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.

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).

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).

Excursus on Negation

Excursus on Negation

Negation is a way of taking cognizance of what is repressed; indeed it is already a lifting of the repression, thought not, of course, an acceptance of what is repressed.

    —Freud, “Negation”[1]

Freud’s notion Verneinung in German, was rendered as (dé)négation in French, i.e.,  négation/dénégation in a construction with Derridean overtones, and translated as “negation” in English. In ordinary German usage, Verneinung denotes negation and denial, and verneinen comes close to verleugen, “to disown, deny, disavow, refute.”[2] In his 1925 essay on negation, Freud effectively separates the notion of denial as repression (keeping things out of conscious awareness) from negation as a resistance to what surfaces when the repression is acknowledged. In later work, Freud further differentiated negation with the term Verleugnung or disavowal, “the refusal to perceive a fact which is imposed by the external world.”[3] Freud used the interpretation of dreams to illustrate the differences. What is repressed in waking life is a form of denial that may come out in a symbolic way in a dream; when the dream is interpreted, the reaction denying the interpretation is a negation, whereas disavowal is negation in the face of external reality.

Negation is a key concept for both psychoanalysis and philosophy. The link here is through Lacan’s use of Freud’s Verneinung in French as dénégation (rendered more simply as “negation” in English). Slovenian philosopher Slavoj Zizek brings the two together in readings of two major European thinkers – French psychoanalyst Jacques Lacan and German philosopher G.F. Hegel – thinking through the psychoanalytic negation in philosophy and the philosophical negation in psychoanalytic theory.[4]

Negation has been a topic in logic since antiquity but what Hegel brought to it is the notion that the double negative (negation of a negation) is not a simple undoing leading to an affirmation but a process that leaves traces of negation in its wake. The double negative is not a “zero sum game” but a dialectical struggle that permeates thought.

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[1] Sigmund Freud, "Negation," in: The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. 19, trans. James Strachey (1953-1974), pp. 235-239.

[2] Jean Laplanche and J.B. Pontilis, "Negation," in: The Language of Psycho-Analysis (trans. by Donald Nicholson-Smith (1973), pp. 235-237; p. 236.

[3] Ibid.

[4] Wilfried Ver Eecke, Denial, Negation, and the Forces of the Negative: Freud, Hegel, Lacan, Spitz, and Sophocle (2006).