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 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)

"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.  

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.