The following is an excerpt from Vincenzo Di Nicola and Drozdstoj Stoyanov’s Psychiatry in Crisis: At the Crossroads of Social Science, The Humanities, and Neuroscience (2021). For more information about Di Nicola and his work, check out last week’s Recently Published Book Spotlight.
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In an early form of empiricism, Protagoras proclaimed that, “Man is the measure of all things.” Plato criticized this as relativism and contemporary versions of Protagoras’ thought include constructivism and phenomenalism. Where Protagoras grounded his epistemology in a subjective sense-based empiricism, Plato appealed to the knowledge of objective and transcendent realities, beyond the individual’s experience and construction.
With modernity at war with subjectivity (Postman 1993), science in the guise and pursuit of objectivity has now become the all-purpose yardstick that evolutionary biologist Stephen Jay Gould (1996) characterized as “the mismeasure of man.” Why in human psychology and psychiatry – of all things! – has science become the measure of all things? Why have we reduced our fields of knowledge to scientism and methodolatry, where only what is objectively measurable and quantifiable is valued (Di Nicola 2017)?
My colleague Drozdstoj Stoyanov argues that these are epistemological questions, that is to say questions about knowledge, and that the crisis of psychiatry is a crisis of knowledge. While I agree that such issues are pressing and relevant, I believe that they are secondary considerations and that psychiatry is in crisis precisely because it allows itself to be sutured or yoked to its shifting methods (see “Excursus I: Disciplines and Subdisciplines” below).
As a result, psychiatry’s identity crisis is not a result of the difficulties of taxonomy and nomenclature but their cause. Our lack of confidence is a lack of clarity about the mission of psychiatry which obscures three critical gaps: (1) the lack of a consensual psychology (or theory of persons); (2) the lack of an organizing consensual model of psychiatry (or theory of psychopathology, that many call the phenomenology of psychiatry); and (3) the lack of a consensual theory of change (as opposed to mere descriptions of change related to a given model). (See: “Excursus II: Psychiatry’s Triad of Critical Gaps” below).
We must avoid suturing or yoking psychiatry to any given subdiscipline but that is not enough. In order to create the coherence in the field that we currently lack, we must first radically rethink how theories are built in our field. That is precisely what psychiatry cannot do and why we need philosophy. Three possibilities for a philosophy of psychiatry will be examined. (See “Excursus III: The Search for a New Theory” below).
We can give up trying to create a foundation for psychiatry and dismiss psychiatry’s difficulties as “pseudo-problems” (like Ludwig Wittgenstein 1922, 1953) and simply continue with descriptive projects like the DSM (APA 2013) that NIMH’s former director Thomas Insel (2013) dismissed as a mere “dictionary.” We can argue that foundational theories of the mind are “weak” (like Italian philosopher Gianni Vattimo 1988), meaning that they are doomed to be pluralistic and incomplete, like the vaunted but now much-criticized eclectic biopsychosocial model (propounded by American psychiatrist George Engel 1977, 1980; and criticized by another American academic psychiatrist Nassir Ghaemi 2010). Finally, we can reach for a new foundation for psychiatry based not on what sorts of questions we have the tools to sort out, using computational models, genetics, or neuroscience, but on the very nature of human being. That means ontology, the study of being, and French philosopher Alain Badiou (2005, 2009a, 2009b) offers just such a foundation for psychiatry, with a theory of the subject and the nature of being, and with the Event, a theory of change. As distinguished anthropologist Clifford Geertz (2010) affirmed, the proper study of humankind is still humanity. Psychiatry itself must now be measured by that task.
By re-visioning phenomenology, psychiatry can turn again to being as the measure of humanity, not merely behavior, cognition, or emotion, and neither like a computer nor a neural network genetically wired by evolution, but in its full complement of human qualities situated historically and culturally.
