Association for the AA Advancement of Philosophy and P&P Psychiatry Bulletin

Volume18, Number 2 2011

From the Editor President’s Column

This issue of the Bulletin follows a Lately I have been thinking about what I know and on what basis I can know format that we have successfully used it. In particular, I’m thinking of a woman I have seen for many years: I’ll call her before—a target piece with commen- Greta. Greta has a long history of major depressive disorder with seasonal recur- taries and a response by the authors. As rences that generally respond well to antidepressants. I have observed avoidant, with previous symposia, this one has dependent, and histrionic characteristics, and family members have described how generated lively and informative dis- these personality features have kept her from pursuing some of her life goals. cussion. For that we thank both our Still, when she is euthymic, she is indeed a happy and well-adjusted person, with a authors and our commentators. career, and family and friends who love her. In this symposium, the commen- A year ago her husband passed away, and what I have observed in Greta since taries have developed in a variety of bewilders me. She grieved, as would be expected, but after six months a number directions, raising questions that are at of other changes emerged. Now in her 80s, she developed what looked like her times related to, but not at the heart of, usual depressive syndrome – apathy, anhedonia, paucity of thought, anergia, hy- the target article. That is of course all to persomnia, and passive suicidal thinking without a plan of action or real intention. the good, as the questions all involve At the risk of overpathologizing, I attributed this mood deterioration to bereave- the conceptual status of psychiatry and ment, although I did not object to the antidepressant her internist prescribed. Over mental illness. Stated in other terms, I the next months, Greta became increasingly confused and overwhelmed, but con- might say that you can’t analyze anti- tinued to tend to her household affairs, and maintain her closest relationships. Her psychiatry without analyzing psychia- therapist noticed that she had missed a number of appointments, and learned that try, and that’s what we have in the she had stopped paying her bills, recommended that Greta see a neurologist to rule commentaries and responses. out cognitive changes. The MRI showed diffuse brain atrophy advanced for With their target paper, “Getting it Greta’s age. Neuropsychological testing confirmed a diagnosis of mild cognitive from Both Sides: Foundational and impairment. Several months later Greta sustained a fall, and the emergency room Antifoundational Critiques of Psychia- evaluation showed considerable alcohol intoxication, which Greta dismissed as try,” the authors aim to divide and ana- irrelevant. Since she now lives alone, no one can confirm how much or how regu- lyze the variety of anti-psychiatries and larly she uses intoxicants. anti-psychiatrists into two related pairs: I find that I don’t know how to assess the quality of these data, or how to use on the one hand logical positivism and them meaningfully. Is this bereavement or depression, and does it matter what we postmodernism, and in a broader way call her mood changes at this point? If she is depressed, what role did alcohol use philosophical foundationalism and phi- and brain atrophy play in its development or progression, and over what period of losophical antifoundationalism. They time? Should I worry about other drugs of abuse? How do I understand her cog- view logical positivism as a paradig- nitive changes in light of the grief/depression, which could have influenced the matic example of foundationalism and effort Greta made in the ostensibly objective neuropsychological tests. And what postmodernism as a paradigmatic ex- to do with the most objective test, the MRI, which shows no focal anomalies, but ample of antifoundationalism. also provides no general schema for understanding the other clinical features of In an atmosphere of general appre- ciation, the commentators offer notes (Continued on page 38) of agreement, expansion, and at times disagreement. Cerullo is in strong agreement with the analysis but feels it Review of Books were published after these pieces were written. could be strengthened by attending to One complaint running through some of the commentaries is that the authors, contemporary variants of anti- in their critiques of the various anti-psychiatrists, are rather silent about their own psychiatry: e.g., Kramer in his early position in this discussion. Lewis suggests that they “have a philosophy that com- work, Healy, Elliot, and the President’s bines foundationalist facts with antifoundationalist values.” He is probably right in Council on Bioethics. In tune with Ce- that assumption. The authors suggest as much in the “Facts and Values” section of rullo’s remarks, It is a misfortune of their paper, and it might have useful for them to be explicit about it. timing—for both the authors and the Another issue that emerges in the commentaries is the value of the rather or- commentators— that Marcia Angel’s thogonal foundationalist/antifoundationalist division—whether it is a productive attacks on psychiatry in the New York (Continued on page 39) Volume 18, Number 2 2011

heuristic term in understanding vari- To be sure, the voluminous cri- Symposium ous critiques of psychiatry. tiques from Prof. Szasz—beginning The burden of this paper will be with The Myth of Mental Illness in to outline the historical roots of foun- 1961—have often been considered part Getting It from Both dational and anti-foundational phi- of the “antipsychiatry movement.” losophies; describe how these phi- However, Szasz has clearly and repeat- Sides: losophies have provided the basis for edly rejected this label. Szasz himself Foundational and Anti- a “double-barreled” assault on mod- employs the term "anti-psychiatry" Foundational Critiques of ern-day psychiatry; and finally, to very narrowly, as a label for the posi- adumbrate very briefly why both tion of David Cooper (1931-86) and Psychiatry kinds of attacks on psychiatry are R.D. Laing (1927-89). Szasz argues generally unfounded. First, however, that these individuals continued to use Ronald Pies, M.D. we need to provide at least a notional "...coercions and excuses based on psy- Sairah Thommi, B.S. idea of what the term chiatric authority and power" (Szasz Nassir Ghaemi, M.D. “antipsychiatry” encompasses. 2009, p. ix). Thus, for Szasz, "antipsychiatry" is merely another type (Follwing the format of other symposia A Brief Typology of Anti- of psychiatry. He avers that "...for published in the Bulletin, this sympo- pychiatry and an Apologia more than half a century, I have consis- sium will take the form of a target pa- tently asserted two simple but funda- per by our three authors, followed by As Edward Shorter’s analysis mental propositions: mental illnesses commentaries and a response to com- suggests, the construct of "anti- do not exist; and coercions justified by mentaries. Let me thank Ron Pies, psychiatry" is, at best, polymorphous; them are wrong… my writings form no Sairah Thommi, and Nassir Ghaemi, as and at worst, simply incoherent. part of either psychiatry or antipsychia- well as all of our commentators, for Nonetheless, Shorter’s synopsis of try and belong to neither" (Szasz 2009, their efforts in this exercise. the "Antipsychiatry Movement" p. x). JP) serves as a useful provisional defini- One of the authors (RP), along tion of the term: with many others, has provided several Early in the 1960s, as part of extensive critiques of Dr. Szasz’s views Introduction the general intellectual tumult of on mental illness, and these will not be the time, a protest movement belabored here (Pies 1979, Pies 2004). Modern-day psychiatry has been arose against psychiatry. Mem- Moreover, there are plausible reasons the target of numerous social, philoso- bers of the movement were by no to accept Szasz’s claim that he is not phical and scientific critiques over the means all in agreement about doc- “anti-psychiatry” in his motivation and past century, sometimes lumped to- trine; some argued that there was intention—even if, as we believe, gether as manifestations of “anti- no such thing as psychiatric ill- many of Szasz’s claims have been used psychiatry.” The aim of the present ness; others that adverse sociocul- (or misused) to denigrate, marginalize paper is to place the critics of psychiat- tural conditions exposed members and attack the profession of psychiatry. ric theory and practice in the broader of marginalized groups to political Other claims by Szasz have stirred use- framework of two philosophical tradi- oppression conducted under the ful debate and discussion; e.g., his tions: logical positivism and post- guise of medical diagnosis; still staunch opposition to the use of mental modernism . Even more broadly, we others that treating mental patients institutions as holding facilities for sex want to distinguish two “meta- against their will was unethical, offenders whose prison terms have categories” of philosophical discourse, and that electroconvulsive therapy expired (“Should states be allowed..” which we call “Foundational” and was brain-destroying rather than 1997). “Anti-Foundational.” To oversimplify therapeutic. This grab-bag of di- In this regard, we wish to empha- greatly, logical positivism may be con- verse claims and objectives came size, as D.B. Double (2000) has argued, sidered a subset of foundational phi- together under the banner that not every person or viewpoint that losophies; and post-modernism, a sub- 'antipsychiatry'. (Shorter 2005, p. is critical of psychiatry is necessarily set of anti-foundational philosophies. 22) anti psychiatry. For example, the Criti- We make the latter claim, fully aware Shorter goes on to name several cal Psychiatry Network enunciates the that the term “post-modernism” is sub- prominent critics of psychiatry, under following basic tenets: ject to many interpretations; is some- the rubric of antipsychiatry, including 1. “Modern-day psychiatry re- times considered vague to the point of Erving M. Goffman, Michel Fou- lies too much on the "medical meaninglessness; and is, in some ways, cault, Franco Basaglia, and Ronald D. model" and emphasizes diagnostic more a literary and cultural attitude Laing. However, Shorter insists that decisions. If psychiatrists adopted a than a well-articulated philosophical “…the credit for launching antipsy- more social or therapeutic commu- position. Nevertheless, as a particular chiatry among a mass audience goes nity approach treatments would be subtype of anti-foundational philoso- to [Thomas] Szasz” (Shorter 2005, p. more effective.” phy, post-modernism remains a useful 22).

