Psychiatry in Crisis: At the Crossroads of Social Science, the Humanities, and Neuroscience

Vincenzo Di Nicola, MD, PhD

Drozdstoj Stoyanov, MD, PhD

Springer Publishing

New York
2018 

Premise of the volume:

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.

Is psychiatry a social science like psychology or anthropology?

Is it better understood as part of the humanities like philosophy, history and literature?

Or is the future of psychiatry best assured as a neuroscience?

From psychiatry in crisis as a medical discipline to critical psychiatry casting for a new model …

What will be the result?

The “end of psychiatry” or its renaissance as something new and different, either as a more comprehensive theory and practice of human being or as a new branch of medicine called the neurosciences?

Principal authors:

The two principal authors are both professors of psychiatry with mainstream academic training, activities and appointments in respected university departments of psychiatry. Both also share professional training and engaged activities in the philosophy of psychiatry. Both Europeans, one working in Europe, the other in North America, Professors Stoyanov and Di Nicola are active in national and international organizations and together bring varied international expertise to this study. From these informed perspectives, Di Nicola and Stoyanov pose some fundamental epistemological and ontological questions about the crisis of psychiatry, what they imply, and how to go about resolving them to renew psychiatry today.

Vincenzo Di Nicola, MPhil, MD, PhD

Full Professor, Dept. of Psychiatry

University of Montreal

Drozdstoj Stoyanov, MD, PhD

Professor, Dept. of Psychiatry and Medical Psychology

Medical University of Plovdiv

* 

Proposed Table of Contents:

Foreword (by a psychiatrist or a philosopher)

Preface/Introduction by Drozdstoj S.Stoyanov & Vincenzo Di Nicola

Part I: Psychiatry in Crisis as a Medical Discipline

Drozdstoj S. Stoyanov

1.     Methods for clinical evaluation in psychiatry: quantitatve decomposition of narratives vs. qualitative approach. Reconstruction of the methodological discrepancies based on an exemplary case: Major Depressive Disorder

2.     Psychiatric nosology revisited: at the crossroads of psychology and medicine. Categorical vs. dimensional; nomothetic vs. ideographic classification and nomenclature; post-modern perspectives

3.     Psychiatry and neuroscience: at the interface. How to incorporate scientific data from neuroscience without turning psychiatry into an applied branch of neurology

Invited commentary/commentaries

Part II: Critical Psychiatry

  Vincenzo Di Nicola

1.     The Beginning of the End of Psychiatry: A Philosophical Archaeology

Psychology: Introspection and Consciousness

Foundations of Modern Psychiatry

Schizophrenia: The Worm in Psychiatry’s Apple

Excursus: The History of Psychiatry is Not the History of Madness

2.     The End of Phenomenology

“Who Killed Ellen West?”

A Critical Review of Ludwig Binswanger’s Foundational Case of Existential Analysis

3.     The End of Psychiatry

“Psychiatry Against Itself”

A Philosophical Archaeology of Antipsychiatry

Invited commentary/commentaries

Part III: Renewal in Psychiatry

   Drozdstoj S. Stoyanov in Dialogue with Vincenzo Di Nicola

Invited commentary/commentaries

Afterword (by a psychiatrist or a philosopher)

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.

---

[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.

Excursus on Madness versus Reason/Unreason

Excursus on Madness versus Reason/Unreason

It is instructive that the English translation of Foucault’s most famous work, Madness and Civilization (1973),[1] 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[2] and elaborated in his essay, “Déraison,”[3] 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.”[4] The major English translations of this Foucauldian archaeology include: Madness: The Invention of an Idea, his introduction to Binswanger’s Dream and Existence,[5] Madness and Civilization (abridged version) and History of Madness (complete version), Abnormal,[6] Psychiatric Power,[7] and his essay on “Madness and Society.”[8] Edgardo Castro’s lexicon of the Foucauldian oeuvre covers: Abnormal, Antipsychiatry, Apparatus, Asylum, Madness, Medicine, Normal, Power, Psychoanalysis, Psychology, Psychiatry, Subject, and Subjectivation.[9] 

---

[1] Michel Foucault, Madness and Civilization (1973); intriguingly, no translator is named.

[2] Michel Foucault, History of Madness (2006).

[3] Ian Hacking, “Déraison,” in: James D. Faubion, ed., Foucault Now (2014), pp. 38-51.

[4] Michel Foucault, Madness and Civilization (1973), pp. x-xii.

[5] Michel Foucault and Ludwig Binswanger, Dream and Existence (1993).

[6] Michel Foucault, Abnormal (2003b).

[7] Michel Foucault, Psychiatric Power (2008).

[8] Michel Foucault, “Madness and society,” in: The Essential Foucault (2003), pp. 370-376.

[9] Edgardo Castro, El Vocabulario de Michel Foucault – Un recorrido alfabético por sus temas, conceptos y autores (Spanish original, 2004); Vocubulário de Foucault (Portuguese translation, 2008).

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).

---

[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).