Excursus I: Disciplines and Subdisciplines
Following his philosophical mentor Louis Althusser, French philosopher Alain Badiou acknowledged that there are general and regional theories of knowledge. Based on this, Badiou (2008) argues that philosophy as a general theory must be separated from its “conditions” or truth procedures. Problems arise when philosophy as a general theory becomes “sutured” – we could say “yoked” – to one of its conditions and philosophy cannot be reduced to say, philosophy of science or philosophy of mind.
Nobel Laureate in Medicine, Eric Kandel (2005) similarly argues that there are scientific disciplines and subdisciplines whose boundaries and definitions change based on the research problem at hand. Applying this to our field, psychiatry as a discipline cannot be sutured or yoked to any given sub-discipline. The effort to choose among its subdisciplines and impose one or another of them as the dominant model of the field is both the cause of its identity crisis and the result of it because that project is doomed to failure. Endlessly casting about for the equivalent of physics’ “standard model” is what generates psychiatry’s identity crisis, not the limitations of its methods.
And like psychology, psychiatry has veered between theoretical models (what Francis Bacon in 1620 called “dogmas”) and methods of inquiry (Bacon’s “experiments”; see Bacon 2000). Theoretical models have the quality of addressing explanations and representations of the mind and may speak to questions of existence and meaning, while methods of inquiry address ways of knowing, including the reliability of observations. These positions may be translated into issues of validity and reliability or of truth and knowledge. But beyond these issues of accurate and valid representations, deeper questions emerge. Once we get to valid representations of human being, ontological questions appear. What is a person? For example, whether behaviorism is reliable and valid, does it address what is important about humans? Does cognitive science do that? In selecting language or consciousness as quintessential human qualities and subjects of inquiry, do we construct a proper psychology, a science of persons?
Excursus II: Psychiatry’s Triad of Critical Gaps
Psychiatry is in crisis because of a triad of critical gaps:
- First of all, the discipline of psychiatry does not have a consensual science of persons that is not sutured to one view of psychology or one of the sub-disciplines of psychiatry.
- Secondly, psychiatry does not have a consensual general theory of clinical psychiatry or psychopathology beyond descriptive nosographies, such as the APA’s DSM (1980, 2013) or the WHO’s ICD (1992, 1993).
- And thirdly, psychiatry does not have a general theory of change as opposed to descriptions of change that are sutured to one or another approach (e.g., psychoanalytic, behavioral, relational, genetic/neuroscientific).
To state this more broadly, any helping profession, any approach to human problems, needs to address three things:
- How people function (normal psychology – cognitive scientist Steven Pinker 1997, calls it “how the mind works,” but I would not limit it to “mind,” minimally we need to address mind, brain, behavior, and relations – these four domains are not reducible one to the other; philosophically we can ask what is a person or what is a subject? One of Pinker’s critics, philosopher Jerry Fodor 2000, wrote a rejoinder to Pinker called, The Mind Doesn’t Work That Way.)
- How problems arise (a theory of psychiatry beyond clinical descriptions or “phenomenology,” as it has come to be known in psychiatry; cf. McHugh and Slavney 1998).
- What are the conditions of change (including what is change and how does novelty arise in human experience? Badiou 2005, 2009a).
In light of psychiatry’s gaps and needs, Badiou offers three profound things to psychiatry:
- First, his theory of how philosophy works, with its conditions and truth procedures, clarifies what is proper to psychiatry and what are its subdisciplines (Badiou 2008).
- Second, Badiou (2009b) offers a theory of the subject.
- Third, Badiou (2005, 2009a) offers a theory of change based on the Event.
In Badiou’s work, the latter two issues are connected, a theory of the subject and of change.
In my reading of Badiou, the three conditions for an event are: to encounter an event, to name it, and to be faithful to it. The subject emerges through the event. By naming it and maintaining fidelity to the event, the subject emerges as a subject to its truth. Simply “being there,” as subjective phenomenology would have it, is not enough.
Excursus III: The Search for a New Theory
The philosopher’s treatment of a question is like the treatment of an illness.
– Ludwig Wittgenstein (1953, p. 91).
For renewal in psychiatry based on a theory of being (ontology), we must first radically rethink how theories are built in our field.
