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

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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)

"Envoi"

Tentative conclusion for my essay: 

PSYCHIATRY AGAINST ITSELF

Radicals, Rebels, Reformers, and Revolutionaries 

A Philosophical Archaeology

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[1]

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 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!”.[2]

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 punchline. 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.”[3] 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.”[4] 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 anti-war 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.[5] 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 violence if it persists, but madness? Unlikely.

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, 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 romantic, 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 (with PTSD for example), 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 political ones.[6]

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 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. 

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[1] Leo Maslíah, Diccionario Privado (2014), p. 138.

[2] Slavoj Žižek, The Sublime Object of Ideology (1989), p. 160; cited in Žižek’s Jokes (2014), p. 125.

[3] Ibid., p. 160.

[4] Ibid., p. 161.

[5] Gregory L. Bateson, Steps to an Ecology of Mind (1972).

[6] See: Didier Fassin and Estelle d’Halluin, “Critical evidence: The politics of trauma in French asylum policies.” Ethos, 2007, 35(3): 300-329. 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, “A Garden of Forking Paths: Exploring a Family’s Alternities of Being,” in A Stranger in the Family: Culture, Families, and Therapy (1997), pp. 237-292.  

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] 

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[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).