Does Social and Transcultural Psychiatry Have a Political Agenda? Should It?

Culture, Mind & Brain Program

Division of Social & Transcultural Psychiatry

McGill University

Does Social and Transcultural Psychiatry

Have a Political Agenda?

Should It?

Vincenzo Di Nicola, MPhil, MD, PhD

Professor titulaire

Département de psychiatrie et d’addictologie

Université de Montréal

Clinical Professor of Psychiatry

The George Washington University

  

Argument

“After the upheavals of the twentieth century, philosophy has lost the privilege of existing in a realm that was somehow above politics.”

–  Peter Sloterdijk, What Happened in the Twentieth Century? (2018, p. 127)

If philosophy lost the privilege of floating above politics, medicine and social science have never had that privilege. A contemporary “quietism” which holds philosophy as a kind of therapy for humanity’s confusion, uncontaminated and undeterred by linguistic errors and “pseudo-problems,” initiated by Ludwig Wittgenstein (2002) and upheld by American pragmatist Richard Rorty (2010; cf. McDowell, 2009), no longer seems possible. The vision of a non-partisan, and to the extent that such a thing is possible, a non-ideological evidence-based study of “human nature” (cf. Steven Pinker’s The Blank Slate, 2002) is now evaporating (cf. Raymond Tallis’ Aping Mankind, 2014). Despite a growing nativism and biologism, medical and social sciences cannot reach for immutable laws, independent of historically-shaped social relationships (cf. Antonio Gramsci, 2011; see Codevilla, 2016).

Social and transcultural psychiatry understood in its best iteration, a systemic understanding of relationships, the social determinants of health and their cognate approaches and studies, now compel psychiatry to consider the political.

What I am talking about is the Western tradition of the polis - politics as an understanding of the organization of social life. There precisely is where the error began. We inherited from Aristotle a fundamental dichotomy between natural and political, private and public life. In a series of detailed historical and philosophical studies of Homo Sacer, Giorgio Agamben (1998, 1999c, 2005) argues that the separation of natural and private life from the political has allowed the state to politicize biological life, creating a crude “bare life,” denuded of human qualities. In Agamben’s (1999c) profound testament, Remnants of Auschwitz, he attempts to give testimony if not voice to the living dead, the Muselmänner, reduced to bare life in the Nazi death camps. 

Michel Foucault (1997) opened these questions with his notion of “biopolitics.” Extending that line of inquiry, Agamben (1998) argues that this separation of biological life from the polis culminates in a “lasting eclipse” of politics today.

Applying Agamben’s analysis, we will consider the cases of two key figures in 20^th century psychiatry – Martinican revolutionary psychiatrist Frantz Fanon (1925-1961; Fanon, 2008) and Italian psychiatric reformer Franco Basaglia (1924-1980; see Basaglia, 2010; de Girolamo, et al., 2008). We will examine their legacy and recall the impact of eugenics: Stephen Jay Gould, The Mismeasure of Man (1996); and the uses and abuses of psychiatry for political purposes both in the West and the USSR – psychiatrists E Fuller Torrey (1999) who documented Ezra Pound’s insanity defense against charges of collaborating with Italian Fascists, and Walter Reich (1983) who investigated schizophrenia in the Soviet Union and the notorious case of General Grigorenko. And we will identify such contemporary issues such as migration and trauma, borders and belonging, about which psychiatry has or should have much to say (cf. philosopher Thomas Nail on migrants and borders, 2015, 2016).

All this will be put to the test in brief readings of two contemporary texts by thoughtful clinicians and social scientists who accompany psychiatry’s work. Didier Fassin (2011), a French physician-anthropologist, has given us a trenchant study of “humanitarian reason,” and American psychologist Martin La Roche (2013) in his work on cultural psychotherapy argues that we should not only advocate on behalf of patients but foster their own advocacy and militancy through empowerment.

And, finally, what conclusions are warranted by such an investigation? I am a student of dichotomies; in fact, I argue that Western philosophy is the study of the binary thinking we inherited from the Hebrews, the Greeks and the Romans – and their emanations. We must give up the hope of reintegrating that which was “cast asunder,” in a return to some preternatural Edenic whole. Rather than a therapeutic intervention of curing dichotomies through linguistic philosophy (Wittgenstein) or integrating the strands of psychiatry in a promised but failed biopsychosocial synthesis (Engel, 1977; Ghaemi, 2009), I would argue for a new politics and a new psychiatry.