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2. “The categorization of psy- self-described “survivors” of psychia- chiatric illness is not as clear as try who routinely post their views on AAPP most psychiatrists believe. Assess- the internet; see, e.g., “The Anti- Annual Meeting ment of etiology too often fails to Psychiatry Coalition” (Smith 2010). take personal and social factors into For these reasons—and consistent 2012 account.” with the title of Schramme’s own The Biopsychosocial 3. “There is too much emphasis book chapter—we will retain the term and Other Models for on the scientific possibilities of ran- “antipsychiatry” in this paper, while domized controlled trials. The evi- acknowledging that it embraces a Psychiatry: Philoso ‑‑‑ dence of these trials is biased.” wide diversity of viewpoints. phical Perspectives

One might disagree with aspects of these claims, without necessarily re- Foundational and Antifounda- May 5 & 6, 2012 garding them as “anti-psychiatry.” tional Philosophies and Philoso- Philadelphia, PA Similarly, philosopher Thomas phers Crown Plaza Philadelphia Schramme prefers to avoid the term (Market Street) “antipsychiatry” arguing that Dichotomies of various types …it was coined [with] a polemic have long been imputed to Western Room: Independence A on intention by adherents of the culture and civilization. Thus, histo- Second Floor ‘classical’ psychiatry to suggest that rian Thomas Greer suggests that “A (in conjunction with the Ameri- the ‘antipsychiatrists’ would indeed longstanding division within Western can Psychiatric Association Annual Meeting. Conference) like to abolish psychiatry and to culture… [has pitted] those who leave the mentally ill to their fate. stressed science and reason, equality This is… wrong. Many critics of and democracy… [against] those who Edwin R. Wallace IV the concept of mental illness opted stressed tradition and sentiment, aris- Lectureship in the Philosophy mainly for another kind of psychia- tocracy and authority” (1987, p. 417). of Psychiatry try, primarily focused not on the Similarly, the philosopher and disease to be treated, but… [on the] mathematician, Kurt Godel, dichoto- Moderator human being with his particular mized philosophy into the following Peter Zachar, Ph.D. mental problems… [therefore] catagories: “…skepticism, material- whenever we refer generally to ism, and positivism stand on one side; Speaker theories which reject the concept of spiritualism, idealism, and theology Kenneth S. Kendler, M.D. mental illness… we will use the on the other side.” (Chalton 2008, p. Professor, Departments of Psychia- term “skeptical psychiatry” and 164) try and Human and “skeptics” in the case of the corre- While both these dichotomies molecular Genetics sponding authors… (Schramme have many points in their favor, we Medical College of Virginia of Vir- 2004, p. 94-95) believe there is a more fundamental ginia Commonwealth We agree with Schramme that dichotomy that helps us understand University “skepticism” regarding the theories and some of psychiatry’s most vociferous Virginia Institute for Psychiatric practices of institutional psychiatry critics. In simplest terms, founda- and Behavioral Genetics accurately describes some authors, tional philosophies and philosophers among whom Schramme would include hold that we can reliably describe a Title Thomas Szasz, Michel Foucault, coherent, objectively-measurable Issues at the Interface of Ronald Laing, Ervin Goffman, Franco “reality” or “truth,” whether one Philosophy and Psychiatric Basaglia, Thomas Scheff, and David considers the world as a whole, or Research and Nosology Cooper, “…all of whom differ consid- specific aspects of it, such as the of erably in their reasoning…” but have in disease. Anti-foundational philoso- Program Chairs common the desire “…to challenge the phies and philosophers deny this traditional conceptualization of mental claim, asserting that there are no ob- Christian Perring, Ph.D. illness.” (Schramme 2004, p. 95). Un- jectively demonstrable “truths”— Department of Philosophy and fortunately, “skepticism”, in our view, only various “perspectives” or Religious Studies does not describe the more polemical “narratives” that cannot be privileged Dowling College and vitriolic attacks launched on the as uniquely or objectively “true.” ([email protected]) field of psychiatry from several quar- Anti-foundational views overlap with ters, often invoking the views of such some elements of post-modernism , James Phillips, M.D. “skeptics” to fuel their own, less rea- particularly those (such as Fou- Department of Psychiatry soned philippics. Many of these cault’s) that emphasize “power struc- Yale University School of Medicine overtly anti-psychiatry individuals are tures” and their effect on scientific ([email protected]) not academic philosophers and clini- and medical claims. cians, but rather, “freelance” critics or

