnosis, 24, 38, 40 Diagnostic and Statistical Manual (DSM), 9 See also American Psychiatric Association (APA) Dimensional approach, 35 Di Nicola, V., vii, xvii, 2, 19, 154 about the author, xxiii elitist cognitivism, 154 (see also Cognitive therapy) evental psychiatry, 117, 158–159, 162 preface, xi (see also Stoyanov, D.) psychiatry, fast and slow, 126, 127 renewal in psychiatry, 151–162 word failure, 3 Disciplinary matrices, 22, 24 Divergent validity, 32 E Eclipse of the person, 153 See also Behaviorism Einheitspsychose, 34 Elevated troponin, 23 Eliminative materialism, 45–48 Empire of reason, 153 See also Cognitive therapy Engel, G., 1, 5 See also Biopsychosocial (BPS) model Enlightenment, 44 Epiphenomenalism, 45 Epistemes, 109, 110 Epistemology, vii, 23, 25 Event, 8, 117 See also Evental psychiatry Evental psychiatry, 74, 158 See also Psychiatry of the event Evidence-based medicine (EBM), 38, 91 Existential analysis, 65–68, 74 See also Binswanger, L. Existentialism, 58 Explanation, 31, 34, 35, 38 Expressed emotion (EE) paradigm, 131 External-to-the-narrative biomarkers, 22 F Family therapy, 90 Fanon, F., 84 academic psychiatry, 107 alienation, 95 anti-psychiatrist, 108 critiques, 84 double alienation, 95
Index European psychiatry, 84, 107 revolutionary anti-psychiatry, 108 “underdeveloped people”, 108 Fast psychiatry, 126 Foucauldian terms, 61 discourse/épistémè, 61 Foucault, M., vii, xiii, 76, 84, 155 anti-philosophy, 109 anti-psychiatry, 111 demedicalization of madness, 103 depsychiatrization, 111 episteme, 109, 110 epistemological field, 86 history of psychiatry, 112 interpenetration of antinomies, 113 Madness and Civilization, 101 madness vs. reason (civilization), 110 medical perception and psychiatric thought, 84, 108, 109 modern psychiatry, 103 negation, 84 “point of heresy”, 109 psychiatric power, 111 reordering, 112 skills, 85 See also Binswanger, L.; West, E. Frances, A., xv Frankl, V., 61 logotherapy, 61 Freudian psychoanalysis, 62 Fulford, K.W.M. (Bill), xv, 156 See also Values-Based Practice G Genetics, 91 Gestalt psychology, 34 Global mental health (GMH), 158 Global supervenience, 50 Gould, S.J., 7 “the mismeasure of man”, 7 Gregory Bateson’s systems theory, 55 Groundhog Day, 147 See also Asymptote H Hamilton Scale for Depression (HAM-D), 26 Hegel, G.W.F., 59 See also Phenomenology Human nature, 155 Enlightenment, 155 Pinker, S., 155 Scruton, R., 155
171 Singer, P., 155 Skinner, B.F., 155 Wilson, E.O., 155 Husserl, E., 59 lifeworld, 59 Humanistic psychotherapists, 153 I ICD standards, 36 Identity, 19 Identity theory of mind (ITM), 46, 49, 50 Ideographic knowledge, 37 Illich, I., 87 Medical Nemesis, 87 Insel, T., 7 Integrative taxonomy, 22 J Jaspers, K., viii, xi, 55, 57–60 K Kagan, J., xii Kandel, E., xii, 3, 8, 141 See also Decade of the Brain (1990s) Kleinman, A., xii Kraepelin, E., xii, 71 See also Binswanger, L.; West, E. L Lacan, J., 77, 84 as an anti-philosopher, 88 impact on anti-psychiatry, 98 phenomenological chasm, 94 psychiatric rebel, 84, 97 psychoanalysis, 99 psychoanalysis Badiou’s shears, 115 self, mind and relation, 99 social criticism, 97 subversive psychoanalyst, 84, 97 Laing, R.D., 62, 66, 84 anti-psychiatry, 89, 94 conservative revolutionary, 96 the Divided Self, 96, 99 orthodox psychiatry, 96 radical psychiatrist-psychoanalyst, 84, 95 schizophrenia, 96 social phenomenology, 62 See also Binswanger, L.; West, E. Lem, S., 79 Laws of medicine, 161
