Education is an Event

This is the tentative conclusion of a forthcoming chapter:

Pedagogy of the Event:

A Revolution in Medical Education

Vincenzo Di Nicola

Chapter in:

Žižek and Education

Edited by Antonio Garcia

Foreword by Creston Davis, Afterword by Slavoj Žižek

Rotterdam, Netherlands: Sense Publishing

“Transgressions: Cultural Studies and Education” Series 

Conclusion: Education is an Event

What will philosophy say to us? It will say: ‘We must think the event.’ We must think the exception. We must know what we have to say about that which is not ordinary. We must think change in life.

—Alain Badiou[1]

Just as Badiou the philosopher tells us to think the event, to think change in life, Jaspers the physician-philosopher reminds the physician that philosophy is unavoidable for the practice of medicine. In his groundbreaking textbook of phenomenological psychiatry, Jaspers concluded a century ago that:  

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.[2]

Medicine is the judicious and balanced use of science and technology, humanity and experience in the service of solving biomedical problems and promoting health. It works through aporias to achieve euporia, the balance that philosophy calls sophrosyne, being of sound mind and judgment. Empiricism alone, raw data and  technique cannot be the basis of medical practice. Sophrosyne calls on the physician to go “beyond the information given,”[3] to make clinical decisions, to find the courage to intervene.[4] Once the evidence is before us, there are choices to make. In spite of its pretensions, evidence-based medicine does not offer algorithms and heuristics for medical practice but strategies for reducing the contingency and complexity of human predicaments. For a medical practice based on discernment that embraces subjectivity along with science, we need medicine informed by philosophy; clinical practice requires critical thought.

The faithful physician begins with a pedagogy of the event in order to engage in problem-based learning and continual change in the practice of medicine. A critical pedagogy militates against the repetition of authority. Such a pedagogy will not invoke tradition as authority and traumatically shut down possibilities but will rather open possibilities, in what Badiou calls novation, to create a pedagogy of truth.

A pedagogy that prepares us for novation and is open to the event that creates the possibilities of genuine “subjects to the truth,” faithful to the event, is a pedagogy of truth. A pedagogy of the event is a pedagogy of truth.

In a pithy distillation of all my activities – as a medical educator, as a therapist, and as a critical thinker – I wish to conclude with a statement that is neither an identity nor a tautology but a tesselated series of proposals: 

Education is therapy is change is event is subject.

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[1]. Alain Badiou, Polemics, trans. and with an introduction by Steve Corcoran (2006), p. 8.

[2]. Karl Jaspers, General Psychopathology, trans. by J. Hoenig and Marion W. Hamilton (1997), p. 770.

[3]. Jerome Bruner, Beyond the Information Given: Studies in the Psychology of Knowing (2010).

[4]. My formulation of the tripartite task of the physician is: the effort to understand, the courage to intervene, and the challenge to integrate understanding and practice. See: Vincenzo Di Nicola, Letters to a Young Therapist: Relational Practices for the Coming Community (2011), p. 17.

Excursus – Schizophrenia: “The Sublime Object of Psychiatry”

Excursus – Schizophrenia: “The Sublime Object of Psychiatry”[1]

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, 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.

And yet, as Angela Woods concludes, we have already moved into another era.[2] 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 20^th century, a period I have dubbed the “Age of Trauma.”[3]  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 behaviour 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 Churchland[4] and Catherine Malabou.[5]

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[1] The subtitle comes from Angela Woods, The Sublime Object of Psychiatry: Schizophrenia in Clinical and Cultural Theory (2011). A parallel point was made more polemically by Thomas Szasz, Schizophrenia: The Sacred Symbol of Psychiatry, 2^nd ed. (1988). Laing was unquestionably the psychiatrist who most advanced schizophrenia as an accessible and necessary predicament to understand. See: R.D. Laing, The Divided Self: An Existential Study in Sanity and Madness (1965). Allan Beveridge, Portrait of the Psychiatrist as a Young Man: The Early Writing and Work of R.D. Laing, 1927-1960 (2011). Theodor Itten and Courteney Young, eds., R.D. Laing: 50 Years Since The Divided Self (2012). Andrew Collier, R.D. Laing: The Philosophy and Politics of Psychotherapy (1977).

[2] Angela Woods, op.cit., pp. 220-224.

[3] Vincenzo Di Nicola, Trauma and Event (2012b).

[4] Patricia Smith Churchland, Neurophilosophy: Towards a Unified Science of the Mind/Brain (1986) and Touching a Nerve: The Self as Brain (2013). See the review of the latter book by Colin McGuin, “Storm over the brain,” The New York Review of Books, April 24, 2014, and the exchange between Churchland and McGuin, “Of brains & minds: An exchange,” NYRB, June 19, 2014.

[5] Catherine Malabou, The New Wounded: From Neurosis to Brain Damage (2012).

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).