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Foundational Philosophers whatever ‘appears’ to us” (O’ believed that “…we are directly aware Daly 2001, p. 163). of real objects and are, most of the Although foundational thinkers Furthermore—and more central time, roughly right about the nature of may be “skeptical” in their epistemo- to psychiatric nosology—Augustine the objects of which we are aware… logical claims, they ultimately evince a believes that “…if our perception of [and] that in having conceptions, we confidence—some might say, a faith— an object is comprehensive, and our are aware of real objects that are that the world and its constituents actu- faculties are functioning normally, roughly the way we conceive them to ally exist; that we may discern and de- reliable information may be acquired be” (Yaffe & Nichols 2009). scribe the world more or less accu- about the external world” (O’Daly Logical positivism in its various rately; and that our knowledge of real- 2001, p. 164). forms is a modern-day expression of ity, if not certain, may at least be highly These, arguably, are claims con- the foundational world-view. Associ- probable, if we conduct our investiga- sistent with the general western tradi- ated with the so-called “Vienna Circle” tions appropriately. By so doing, on tion of empiricism and empirical in- led by Schlick and Carnap, logical this view, we can gradually build up a vestigation. positivism essentially held that all reliable and largely accurate picture of Ren é Descartes—who belongs knowledge is based on logical infer- ourselves and the world. With certain much more to the tradition of ration- ence grounded in observable fact; and caveats, a brief list of philosophers in alism than to empiricism—is widely that only empirically verifiable state- this first group would include Saint associated with a radically skeptical ments are meaningful. Some propo- Augustine of Hippo, Ren é Descartes, approach to knowledge, taken in his nents of this philosophy prefer the term Thomas Reid, and logical positivists Meditations . His famous “Cogito,” “logical empiricism,” as explained by like Bertrand Russell, Moritz Schlick, after all, seems to have its origins in a Oswald Hanfling: Rudolf Carnap, and A.J. Ayer. The radical exercise in doubt . And yet, in The philosophy of the [Vienna] early views of Ludwig Wittgenstein— our view, Descartes is ultimately a Circle became known as ‘logical ultimately, repudiated in his Philoso- foundational philosopher. Indeed, positivism’ or ‘logical empiricism.’ phical Investigations (1953)—were “The Meditations opens by de- The former name is more usual, but also expressions of logical positivism. veloping skeptical questions concern- the latter, preferred by Schlick, A detailed discussion of each of ing the possibility of knowledge. seems to me to be more appropriate. these philosophers is obviously far be- Through a series of several carefully It has the advantage of indicating yond the scope of the present paper. thought out meditations, the reader the affinity of the Circle’s ideas However, we may imbibe something of establishes (along with the author) the with those of the empiricist tradition the spirit of foundational philosophy by groundwork for the possibility of begun by Locke in the seventeenth examining a few paradigmatic passages knowledge (scientia). Descartes is century, and later represented by from some of the aforementioned not a skeptic, as some have insisted , such thinkers as Mill and Russell. It thinkers. Saint Augustine provides us a but uses skepticism as a vehicle to is also readily connected with the convenient launching point. motivate his reader to ‘discover’ by Circle[‘s] interest in empirical sci- As Gerard O’Daly observes, way of philosophical investigation ence (Hanfling 1996, p. 195). Augustine believed that skepticism is what constitutes this ground” (Smith Although logical positivism or “…a form of despair of finding truth” 2007, italics added). logical empiricism is nowadays viewed and considered the refutation of skepti- Foundational philosophies, of as largely discredited (Hanfling 1996), cism “…to be of primary impor- course, can include circumscribed it continues to be influential in the phi- tance” (O’Daly 2001). Augustine as- forms of skepticism, as was the case losophy of science, and—as we shall serts that the truth of propositions is with Descartes, and may even take argue—in some antipsychiatry circles. such that “…no one can confuse them the extreme form of non-materialism As Hanfling puts it, “…even if the par- with any likeness to the (“idealism”), seen in Bishop Berke- ent plant is dead, many of its seeds are false” (Augustine 1951). Indeed, ley’s philosophy. Berkeley effec- alive and active in one form or an- Augustine produces an anti-skeptical tively dispensed with the concept of other.” (1996, p. 194). argument that some have seen as a pre- material substance, but most certainly Indeed, we shall see that many cursor of Descartes’ famous “Cogito was a foundational philosopher: he modern-day critiques of psychiatry ergo sum.” According to O’Daly, merely argued that the “foundation” (including that of Szasz) rely on a Augustine presents a version of of reality consisted of ideas in the strongly positivist view of science in the skeptical ‘how do I know that I mind of God! (Horner & Westacott general, and of medical-psychiatric am not dreaming?’ argument. 2000). diagnosis in particular. At times, this Against the skeptics, he argues that Perhaps the quintessential foun- positivist stance veers very close to some knowledge claims are not af- dationalist was the founder of the so- scientism; i.e., “…the view that the fected by the assumption that I am called “Common Sense” school of scientific method is the only legitimate (now) dreaming. In fact, Augustine philosophy, Thomas Reid (1710-96). method for discovering truth and that allows… against skeptical argu- Arguing against the influential views science exhausts our knowledge of ment, that subjective states give of Hume, Locke, and Berkeley, Reid reality” (Horner & Westacott 2000, p. certain knowledge about a ‘world’ took a resolutely commonsensical 242). Of course, one may reject this that may simply be tantamount to view of epistemology. Thus, Reid extreme view and still insist that psy- 4 Volume 18, Number 2 2011

chiatry is essentially a scientific enter- of their claims. Finally, some of the prise. That does not mean, however, claims of W.V.O. Quine (1908-2000) that psychiatry is solely or exclusively also seem anti-foundational, in that scientific; on the contrary, we would they appear to deny the possibility of argue that there are dimensions of the certain types of “objective” knowl- clinical encounter that cannot be sub- edge. We shall say more about Quine XVth International sumed within traditional empirical sci- presently. Conference on ence, and that this is true to some de- Among those considered exem- Philosophy and gree of all medical specialties. plars of the “post-modern” tradition, Finally, a brief note on the views Michel Foucault (1926-84) and Psychiatry of novelist and philosopher, Ayn Rand, Jacques Derrida (1930-2004) also the founder of “objectivism”: we might qualify as anti-foundational in many consider Rand’s views—whatever their of their views. Foucault, of course, is Culture and flaws—as perhaps the clearest expres- famous for his critical history, Mad- Mental Health sion of foundationalism. The Atlas So- ness and Civilization (1973), which ciety—which “…affirms and embodies has done much to sustain antipsy- July 5-7, 2012 the core Objectivist values of reason, chiatric polemics, even as some crit- University of Otago individualism, freedom, and achieve- ics of psychiatry (such as Szasz) have Dunedin, New Zealand ment…” summarizes the foundational rejected many of Foucault’s claims. elements of Rand’s philosophy as fol- Indeed, we shall suggest that Szasz The conference aims to go to the heart of debates about the nature of lows: approaches his critique of psychiatry mental disorder, as it occurs in a “Objectivism” celebrates the much more from the tradition of logi- multicultural setting. Psychiatric power of man's mind, defending cal positivism (empiricism) than from diagnoses, arising as they tend to reason and science against every the anti-foundational, post-modern from Western sources (for example, form of irrationalism. It provides an view of Foucault. Nonetheless, the the American Psychiatric Associa- intellectual foundation for objective peculiar relationship between Szasz tion’s Diagnostic and Statistical standards of truth and value and Foucault merits a brief digression Manual of Mental Disorders), are (“Objectivism” 2011). at this point. As Daniel Berthold- often not well suited to the traditions As we shall now see, this ringing Bond has succinctly put it, of indigenous peoples. Recent neu- roscience is beginning to acknowl- manifesto of Western, rational- The differences between edge the influence of culture on the empirical objectivity is opposed in Szasz and Foucault are many and development of the brain in ways equally strong terms by several anti- profound. This no doubt explains that can inform our thinking about foundational critics. why the two, although contempo- mental disorders. Leading thinkers raries… never developed a dia- from within M āori culture will be Anti-foundational philosophers logue… Notwithstanding these among the conference’s keynote differences, the two share a num- speakers, providing a very special This tradition overlaps with that of ber of basic claims in their critique opportunity for dialogue and ex- skepticism, but unlike, say, the of the idea of madness. By what- change of ideas.

“resolved” skepticism of Descartes, ever different routes… both arrive Conference themes will include modern anti-foundational philosophies at a view of madness as a social culture, identity and the brain; men- do not move beyond a certain spirit of construction, and of the medical tal disorder and displaced peoples; negation , or epistemological nihilism. model of insanity as a moral and culture and forensic psychiatry; and As with foundational philosophers, the political mythology (Berthold- culture and maladies of the soul. anti-foundational thinkers are not a Bond 1995, p. 182). homogeneous lot. Some have broad To appreciate the spirit of the affinities with the Sophists and Skep- anti-foundational thinkers, we may tics of the classical era, such as Prota- begin with the Sophist, Protagoras Second Call for Papers by April 2, 2012 goras (ca. 490-420 BCE) and Sextus (490-420 BCE), perhaps best known Empiricus (ca. 160-210 AD), respec- for his maxim, “Man is the measure tively; as well as with some of all things.” As Cardinal has sum- “nominalists” of the medieval period. marized Protagoras’ epistemology, Others, such as that late prototype of …because individual judgments Conference Web Site the anti-foundational philosopher, Frie- are inherently subjective, we can- www.otago.ac.nz/ppp drich Nietzsche (1844-1900), have af- not hope to achieve objective finities with thinkers in the Existential- knowledge. If human nature de- ist tradition. Closer to our own time, termines any judgment, then there several philosophers of science, such as is no universal truth on any sub- Thomas Kuhn (1922-96) and his con- ject… For example, while one temporary, Paul Feyerabend (1924-94) person may find a room too hot, are arguably anti-foundational in many another may find it too cold. 5 Volume 18, Number 2 2011