172 M Mayer-Gross, W., 57 Medical diagnosis, 25 Medical model, 55, 130 See also Anorexia nervosa Medicine, 18, 160, 162 Mental disorders, 18 Mental health movement, 35 Mental incapacity, 21 Mentalization, 90 Meta-linguistic compatibility, 22 Metaphysical malad, 151 Methodolatry, 142 Middle frontal gyrus (MFG), 50 Mind, 90 Mind-brain problem, 43, 48 Monistic physicalism, 45 Monolithic "medical model", 88 Montgomery-Asberg Depression Rating Scale (MADRS), 26 Multiple realizability, 47 Myocardial infarction biochemistry, 23 elevated troponin, 23 physiology, 23 radiology, 23 N Narrative-based clinical assessment, 20 National Institute of Mental Health (NIMH), xii Decade of the Brain (1990s) (see also Insel, T.; Kandel, E.) Negation, 117 alienation, 95 anti-psychiatrist’s, 110 anti-psychiatry, 92, 94 anti-psychiatry movement, 83 Basaglia’s, 117 Binswanger’s phenomenology, 96 double negative, 93 in English, 93 Foucault’s, 84, 108 institutionalization of psychoanalytic practice, 84 key critical negation, 83 psychoanalysis and philosophy, 93 Szasz’s, 84, 105 Neo-Darwinian project, 56 Neurobiology and cognitive neuroscience, 62 Neuronal theory, 19
Neuro-psychoanalysis, 45 Neuroscience, 91 Nomenclature, 32 Nonbiological interventions, 92 Nosological entities, 32 Nosology, 31 O Ontologically reductive, 44 Ontology, 8 being, 8, 137 Ontological, vii Osler, W., 159, 160, 162 P Personality theory, 19 Person-centered medicine (PCM), 38, 40, 41 Phenomenological psychiatry, 58–61 philosophical shortcuts, 60 See also Phenomenology Phenomenological psychopathology, 35 Phenomenology, 57, 59, 63, 65, 74, 146 Phenomenology in psychiatry, 58 See also Phenomenological psychiatry Philosophical analogue of case history, 80 Philosophical archaeology, 83–86, 152 See also Agamben, G. Philosophical treatment, 151–152 Philosophy and anti-philosophy, 89 and psychiatry, 62 Philosophy and psychiatry, 147 Philosophy of psychiatry, 162 Physicalism, 48 Physiology, 23 Pinker, S., 9 Poe, E.A., 70, 78 “The Purloined Letter” (see also Lacan, J.) Porosity, 76 See also Benjamin, W. Postman, N., 7, 154 Technopoly: war against subjectivity, 154 Principles of Psychology (1890), 56 Problematization, 80 Protagoras, 7, 137 “Man is the measure of all things”, 7, 137 Psychiatric classifications, 37 Psychiatric deinstitutionalization, 84, 100 Psychiatric diagnosis, 27, 32 Psychiatric medicine, 152 Psychiatric taxonomies, 18
Index Psychiatric temperament Phenomenological temperament, 153 Psychiatric thinkers bifurcated view, 141 cognitive psychologist, 142 critical analysis, 140 methodologists, 142 Psychiatry, 57, 58, 60–62, 126, 143, 146 and anti-psychiatry, 84, 86 “bedlam”, 85 behaviorism, 59 clinical assessment methods, 20, 21 clinical psychology assessment, 20 co-evolution, 18 crisis of knowledge, 137 critical gaps, 138 definition, 18 empiricism, 137 etymology, 18 foundation, 139 general theory of change, 19 history, 85 and human psychology, 137 incompleteness theorems, 138 as medical project, 18 medicine, 18 mental incapacity, 