What would such a politics look like to us? Following Agamben (2000), I work for a “politics of means without ends,” of singularities without identity, of beings with no necessary “nature,” no given task and no biological destiny. This is a potential politics, based on potenza or potentiality, that can overcome the warring forms of inclusion and exclusion that arise in communities founded on identity. A psychiatry embracing this potential politics becomes a psychiatry of potenza – always possible yet radically contingent. In this view, the human being is that being which cannot exhaust itself (and cannot be defined or reduced to categories and criteria) in its potential as its confronts its impotenza – impotentiality, the possibility-not-to (be or do). What does this mean? Just as for Agamben (1999a), a canonical case of potenza-impotenza is Bartleby the Scrivener’s negation, “I would prefer not to,” for me the cases that define my work as a psychiatrist are what I call “syndromes of denial” – anorexia nervosa, selective mutism, depersonalization and dissociation – associated with Victor Turner’s (2017) liminal people, “betwixt and between” potenza and impotenza.  

References

Agamben, Giorgio (1998). Homo Sacer: Sovereign Power and Bare Life. Trans. David Heller-Roazen. Stanford: Stanford University Press.

Agamben, Giorgio (1999a). Bartleby, or On Contingency. In: Potentialities: Collected Essays in Philosophy. Trans. and ed. Daniel Heller-Roazen. Stanford: Stanford University Press, pp. 243-271.

Agamben, Giorgio (1999b). Potentialities: Collected Essays in Philosophy. Trans. and ed. Daniel Heller-Roazen. Stanford: Stanford University Press.

Agamben, Giorgio (1999c). Remnants of Auschwitz: The Witness and the Archive. Trans. David Heller-Roazen. New York: Zone.

Agamben, Giorgio (2000). Means Without Ends: Notes on Politics. Trans. Vincenzo Binetti and Cesare Casarino. Minneapolis: University of Minnesota Press.

Agamben, Giorgio (2005). State of Exception. Trans. Kevin Attell. Chicago: University of Chicago Press.

Basaglia, Franco, ed. (2010). L’istituzione negata. Rapporto da un ospedale psichiatrico.  

Milan: Baldini, Castoldi Dalai Editore.

Codevilla, Angelo M. (2016). The Rise of Political Correctness. The Claremount Review of Books, XVI(4).

https://www.claremont.org/crb/article/the-rise-of-political-correctness/?fbclid=IwAR3NP7RV9zP19e5tFuQvGsWU4ZMttBH2rTvdiptcf4JpAveRYTIKweLYnTs

Accessed 10.03.2019

de Girolamo, Giovanni, Barale, Francesco, Politi, Pierluigi & Fusar-Poli, Paolo (2008). Franco Basaglia, 1924-1980 (PDF). American Journal of Psychiatry, 165 (8): 968.

Engel, Geroge L. (1977). The need for a new medical model: a challenge for  biomedicine. Science, 196 (4286): 129–136.

Fanon, Frantz (2008). Black Skin, White Masks. Trans. Richard Philcox. New York: Gorve Press.

Fassin, Didier (2011). Humanitarian Reason: A Moral History of the Present. Los Angeles: University of California Press.

Foucault, Michel (1997). The Birth of Biopolitics. In: P. Rabinow and J.D. Faubion (eds.), Ethics, Subjectivity, and Truth, New York: New Press, pp. 73-79.

Fuller Torrey, E. (1999). The Roots of Treason: Ezra Pound and the Secret of St. Elizabeths. Lucas Publishers.

Ghaemi, S Nassir (2009). The rise and fall of the biopsychosocial model. The British Journal of Psychiatry, 195 (1): 3–4

Gould, Stephen Jay (1996). The Mismeasure of Man, Revised & Expanded. New York: W.W. Norton & Company.

Gramsci, Antonio (2011). The Prison Notebooks (3 vols). New York: Columbia University Press.

La Roche, Martin J. (2013). Cultural Psychotherapy: Theory, Methdods, and Practice. Los Angeles: Sage Publications.