Since each judgment seems equally “objective” translation of texts. Spe- well justified, there cannot be an cifically, in translating from one lan- Post-Modernism: Foucault objective truth of the matter… guage to another, “…a correct trans- and Derrida (Cardinal 2008, p. 23). lation cannot be discovered through In a leap of over two millennia, we any empirical means, free of all theo- It is probably fair to say that no find, in Friedrich Nietzsche (1844- retical frameworks” (Dipert 2003, p. fully satisfactory definition of “post- 1900) a spirit of anti-foundationalism 569). We shall see that, in ways modernism” has yet been advanced, akin to that of Protagoras. (Nietzsche Quine probably never anticipated, despite many learned treatises on “the also foreshadows some elements of these views have helped bolster cer- post-modern.” The difficulty lies in the post-modernism, which we shall ad- tain anti-foundational, post-modern pleomorphic and sometimes obscure dress shortly). Nietzsche’s particular critiques of psychiatric diagnosis. nature of so-called post-modern litera- variety of anti-foundationalism is usu- In some ways, the views of Paul ture, art, philosophy, and criticism. As ally referred to as “perspectivism”— Karl Feyerabend (1924-94) are even Klages points out, a first-pass at the what Robert Wicks has defined as “… more “anti-foundational” than those notion of post-modernism requires a the idea that there is no absolute, of Quine. Indeed, the term Feyera- brief sketch of what “modernism” en- ‘God's eye’ standpoint from which one bend himself applied to his theory tails. Klages links modernism—or at can survey everything that is” (Wicks was “epistemological anarchism”! least, the modern era—with the Euro- 2008). To put it in Nietzsche’s own Preston describes Feyerabend as "An pean Enlightenment, which begins terms, “The only seeing we have is imaginative maverick… [who] be- roughly in the middle of the eighteenth seeing from a perspective; the only came a critic of philosophy of science century (Klages 2003). Citing the work knowledge we have is knowledge from itself, particularly of ‘rationalist’ at- of Jane Flax, Klages notes (among a perspective” (Nietzsche 1967). Simi- tempts to lay down or discover rules other features) the following underly- larly, as Robert Solomon notes, of scientific method” (Preston 2009). ing ideas of the Enlightenment: “Perspectivism in morals [for More important for the purposes of 1. There is a stable, coherent, know- Nietzsche] means that there is no one psychiatry’s anti-foundational critics, able self that is conscious and ra- scale of values and no single way of Feyerabend “…also sought further to tional. measuring people and their virtues…” downgrade the importance of empiri- 2. This self knows itself and the However, Solomon adds that this does cal arguments by suggesting that aes- world through reason, which is the not mean that “…some perspectives thetic criteria, personal whims and highest –and only “objective”— cannot be seen as preferable to oth- social factors have a far more deci- form of mental functioning. ers…” (Solomon 1996, p. 203-204). sive role in the history of science than 3. The mode of knowing produced Despite this qualification, Nietzche’s rationalist or empiricist historiogra- by the objective rational self is perspectivism has probably fueled phy would indicate” (Preston 2009). "science," which can provide uni- some post-modern critiques of psychia- Indeed, for Feyerabend, not only versal truths about the world, re- try, as we shall see. was Western empirical science not gardless of the knower’s perspec- Willard van Orman Quine (1908- “privileged” in any epistemological tive. 2000) is widely considered among the way, it gained its world-wide foot- 4. Such knowledge and truth pro- most influential American philosophers hold through essentially coercive duced by science will inevitably of the 20 th century. Arguably, Quine is means—a notion some anti- lead toward progress and improve- also the philosopher of language who psychiatry factions would later ex- ment. most effectively undermined the claims ploit in their attacks on institutional 5. Language is rational, in that it of logical positivism—particularly the psychiatry. Thus, in his best-known represents the real/perceivable views of his former mentor, Rudolph work, Against Method , Feyerabend world which the rational mind ob- Carnap. Thus, in his best-known work, argues that “It is true that Western serves. Word and Object (1960), “…Quine science now reigns supreme all over 6. Language embodies a firm and self-consciously positions himself the globe; however, the reason was objective connection between the against empiricist attempts to construct not insight in its ‘inherent rational- objects of perception and the words reality solely from sense data… ity,’ but power play (the colonizing used to name them (between signi- [however] it is perhaps not precisely nations imposed their ways of living) fier and signified). with empiricism that he parts ways so and the need for weapons: Western With these principles of Enlighten- much as with foundationalist empiri- science so far has created the most ment-based “modernism” in hand, we cism” (Dipert 2003, p. 566). efficient weapons of can reach at least a notional under- There are at least two important death” (Feyerabend 1993, p. 3). standing of post-modernism: in effect, senses in which Quine’s work is anti- Preston (2009) suggests that sev- it is that view which denies, subverts, foundational; first, in its attack on the eral of Feyerabend’s themes have negates, or satirizes the”modernist,” long-established distinction between affinities with those of post- foundational principles of the Western analytic and synthetic statements modernism; and, indeed, Feyera- rational-empirical tradition. More (which has important implications for bend’s views provide a convenient specifically, following the terminology Szasz’s recent claims); and second, in launch point for our discussion of of the post-modern theorist, Francois Quine’s thesis that there can be no post-modernism. Leotard, post-modernism denies the

