Author's response-III

G. Khushf (ed.), Handbook of Bioethics: Taking Stock of the Field from a Philosophical Perspective, pps. 473–488., 2004

INTRODUCTION: MENTAL DISTURBANCES AND WESTERN MEDICAL SCIENCE In earlier periods of human history some members of society were certainly seen as mentally disturbed or at least as behaving in remarkably exceptional ways. This persistent, unusual behavior was often interpreted in moral or religious terms: the person was viewed as violating the established morality or as introducing a higher morality, as being demon-possessed or divinely inspired. These extraordinary modes of behavior were thus conceived through schemes of interpretation that were already operative in the society. Today these modes of behavior would be medically conceived. The person would no longer be morally condemned or subjected to exorcism. He or she would now be seen as suffering from an “illness” somewhat similar to other (i.e., physical) illnesses, with uniform symptomatologies and supposedly uniform etiologies. Since these are medical problems, they must be understood through scientific concepts and treated with scientifically established techniques. Only in the past two decades have signs appeared that this scientific-medical approach to mental disturbances is on the right track. With the increasing “medicalization” of psychiatry during these decades, psychiatry has sought to model its treatment procedures, theoretical concepts, and research methods on hose of biomedicine. This modeling has produced significant advances. We shall mention only three of the most prominent. (1) The official diagnostic manual published by the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM), has continued to undergo refinement and is more and more viewed as authoritative. This manual hasestablished criteria of diagnosis that have high degrees of reliability, and nowefforts are underway to determine their validity. (2) Proof of the efficacy of several different kinds of pharmacotherapy has given psychiatry chemical tools for alleviating suffering that rival the effective medications of other medical specialties. These advances in psychopharmacology have been accompanied by a growing suspiciousness about the scientific credentials and therapeutic efficacy of Freudian and other forms of psychotherapy. (3) Related to pharmacotherapy have been studies of brain chemistry and structure that spur the hope that the neuromechanisms of mental disorders will be increasingly understood and therefore controlled. Hence neuroscience, with its solid experimental foundation, plays a larger and larger role in the basic conception of mental disorders and in strategies for their treatment. As a result of these recent advances, there are those who think that psychiatry has at last entered upon the sure path of a successful medical specialty. For example, here is how Joseph T. Coyle and Richard Mollica, both of Harvard Medical School, depict the capabilities of present-day psychiatry: “Psychiatry, fortunately, has developed highly reliable, phenomenologically based diagnostic instruments (DSM-IV and ICD-10) that are easy to apply for the diagnosis of common psychiatric disorders. Furthermore, a new generation of psychotherapeutic drugs has been developed that are more effective and exhibit fewer and less serious side effects than the previous generation of psychotropic drugs. The symptoms of the most common disorders, including depression, posttraumatic stress disorder, anxiety disorders, schizophrenia and bipolar disorder, can be very effectively managed in most patients with psychotropic drugs.” (Coyle et al, p. 494) These advances have seemed to many, moreover, to confirm the superiority of the scientific approaches that produced them. Hence certain spokespersons for these approaches have boasted that the future of psychiatry lies with them and that the fruitlessness of other approaches will become increasingly apparent. It will be noted that these “successful” approaches – DSM, psychopharmacology, and neuroscience – are ones closely associated with the natural sciences, and this too seems to confirm psychiatry’s close kinship with biomedicine. The approaches toward which a growing skepticism has been directed are the ones akin to the social and psychological disciplines. Not everyone believes, however, that the “successful” approaches alone will yield a fully adequate understanding of mental disorders and their effective treatment. Many psychiatrists feel that other perspectives too need to be included, but there remains significant confusion about just how they should be included. This confusion is so great that most practitioners are wary of any “comprehensive framework” that might be put forward as the systematic and unified discipline of psychiatry. Any such comprehensive framework, it is rightly said, must be “philosophical,” and widespread suspicion exists regarding the demonstrability of large philosophical frameworks. Otherwise stated, philosophical systems are feared to be too subjective. Nevertheless, the confusion in psychiatry to which we have alluded concerns some basic philosophical problems. Among those problems are the following. First, because of the growth of neuroscience, the mind/body question has re-appeared in a slightly new form: Can mental disorders be conceived exclusively as “diseases of the brain” without bothering with a careful understanding of the psychopathology? And if both neurobiology and psychopathology are to be considered, how does one combine these two? Second, the nature/nurture problem has resurfaced: To what extent should mental disorders be conceived as influenced by social environment and to what extent can they be approached as biologically conditioned, ultimately even genetically conditioned? Third, what sorts of methods are most appropriate for research and what sorts of procedures are most effective in treatment? Also among the philosophical problems are, fourth, the ethical problems: What is the proper ethical treatment of persons with mental disorders? At present little agreement exists on how to answer these questions. Faced with these apparently unanswerable philosophical questions, therefore, only a few options remain available for psychiatrists to decide how to understand their professional field and daily work. One option would be that of pure pragmatism: one adopts “what works” without too much worry about why or how it works. One despairs of being able to make comprehensive coherent sense of psychiatric practice and tries simply “to do what’s effective.” Another option is to settle for one’s own personally satisfying world-view, remaining convinced that nothing more rationally defensible can be attained. This world-view may contain a variety of elements from different domains, neuroscience, diverse psychotherapies, religion, common sense morality, etc. Indeed, this collection of items may even be fitted into a roughly unified whole. But one sees it as one’s personal perspective and therefore incapable of proof – indeed incapable of defense against other contrasting and competing “perspectives.” Both of the above options are, of course, permeated by skepticism. Rationality is deemed incapable of supplying and grounding psychiatry as a whole, and consequently only a non-rational ground is available. The kind of pragmatism that pervades all of medicine, however, may offer consolation in the midst of this intellectual resignation: you don’t have to understand as long as the patient got better.

Journal of the History of the Behavioral Sciences, 1999

The British Journal of Psychiatry, 2008

Journal of The International Association of Transdisciplinary Psychology, 2015

Psychiatry against itself: Radicals, rebels, reformers & revolutionaries. A philosophical archaeology Journal of The International Association of Transdisciplinary Psychology, December 2015, 4(1): 1-18. Abstract This essay inverts the logic of antipsychiatry 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 antipsychiatric 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 antipsychiatrist. (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 20th 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 antipsychiatrists, 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.

2015

PSYCHIATRY AGAINT ITSELF: Radicals, Rebels, Reformers, and Revolutionaries A Philosophical Archaeology 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 20th 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.

1995

Philosophical approaches to psychiatry have their own history, and historical approaches have their own philosophical assumptions. History and philosophy are often in a complementary relationship, a theme suggested by this year's reviews. Historical investigations of the assumptions of the discipline can raise questions of ethics, knowledge and truth, while the questioning of the philosophical assumptions of a discipline points to their historical nature, without necessarily resulting in historical relativism.

2009

2017