There are three possibilities:
- “Wittgenstein’s Ladder.” We can give up trying to create a foundation for psychiatry and dismiss psychiatry’s difficulties as “pseudo-problems” and simply continue with descriptive projects like the DSM that NIMH’s Thomas Insel (2013) dismissed as “at best a dictionary, creating a set of labels and defining each.” Ludwig Wittgenstein dismissed metaphysical puzzles including the question of being as pseudo-problems. This is why Badiou (2011) calls him an anti-philosopher. Rather than building a systematic philosophical foundation, Wittgenstein (1922) wanted to show that metaphysical notions are like a ladder which we use to scramble up and then discard. In a famous image, the task of philosophy is “To show the fly the way out of the fly-bottle” (Wittgenstein, 1953). Language and tradition create traps for us and philosophy’s task is to climb the ladder up out of our predicament or liberate the fly from its trap.
- “Vattimo’s Verwendung – Convalescence.” We can argue that foundational theories of the mind are “weak,” meaning that they are doomed to be pluralistic and incomplete, like psychiatry’s vaunted but now much-criticized eclectic biopsychosocial model (Engel 1977, 1980). Gianni Vattimo’s (1988) notion of “weak thought” argues that we cannot master or overcome metaphysics and the best that can be done is to resign our-selves to tradition and the history of metaphysical questions albeit selectively to heal ourselves of it – a kind of convalescence from unresolvable puzzles, like treating a malady that ails us. Both Wittgenstein and Vattimo are anti-foundational thinkers who want to rid us of metaphysics. Wittgenstein wants to eliminate metaphysics altogether, while Vattimo wants to show that the elimination of metaphysics will only lead to another foundation; hence, he wants to engage it through “weak thought,” with selective readings, distorting or twisting the intentions of metaphysical texts in order to undergo a “convalescence.”
- “Badiou’s Scythe.” Finally, we can reach for a new foundation for psychiatry based not on what sorts of questions we have the tools to sort out with but on the very nature of human being. That means ontology, the study of being, and Badiou offers just such a foundation for psychiatry, with a theory of the subject (Badiou 2009b), the nature of being, and with the Event, a theory of change (Badiou 2005, 2009a; Badiou and Tarby 2013). In separating psychiatry from its subdisciplines with what I have dubbed Badiou’s scythe (Di Nicola, 2012), we can free psychiatry to adjudicate among the many methods, models, and subdisciplines what is true and useful for its clinical mission of diagnosis and treatment in seeking healing solutions.
All three philosophical solutions have in common setting out the conditions and the limits of epistemology and of being, but their projects are very different. Wittgenstein and Vattimo want to rid us of metaphysics (they are anti-foundational, hence anti-philosophers in Badiou’s sense), while Badiou wants to recover metaphysics for philosophy (he is a systematic, foundational philosopher). Doing so restores philosophy as “the queen of sciences” and thus in a position to speak to psychiatry’s critical gaps and theoretical needs.
References
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Badiou, A. (2009a). Logics of worlds, being and event II (trans: Alberto Toscano). London.
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Di Nicola, V. (2012). Trauma and event: A philosophical archaeology. Doctoral dissertation, Saas-Fee, Switzerland: European Graduate School.
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Vincenzo Di Nicola
Vincenzo Di Nicola is Professor of Psychiatry at the University of Montreal where he co-directs a postgraduate course on psychiatry and the humanities. He was recently elected Fellow of the Canadian Academy of Health Sciences, the highest honor granted to health sciences scholars in Canada. In his doctoral dissertation, "Trauma and Event: A Philosophical Archaeology", supervised by Alain Badiou at the European Graduate School, Di Nicola critically examined trauma and the negations of anti-psychiatry to declare the end of the phenomenological tradition in psychiatry and call for a psychiatry of the Event. His writing spans psychology, psychiatry, and philosophy as well as literary essays and fiction, including A Stranger in the Family (W.W. Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011), The Unsecured Present (Atropos Press, 2012), and Social Psychiatry (Oxford University Press, forthcoming).