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legitimacy of “grand narratives.” These thought to accomplish (Stephens narratives are essentially the enduring …Foucault maintained that 1994, italics added). myths cultures and societies tell them- the definition and treatment of Stephens also points clearly to selves, in order to sustain their own ‘insanity’ constitutes a form the anti-foundational effect of Der- idealized self-image and coercive of social control. Once ‘madness’ rida’s views, in an almost literal sense: power. Post-modernism begins with was defined as abnormal, rather “Hierarchies that had been taken for “…the awareness that such narratives than simply eccentric, its victims granted… get upended. These hierar- serve to mask the contradictions and were separated from the ‘sane’ chies are tripped up by the swarms of instabilities that are inherent in any population by exile or incarcera- meanings that circle around the words social organization or practice” (Klages tion; then, in the 19 th century, phy- used to support them” (Stephens, 2003). sicians created a science of mental 1994). It does not take much imagina- Science, in particular, comes to be disease, parallel to physical medi- tion to see how highly hierarchical in- associated with coercive power, in the cine, with institutionalized proce- stitutions, such as the profession of post-modern world view. As Spiro dures to restore patients to sanc- psychiatry, might also get “upended” (1996) observes, “…the subjectivity of tioned standards of normalcy. by a critique that aims at showing how the human subject precludes the possi- For Foucault, the asylum — psychiatry “fails to make the points it bility of science discovering objective ostensibly an attempt to humanize the seems to be trying to make.” Indeed, in truth. Second, since objectivity is an treatment of the insane—was really a this “Derridean” sense, Szasz’s read- illusion, science according to the ideo- coercive attempt to confine and mar- ings of psychiatry’s epistemological logical argument, subverts oppressed ginalize madness. It does not take claims could be considered groups, females, ethnics, [and] third- much imagination to see how Fou- “deconstructive.” world peoples.” cault’s arguments have been used to For purposes of this essay, two create a modern stalking-horse, be- Foundational Critiques of Psychiatry figures may be considered paradig- hind which the opponents of psychia- matic, in the history of post-modern try can stage their attacks; e.g., psy- Undoubtedly the best-known foun- thinkers: Michel Foucault and Jacques chiatry is a “covert agent of the dational critique of psychiatric diagno- Derrida. state”, an “agent of social control”, sis has come from Dr. Thomas Szasz— As one of the authors (RP) has etc. though, as noted above, there are ele- argued elsewhere (Pies 2004), Foucault Jacques Derrida is probably best ments of Szasz’s critique that overlap saw himself as an “archaeologist” known for his theory of with anti-foundational arguments. The whose task it was to uncover the latent “deconstruction” and its application “foundation” upon which Szasz builds structures of knowledge and power that to literary texts. In a broader sense, his case is that of pathology in general, are responsible for various Western however, Derrida is intimately associ- and the neuropathological writings of cultural phenomena (Harland 1987). ated with the anti-foundational beliefs Rudolf Virchow, in particular. More Foucault analyzed culture in terms of underlying post-modernism. As accurately, Szasz builds his case upon what he called “discourses.” These are Silverman has put it, “There is no what he believes about Virchow’s essentially the “…complex[es] of cre- doubt that with respect to the devel- views and their implications—beliefs dentials, protocols, jargon, and special- opment of post-modernism and its that have been challenged by several ized knowledge that defines theory and relation to deconstruction, the role of psychiatrists (Pies 1979; Pies 2004; practice within the human sci- Jacques Derrida has been of massive Kendell 2004). Suffice it to say that ences…” (Rohmann 1999, p. 142-43). significance” (Silverman 2002, p. the critique Szasz offers is solidly On this view, it might be argued that 110). Deconstruction per se is diffi- grounded in the Western logico- the American Psychiatric Association’s cult to define, partly as a consequence empirical tradition , if not in logical DSM-IV and DSM-V are prime exam- of Derrida’s own ambiguity on the positivism as such. At least in his ear- ples of “discourses.” matter. However, as a first approxi- lier work, Szasz argues essentially that For Foucault, when such dis- mation, the exposition provided by (1) we know what constitutes genuine courses coalesce around a dominant, Prof. Mitchell Stephens (1994) is as “disease”; i.e., the presence of objec- socially-defining paradigm, the result is good as any: tively verifiable lesions or abnormal an episteme (from “epistemology”). To deconstruct a ‘text’… pathophysiology; (2) we know that so- Such epistemes are society’s vehicles of means to pick it apart, in search of called “diseases” like schizophrenia do power . Foucault argues that all disci- ways in which it fails to make the not demonstrate any such objectively- plines—whether scientific, legal, politi- points it seems to be trying to verifiable abnormalities; and therefore, cal, or social—operate through a sys- make… Deconstruction, in other (3) we know that schizophrenia (and tem of self-legitimizing texts and lin- words, guards against the belief— similar psychiatric inventions) cannot guistic conventions. “Truth,” therefore, a belief that has led to much vio- be genuine (ontologically “real”) dis- cannot be absolute and claims of objec- lence—that the world is simple eases. tivity are impossible. In Madness and and can be known with certainty. Very recently, Szasz has presented Civilization (Foucault 1973), as Roh- It confronts us with the limits of a somewhat modified argument, mann (1999, p. 143) summarizes it: what it is possible for human grounded in the notion of

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“analyticity”—the very target of can even specify one—did not arise ily upon the “pathological alteration of W.V.O. Quine’s critique. In the pref- ex nihilo or out of some syllogism; cells, tissues, and organs” (Schwartz et ace to the 50 th anniversary edition of but rather, from specific empirical al, 2005). As noted earlier, Szasz The Myth of Mental Illness , Szasz observations of cells, tissues and or- does not regard himself as being “anti- (1961) argues that: gans, by pathologists like Virchow psychiatry”, and has given a robust The claim that ‘mental illnesses and von Rokitansky. Thus, Szasz’s historical account of why this is so are diagnosable disorders of the argument that “mental illness is a (Szasz, 2010). We have no reason to brain’ is not based on scientific re- metaphor” seems to us far from a question Szasz’s sincerity in his analy- search; it is a lie, an error, or a naive straightforward “analytic” claim; sis of these matters. Nonetheless, revival of the somatic premise of the rather, it appears to be a non-analytic Szasz’s insistence that “mental ill- long-discredited humoral theory of claim that depends critically on a nesses are counterfeit diseases” (Szasz disease. My claim that mental ill- huge body of subsidiary historical, 2010) has found voice in the publica- nesses are fictitious illnesses is also synthetic and empirical claims. In- tions of many self-styled “anti- not based on scientific research; it deed, the statement, “Mental illness is psychiatry” groups. Consider, for ex- rests on the materialist-scientific a metaphor” does not in any way con- ample, this passage written by Law- definition of illness as a pathologi- form to the usual logical-semantic rence Stevens, JD, described as “…a cal alteration of cells, tissues, and structure of true analytic statements, lawyer whose practice has included organs. If we accept this scientific which are generally definitional tau- representing psychiatric definition of disease, then it follows tologies; e.g., “All triangles contain ‘patients’” (Stevens 2003a): “In this that mental illness is a metaphor, three angles.” pamphlet we will show that there are and that asserting that view is stat- Furthermore, unlike Dr. Szasz, no biological abnormalities responsible ing an analytic truth, not subject to we very much doubt that there is any for so-called mental illness, mental empirical falsification. general or “essential” definition of disease, or mental disorder, and that A full-blown critique of this argu- physical or mental illness, or of therefore mental illness has no biologi- ment is beyond the scope of this paper. “disease” in the abstract. Modern cal existence …” However, it is instructive to note some analytic philosophy—exemplified by (Stevens goes on to offer a quasi- of the key “properties” of Szasz’s the later views of Ludwig Wittgen- postmodern refutation of psychiatric claim: (1) It is based on an implicit stein—cautions us against precisely diagnosis, as well, which we shall con- assertion that “analytic truths” are not such essentialist claims. “Disease” sider in the section on “Anti- empirically falsifiable—a claim that may mean many things, depending on foundational Critiques”). Quine is at pains to challenge; (2) It its intended use and context. More- Stevens’ foundational critique is appears to remove from the realm of over, in our view, “mental illness” built upon a scaffolding of selective scientific investigation the question of does not exist as a general entity or quotes from a large cadre of mental whether schizophrenia or bipolar disor- Platonic form, susceptible to exami- health professionals, including Sey- der, for example, are diseases or ill- nation for the quality of mour S. Kety M.D., Steven Matthysse nesses; (3) It conflates the terms “metaphoricalness.” What exists are Ph.D., Jerrold S. Maxmen M.D., and “disease”,“illness”, and “disorder” specific disturbances of affect, cogni- Peter Breggin M.D., all in the service without any attempt to discern concep- tion, perception, reality testing, etc , of showing that we cannot identify any tual or clinical distinctions among such as bipolar disorder—not “mental biological abnormalities in any of the them; and (4) It implies that there is a illness” in general. Indeed, what mat- major psychiatric disorders; and that, single, univocal “materialist-scientific ters to clinicians in both general absent such physical “causes,” these definition of illness” to which one can medicine and psychiatry is the recog- conditions cannot be considered bona appeal, and which then can be used nition of specific illnesses , and how fide diseases . This is essentially a unambiguously to compose an they affect particular individuals in “Szaszian” argument, at least as Szasz “analytic truth.” Also note that the concrete ways. In short, illness and presented it in his earlier works. In an hyphenated term “materialist- disease are not metaphysical abstrac- update from 2001, Stevens (2003) pro- scientific” implicitly suggests that sci- tions, but human realities, manifest as vides the following quote from a psy- ence and “materialism”—roughly, the specific instantiations of suffering chologist, Bruce E. Levine Ph.D.: view that the only thing that exists is and incapacity in specific individuals. “Remember that no biochemical, neu- “matter”—are linked in some essential Finally, we would argue—contra rological, or genetic markers have been way. Szasz—that a “materialist” view of found for attention deficit disorder, Most curiously, Szasz’s argument disease is by no means the only one oppositional defiant disorder, depres- purports to rest upon an analytic state- that may be called “scientific”. For sion, schizophrenia, anxiety, compul- ment—similar in kind to “All bachelors example, we see no logical reason sive alcohol and drug abuse, overeat- are unmarried males”—while implicitly why one could not construct a legiti- ing, gambling, or any other so-called drawing upon the historical and em- mately “scientific” view of disease mental illness, disease, or disor- pirical claims of “materialist” science. based upon principles of dysfunction, der" (Levine 2001, p. 277). Yet any putative “materialist-scientific incapacity, phenomenology, or bio- Both Stevens and Levine seem definition of illness”—to the extent we logical disadvantage —not necessar- unaware that for most of the history of