21 observational semi-structured interviews, 25 ontology, 139 philosophical archaeology, 86–88 philosophy, 138 pseudo-problems, 138 psychoanalysis, 18 qualities, 146 RDoC model, 21 slow and fast, 126, 127 subdisciplines, 90 temperament, 145 traditional bio-medicine, 24 Psychiatry of the event, 64, 117 See also Event; Evental psychiatry Psychoanalysis, 18, 35, 56, 60, 88 American psychiatry, 98 artistic community, 98 Freud’s, 90 institutional requirements, 99 Lacan, J., 99 social revolution, 101 Psychology, 19, 55, 56, 125, 162 academic, 56 American, 56 and psychiatry, 55 Psychopathology, 60
173 Psychopharmacology, 26, 28 Psychosomatic disorders, 33 Psychotherapy claims, 45 Ptolomaic position, 34 Q Qualia, 47 Qualification, 31 R Radiography, 24 Radiological scans, 23 Randomized clinical trials (RCTs), 27 RDoC model, 21 Reductionism, 128, 130 chemical imbalance, 131 current cultural climate, 130 eating disorders, 131 EE paradigm, 131 genetic testing, 129 genomics/consumer, 129 medical model, 130 medicine and psychiatry, 128 schizophrenias, 131 technological, 130 Reductive physicalism, 45–49 Reification and translation, 27, 28 clinical assessment, 25 definition, 22 diagnosis, 22 troponin, 23 Reinventing ancestry, 129 Reliability, 32 Renewal, psychiatry BPS, 158 Canadian physician, 159 clinical scientist, 156 diversity, 153 documenting, 151 false-positive and false-negative rates, 161 GMH, 158 human nature, 155 medicine, 159 philosophical defense, 155 philosophy, 159 physicians, 160 scientism, 156 scientism and methodolatry, 154 self-evaluation reports, 154 slow medicine, 160
174 Research Domain Criteria (RDoC), 21 Reverse paradigm, 31 S Schizophrenias, 131 Sensitivity, 32 Sheehan’s syndrome, 131 Skinner, B.F., 145, 153 See also Human nature Slow psychiatry, 127 Sociocultural, 91 Sophrosyne, 146 Specificity, 32 Spinoza, B., 145 Stoyanov, D., vii, xvii, 2, 7 about the author, xxiv Supervenience theory, 49 Systems theory, 90 Szasz, T., 84 biological treatments, 106 DSM-5, 105 mental and relational suffering, 84 “mental illness”, 106 myth of Szasz, 105 reactionary anti-psychiatrist, 84, 105, 106 Schizophrenia, 96, 97 T Tallis, R., 3, 87 Darwinitis, 3 Neuromania, 3 Taxonomy, 18, 31 Technocratic temperament, see Psychiatric temperament Tender-minded rationalism, 127 The crisis of confidence, 43 Traditional bio-medicine, 24 Translation, 22–26 Trauma psychiatry, 117 Troponin, 23
U Unitary psychosis, 34 Unitary psychosis concept, 33 V Validity, 32 Values-Based Practice, 156 Vattimo, G., 7, 151 Verwindung (convalescence), 10, 151 weak thought, 7 Verbal acoustic hallucinations (VAH), 47 Verbal hallucinations, 46 Vextensive database, 28 W Watson, J.B., 56 behaviorist manifesto, 56 West, E. anorexia nervosa, 68 Bellevue Sanatorium, 71 (see also Binswanger, L.) evental psychiatry, 74 (see also Psychiatry of the event) existential analysis, 65 Hoche, A.E., 77 (see also Binswanger, L.) melancholy and suicide, 66 Minuchin, S., 66 (see also Binswanger, L.) predicament, 76 Selvini Palazzoli, M., 66 (see also Binswanger, L.) suicide, 67 symptoms, 73 The Case of Ellen West, 71 Wittgenstein, L., 7, 10 pseudo-problems, 7, 152 Wittgenstein’s ladder, 10 See also Philosophical treatment Z Žižek, S., 76, 116