McDowell, John (2009). Wittgensteinian “quietism”. Common Knowledge, 15(3): 365-372,

Nail, Thomas (2015). The Figure of the Migrant. Stanford: Stanford University Press.

Nail, Thomas (2016). Theory of the Border. Oxford: Oxford University Press.

Pinker, Steven (2002). The Blank Slate: The Modern Denial of Human Nature. New York: Penguin Books.

Reich, Walter (1983). The World of Soviet Psychiatry. The New York Times, January 30. https://www.nytimes.com/1983/01/30/magazine/the-world-of-soviet-psychiatry.html

Accessed 10.03.2019

Rorty, Richard (2010). Naturalism and quietism. In: Mario de Caro & David Macarthur (eds.), Naturalism and Normativity. Columbia University Press, pp. 55-68.

Sloterdijk, Peter (2018). What Happened in the Twentieth Century? Cambridge, UK: Polity Press.

Tallis, Raymond (2014). Aping Mankind: Neuromania, Darwinitis, and the Misrepresentation of Humanity. New York: Routledge.

Turner, Victor (2017). The Ritual Process: Structure and Anti-Structure.New York: Routledge.

Wittgenstein, Ludwig (2002). Philosophical Investigations. 3^rd rev. ed. Oxford: Blackwell.

PSYCHIATRY AGAINST ITSELF Radicals, Rebels, Reformers & Revolutionaries - A Philosophical Archaeology

Journal of the International Association of Transdisciplinary Psychology

PSYCHIATRY AGAINST ITSELF

Radicals, Rebels, Reformers, and Revolutionaries

A Philosophical Archaeology[1]

Vincenzo Di Nicola[2]

Abstract

This essay 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 practised 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. 

Four key 20^th 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, post-colonial 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 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.

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[1] Prepared for a seminar on “Psychiatry and the Humanities” at the University of Montreal Department of Psychiatry that is also offered as a course in the Faculty of Medicine. 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). This essay sets out some of the key ideas I will explore in a forthcoming book with the working title, Deconstructing Crazy: Letters to Young Psychiatrists.

[2] Vincenzo Di Nicola, M.Phil., M.D., Ph.D., F.R.C.P.C, F.A.P.A., is a psychologist, psychiatrist and philosopher. Di Nicola is a tenured Full Professor of Psychiatry at the University of Montreal where he is Chief of Child and Adolescent Psychiatry and founder of a seminar and course on Psychiatry and the Humanities.

Anti-Psychiatry – “Negation & Its Vicissitudes”

Anti-Psychiatry – “Negation & Its Vicissitudes”[1]

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[2]

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[3] 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 Arieti[4] in psychoanalytic psychiatry and Gregory Bateson[5] 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 neighbour, 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 dream-work, where, as Freud famously asserted, there is no “No” and the law of non-contradiction is violated.[6] 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.

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[7]

Living and fighting in wartime Martinique and Europe, training in medicine and psychiatry in France, 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. 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.[8] And just as we can invert psychiatric alienation as a kind of separation from a “sane” (that is, 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.”[9] 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).

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[1] Cf. François Baudry, “Negation and its vicissitudes in the history of psychoanalysis: Its particular impact on French psychoanalysis,” Contemporary Psychoanalysis, 1989, 25(3): 501-508.
[2] R.D. Laing, The Politics of Experience & The Bird of Paradise. Harmondsworth, UK: Penguin Books, p. 32.

[3] Karl Jaspers, General Psychopathology (1997).
[4] Silvano Arieti, Interpretation of Schizophrenia, 2^nd ed. (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.
[5] Gregory Bateson, et al., “Towards a theory of schizophrenia,” in: Steps to an Ecology of Mind (1987); pp. 205-232. This is the famous “double bind” theory of schizophrenia.
[6] Jon Mills, ed., Rereading Freud: Psychoanalysis Through Philosophy (2004).

[7] Erich Fromm, Beyond the Chains of Illusion: My Encounter with Marx and Freud (1962), p. 41.

[8] Cf. Roland Littlewood and Maurice Lipsedge, Aliens and Alienists: Ethnic Minorities and Psychiatry, 3^rd ed. (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 admitting himself in his own asylum, The Alienist (2012).

[9] Frantz Fanon, Black Skins, White Masks (2008).