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medicine, only a handful of conditions still be considered diseases—or, more set of pseudo-objective technical terms identified as diseases —both by modern accurately, instantiations of dis- and linguistic conventions— and ancient authorities—were under- ease —on the view that they entail “delusions”, “paranoid”, “acute schizo- stood in terms of their biological prolonged intrinsic suffering and phrenia”, etc.—and then imposed this “causes.” Nor did most conditions marked incapacity, in the absence of framework on largely powerless social considered diseases by ancient and an obvious exogenous cause (Pies misfits. On Foucault’s view, these un- modern physicians have known bio- 1979; Pies, 2009). Indeed, in our fortunates—labeled “insane” or chemical or genetic “markers” associ- view, the notion that only specific “mentally ill” by psychiatrists—have ated with them. Indeed, to this day, we biological abnormalities can elevate a been denied their own “discourse” and recognize many conditions as condition to the status of “disease” is made to conform to the collective dis- “diseases” (or disorders) without un- a gross misapplication of a long- courses (the episteme) of psychiatric derstanding much at all about their discredited logical positivism. More medicine. Moreover, as Harland puts causes or underlying pathophysiology broadly, we concur with the late R.E. it, “…the mind that does not conform is (Pies 1979; Pies 2004). To cite but one Kendell (2004) that “disease” is prop- treated as aberrational, as mad, as per- example, Amyotrophic Lateral Sclero- erly predicated of persons verted” (Harland 1987, p. 108). sis (ALS), known as Lou Gehrig’s Dis- (“people”)—not of minds, brains, In many ways, Attorney Lawrence ease, has no known cause, and no spe- bodies, tissues or organs. Stevens takes a similar tack in his cri- cific laboratory, neuroimaging, or bio- tique of psychiatry. Stevens does not chemical marker that reliably allows Anti-Foundational Critiques of use the “post-modern” terminology of physicians to diagnose the condition Psychiatry Foucault, but would almost certainly antemortem . Post -mortem neuropa- agree with the latter’s general conclu- thology is, of course, evident in ALS; Like post-modernism—a subtype sions. For example, Stevens writes but numerous post-mortem studies of anti-foundationalism—anti- that, have also demonstrated fairly consis- foundational critiques of psychiatry … the label schizophrenia, like tent neuropathology in the brains of generally seek to deny, subvert, ne- the labels pornography or mental those diagnosed with schizophrenia, gate, or satirize the foundational prin- illness, indicates disapproval of that including medication-naïve subjects ciples of the Western rational- to which the label is applied and (Fornito, Yucel et al. 2009). Indeed, empirical tradition. Michel Fou- nothing more. Like ‘mental illness’ while sensory and motor nerve conduc- cault’s analysis of psychiatry is per- or pornography, ‘schizophrenia’ tion studies and electromyography haps the archetypal anti-foundational does not exist in the sense that can- (EMG) are a standard part of the critique, and in many ways, serves as cer and heart disease exist but exists evaluation, ALS remains essentially a a kind of rhetorical template for many only in the sense that good and bad clinical diagnosis, based primarily on similar critiques of psychiatry. exist. As with all other so-called the patient’s history, signs and symp- As Richard Harland summarizes mental illnesses, a diagnosis of toms (“ALS and Neuromuscular Disor- Foucault’s view of psychiatry, ‘schizophrenia’ is a reflection of the ders” 2010). And, whereas a review of ...psychiatric medicine speaker's or ‘diagnostician's’ values biomarkers in psychiatry is beyond the works only to the extent that pa- or ideas about how a person scope of this paper, it is inaccurate and tients are persuaded into speaking ‘should’ be, often coupled with the deeply misleading to claim that there a scientific language about them- false (or at least unproven) assump- are “…no biochemical, neurological, or selves. Patients are 'mad' because tion that the disapproved thinking, genetic markers” associated with “any” they have evaded the primary so- emotions, or behavior results from a mental illness, disease, or disorder. On cialization which ordinarily enters biological abnormality. Consider- the contrary, several biomarkers, such into human beings along with ing the many ways it has been used, as abnormal smooth pursuit eye move- their society's language; but they it's clear ‘schizophrenia’ has no ments and enlarged cerebral ventricles , can still be subdued and at least particular meaning other than ‘we have been repeatedly (though not in- partially socialized by a secondary dislike it’ (Stevens 2003b). variably) associated with schizophre- web of restraining language… Each of Stevens’ claims would nia, notwithstanding the syndromal [This] seemingly successful result require lengthy rebuttal. For our pur- heterogeneity of this condition (Pies in no way proves the validity of poses, it will suffice to say that, like 2008a; Chua, Cheung et al. 2007). the psychiatrist's language. The many critics of psychiatry, Stevens Incidentally, the oft-repeated charge psychiatrist has not caught the does not understand the role of that psychiatric disorders like schizo- truth of madness in his language, “values” in the construction of so- phrenia and bipolar disorder “do not he has merely taught it to speak called “medical” diseases, including appear in pathology texts” is demon- the same language back to him… but not limited to cancer and heart dis- strably false and has been so for many this is a kind of objectivity that ease. As human beings who share cer- years (Pies 2008b). first creates its object for being tain goals in life, we understandably It must be stressed, however, that objective about (Harland 1987, p. attach “value” to those conditions of even if no biomarkers existed for psy- 104). the body that maintain and enhance chiatric conditions such as bipolar dis- In effect, for Foucault, psychiat- life. Conversely, we tend to “devalue” order and schizophrenia, they could ric medicine has merely fabricated a conditions that limit life’s possibilities, 9 Volume 18, Number 2 2011

decrease life’s duration, or impede its disease depends, in the final analysis, passively recording data, but is in- highly-valued functions, such as walk- on certain kinds of value judgments . stead actively shaped in complex ing, running, calculating, writing, etc. Furthermore, “values” underlie judgments. . .(Fulford et al. 2006, p. That is, we construct a set of values as Foucault’s position that his particular 565) regards how a “healthy” human body episteme ought to be given greater The Oxford authors wisely observe “should be.” In a hypothetical society weight than competing epistemes. that “adding values” does not entail in which, say, reduced exercise toler- Harland implicitly makes this point “subtracting facts” (Fulford et al. ance and dying at a relatively young when he observes, 2006). Thus, when we assert that age were highly valued traits, a condi- “"Foucault... identifies with the someone with paraplegia has a patho- tion such as blocked coronary arteries victims. He identifies with them not logical (from the Greek pathos, would not be considered “disease”; on because their discourse would be “suffering”) condition, we are making a the contrary, it would be a highly- more true, but because it would be no claim grounded in a certain kind of valued bodily state. Something resem- less true, and yet they are made to value judgment; namely, that the in- bling this “re-valuation” may be seen in suffer for it ." (Harland 1987, p. 108 ability to move one’s legs is in some present-day Hmong culture, according italics added) sense “not a good thing.” In a society to author Anne Fadiman. In her book, Indeed, while Foucault and Szasz that greatly valued paralysis and deval- The Spirit Catches You and You Fall proceed from quite different initial ued walking, paraplegia would not con- Down, Fadiman describes the Hmong assumptions, both advance arguments stitute “pathology.” On the other hand, culture’s view of epilepsy as follows: against the activities of institutional we also “add facts” in asserting that "...the Hmong consider qaug psychiatry that are fundamentally Mr. Jones cannot move his legs be- dab peg [epilepsy] to be an illness hortatory and value-based —not sci- cause he has suffered a fracture- of some distinction... Hmong epi- entific—in nature (Pies 2006). dislocation of the lumbar vertebrae. To leptics often become shamans. Their the extent that this last conclusion is seizures are thought to be evidence Facts and Values in Psychiatry: relatively free of cultural or personal that they have the power to perceive Some Qualifications values, and has some objective corre- things other people cannot see, as late in our radiograph of Jones’s spine, well as facilitating their entry into An important caveat is needed at our statement that “Jones has spinal trances, a pre-requisite for their this point, even if it digresses from disease” is more than merely a value journeys into the realm of the un- the main thesis of this paper. We do judgment (though it surely is that). seen..." (Fadiman 1998, p. 21). not want to suggest that the category However, this fusion of “facts and val- For our purposes, the anthropo- called “disease” is nothing but a deci- ues” is also true of psychiatric disease logical accuracy of Fadiman’s claim is sion about values; or—as Lawrence categories, such as schizophrenia, as not critical. It suffices to note that, in Stevens asserts—that what is called has been argued elsewhere (Pies 2009). principle, most conditions we regard as “mental disorder” is solely a value Furthermore, as Zachar and Kendler instantiations of somatic disease are judgment. The determination that point out: ultimately grounded in very basic value someone suffers from disease in gen- Proponents of the evaluative judgments about how the body eral or “psychiatric disease” (or approach [to understanding psychi- “should” function. From a logical and “mental disorder”) in particular is a atric diagnosis] would also point out scientific perspective, such value judg- complex and over-determined judg- that ‘values’ do not have to be in- ments are no different than those relat- ment, involving facts and values , choate, fuzzy, or undefinable. For ing to how the mind “should” function. objectivity and subjectivity. To quote example, in the DSM-IV-TR appen- In short, there is no fundamental from the Oxford Textbook of Philoso- dix, the Global Assessment of Rela- evaluative difference between the phy and Psychiatry, chapter 20, tional Functioning Axis (V) can be claim, “The coronary arteries should “Values in Psychiatric Diagnosis”: seen as an attempt to operationalize not be clogged with plaque, if you want Our conclusion . . . [is] that psychiatric values. (Zachar and good physical health,” and the claim, the traditional medical model, and Kendler 2007) “The mind should not be bombarded the claim to value-free diagnosis Indeed, we should also be clear with auditory hallucinations, if you on which it rests, is unsupportable; that not all critiques aimed at demon- want good mental health.” This is not and that, to the contrary, diagno- strating the role of cultural values in to say that body and mind are similar sis, although properly grounded psychiatric diagnosis are “anti- constructs; that coronary artery disease on facts, is also, and essentially, psychiatry”; nor do they necessarily and schizophrenia are related condi- grounded on values. . . [This] is originate from sources anyone would tions; that the investigations required to consistent with late twentieth cen- reasonably consider “anti-psychiatry” establish their diagnosis are similar; or tury work in the philosophy of in his or her views. For example, Laur- that the two conditions are experien- science. . . showing the extent to ence J. Kirmayer MD, an academic tially similar. It is simply to aver that which the scientific process, from psychiatrist, has argued that whether or not we regard either condi- observation and classification to …many problems in other tion—coronary artery disease or explanation and theory construc- cultures (and perhaps in our own) schizophrenia—as an instantiation of tion, does not depend on merely that current nosology attempts to

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construct as discrete disorders are how mental health theories effect tion, and from logical positivism, in not deviant or disorders at all. They [sic ] public policy, and all of particular. In contrast, anti- are culturally constituted and sanc- us” (Breggin 2010). The views of foundationalists seek to undermine tioned idioms of distress— ICSPP, of course, are not necessarily psychiatric diagnosis and treatment by vocabularies and styles for explain- identical to those of Dr. Breggin; and subverting the very principles and ing and expressing a wide range of indeed, the ICSPP website notes that “privileged narratives” that they claim personal and social problems. whereas it is critical of “the so-called underlie Western empirical science. These idioms of distress cannot sim- medical model of psychiatry,” it is Thomas Szasz has fostered a strong ply be added to our lists of discrete not opposed in all cases to the use of foundational critique of psychiatry, entities. Instead, they must be un- psychotropic medication “…by com- which has been “appropriated” in vary- derstood as rhetorical devices for petent adults who have been thor- ing degrees by anti-psychiatry forces making sense of human predica- oughly informed of their value, po- and factions. In contrast, Michel Fou- ments. (Kirmayer 1994, p. 7). tential side effects and alterna- cault is probably the best exemplar of Jerome Wakefield presents a com- tives” (Breggin 2010). the anti-foundational argument against pelling critique of Kirmayer’s argu- A critical assessment of Breg- modern-day psychiatry. ment (Wakefield 1994, p. 9-17); how- gin’s numerous claims—most of Both foundational and anti- ever, discussion of this rejoinder would which relate to alleged “toxic” effects foundational arguments founder on take us far afield. Suffice to say that of psychotropic medication and elec- several misapprehensions regarding the nothing in Kirmayer’s view of cultural troconvulsive therapy (ECT)—is be- nature of “disease”; the role of “values” influences on diagnosis can reasonably yond the scope of this article. How- in determining the presence of pathol- be construed as “anti-psychiatry”, even ever, a trenchant critique of Breggin’s ogy; and on supposed differences be- if—as Wakefield argues—Kirmayer’s claims regarding Attention Deficit tween psychiatry and the other special- position seems to lay the groundwork Hyperactivity Disorder (ADHD) is ties within general medicine. Many for the sort of “concept relativism” that provided by psychiatrist Stephen Bar- critics of psychiatry have persistently has been exploited by some in the anti- rett MD (Barrett 2002). conflated epistemological and ontologi- psychiatry movement. On the other Ironically, one of the fiercest cal claims regarding the nature of hand, Kirmayer’s rebuttal to Wakefield critics of Dr. Breggin has been Jef- “disease” with hortatory arguments points out that even judgments based frey A. Schaler PhD—himself a regarding the legal and ethical treat- on supposedly objective “evolutionary” prominent critic of the "medical ment of those diagnosed with serious criteria are themselves dependent on model" of psychiatric diagnosis. psychiatric disorders. Such legal- certain value judgments; i.e., Wake- Though beyond the scope of this re- ethical concerns are of great impor- field’s construct of evolutionarily- view, the schism between Breggin tance in their own right, but are logi- determined “natural function” is in fact and Schaler [detailed at great length cally distinct from ontological claims dependent on a number of “culturally on Dr. Schaler’s website (Schaler regarding the nature or treatment of and historically relative” value judg- 2006)], makes for interesting reading psychiatric disease categories. None- ments (Kirmayer 1994, p. 18). in the annals of anti-psychiatry and theless, we would acknowledge many its many variants. weaknesses and deficiencies in psychi- “Hybrid” Critiques of Psychiatry atric nosology that warrant careful re- Conclusion assessment, as psychiatry faces the Though we have categorized antip- daunting task of creating the DSM-5 sychiatry critiques as broadly divided We have emphasized the struc- [see this journal, issues Vol. 17, # 1 & into “foundational” and tural and epistemological nature of 2]. There are also many areas of psy- “antifoundational,” it should not be arguments directed against psychiat- chiatric practice that must be examined surprising that “hybrid” arguments also ric diagnosis and practice, often con- from the standpoint of civil liberties abound. Some prominent critiques sidered under the rubric, “anti- and equitable, humane treatment of come from within the profession of psychiatry.” Though the various crit- psychiatric patients. In order to defend psychiatry itself, as exemplified by the ics differ in their language and spe- itself—and, indeed, to reform itself— work of Peter Breggin, MD. Most cific claims, all call into question the psychiatry must understand the nature striking in Breggin’s various critiques legitimacy and validity of present-day of the arguments arrayed against it. We of psychiatry is his appeal to published psychiatric diagnosis; and, deriva- hope that the foundational/ psychiatric research and leading scien- tively, psychiatric treatment. We antifoundational schema described here tific authorities, in support of the very have argued that these schools of claims he makes against the psychiatric thought may be understood as arising References profession. Breggin, who studied with principally from one of two main

Thomas Szasz, is the founder and Inter- traditions, which we have called (1997). "Should states be allowed national Director of the Center for the “foundational” and to confine sex offenders to mental hos- Study of Psychiatry and Psychology “antifoundational.” Foundationalists pitals after they've served their criminal (ICSPP), described on its website as derive their methods and claims from sentences?" Debates Debates . Re- “…a network of people concerned with the Western logico-empirical tradi- trieved from http://www.szasz.com/ 11 Volume 18, Number 2 2011

debatesdebatessexoffenderstran- ing the gap between neuroimaging Cambridge: Cambridge University script.pdf. and neuropathology." Schizophrenia Press; 159. (2011). “Objectivism.” The Atlas bulletin. 35(5): 973-993. Pies, R. (1979). "On myths and Society. Web. Retrieved from http:// Foucault, M. (1973). Madness countermyths." Archives of General www.atlassociety.org/objectivism. and civilization . New York: Vintage Psychiatry . 33(2): 139-144. (2010). “ALS and Neuromuscular Books. Pies, R. (2004). “Moving Beyond Disorders.” Department of Neurology, Fulford K.W.M., T. Thornton, the ‘Myth’ of Mental Illness.” Szasz Columbia University Medical Center. and G. Graham. Eds. (2006). Oxford Under Fire: The Psychiatric Abolition- Retrieved from http:// Textbook of Philosophy and Psychia- ist Faces His Critics. Ed. JA Schaler. www.cumc.columbia.edu/dept/als/ try. New York: Oxford University Chicago: Open Court; 327-53. patient/autopsy.html. Press. Pies, R. (2008a). "Beyond reli- Augustine, S. (1951). Against the Greer, T. H. (1987). A Brief His- ability: biomarkers and validity in psy- Academics . New York: The Paulist Press. tory of the Western World . San chiatry." Psychiatry (Edgmont). 5(1): Barrett, S. (2002). “Some Notes on Diego: Harcourt Brace Jovanovich. 48-52. ADHD and Peter R. Breggin’s Unfair Hanfling, O. (1996). “Logical Pies, R. (2008b). "Psychiatric Attack on Ritalin.” Quackwatch. Re- Positivism.” Philosophy of Science, Diagnosis and the Pathologist’s View trieved from http:// Logic, and Mathematics in the Twen- of Schizophrenia." Psychiatry www.quackwatch.com/11Ind/ tieth Century . Ed. Stuart Shanker. (Edgmont) . 5(7): 62-5. breggin.html. New York: Routledge History of Phi- Pies R. (2009). “What Should Berthold-Bond, D. (1995). Hegel's losophy; 193- 213. Count as a Mental Disorder in DSM- Theory of Madness . Albany: State Uni- Harland, R. (1987). "Foucault as V?” Psychiatric Times . 26 (4). Re- versity of New York Press. Retrieved Archaeologist” Harland R, Super- trieved from http:// from http://books.google.com. structuralism: the philosophy of www.psychiatrictimes.com/display/ Breggin P. (2010). “ICSPP for Em- structuralism and post-structuralism . article/10168/1402032?verify=0 pathic Human Sciences and Services.” London: Methuen; 101-120. Preston, J. (2009). “Paul Feyera- Website. Retreived from http:// Horner, C. and E. Westacott bend.”. The Stanford Encyclopedia of www.icspp.org. (2000). Thinking Through Philoso- Philosophy . Retrieved from http:// Cardinal, D. (2008) “Protagoras.” phy . Cambridge: Cambridge Univer- plato.stanford.edu/entries/feyerabend. Philosophers . Ed. N. Chalton. London; sity Press. Quine, WVO. (1960). Word and Basement Press; 23. Kendell, RE. (2004). “The Myth object . Cambridge: The MIT Press. Chalton, N, ed. (2008). Philoso- of Mental Illness.” Szasz Under Fire: Rohmann, C. (99). A World of phers: Extraordinary People Who Altered The Psychiatric Abolitionist Faces Ideas . New York: Ballantine Pub. the Course of History. New York: Ster- His Critics. Ed. JA Schaler. Chicago: Group. ling Publishers. Open Court; 29-48. Schaler, J. (2006). “Doublethink at Chua, S. E., C. Cheung, et al. Kirmayer L.J. (1994). “Is the the ICSPP Corral: A Rejoinder to Peter (2007). "Cerebral grey, white matter and Concept of Mental Disorder Cultur- R. Breggin, M.D.” The Website of csf in never-medicated, first-episode ally Relative? Yes.” Controversial Jeffrey A. Schaler, Ph.D. Retrieved schizophrenia." Schizophrenia research . Issues in Mental Health . Eds. S.A. from http://www.schaler.net/fifth/ 89(1-3): 12-21. Kirk and S.D. Einbinder. Boston: breggin.html Dipert, R (2003). “W.V.O. Quine: Allyn & Bacon. Schramme, T. (2004). “The Leg- Word and Object, the Metaphysics of Klages, M. (2003). acy of antipsychiatry.” Philosophy and Meaning.” The Classics of Western Phi- “Postmodernism.” U Colorado Boul- Psychiatry . Eds. T. Schramme and J. losophy: A Reader's Guide . Eds. Jorge J. der. Web. Retrieved from http:// Thome. Berlin: de Gruyter; 94- 119. E. Gracia, Gregory M. Reichberg, & Ber- www.colorado.edu/English/courses/ Schwartz MA, Wiggins OP, nard N. Schumacher. Malden:Wiley- ENGL2012Klages/pomo.html Naudin J, Spitzer M. (2005). Rebuild- Blackwell; 566-574. Levine, B. (2001). Common- ing reality: A phenomenology of some Double, D. B. (2006). "Historical sense Rebellion: Debunking Psychia- aspects of chronic schizophrenia. J perspectives on anti-psychiatry." Critical try, Confronting Society. New York: Phenomenol Cog Sci. 4:91-115. psychiatry: The limits of madness. DB Continuum Publishers. Shorter, E. (2005). A historical Double (ed.). Retrieved from http:// Nietzsche, F. (1967). "On the dictionary of psychiatry . New York: www.dbdouble.freeuk.com/ Genealogy of Morals: A Polemic, Oxford University Press. Chapter2DBD.htm. Essay 3.” Trans. Walter Kaufmann Silverman, H. (2002). “Jacques Fadiman A. (1998). The Spirit and RJ Hollingdale. On the Geneal- Derrida.” Postmodernism: The Key Catches You and You Fall Down . New ogy of Morals and Ecce Homo . New Figures . Eds. Hans Bertens & Joseph York: Farrar, Straus and Giroux. York: Random House. Natoli. Malden: Wiley-Blackwell; 110- Feyerabend, P. (1993). Against O'Daly, G. (2001). "The re- 119. Method . London: Verso. sponse to skepticism and the mecha- Smith, K. (2007). "Descartes' Life Fornito, A., M. Yucel, et al. (2009). nisms of cognition." The Cambridge and Works." Stanford Encyclopedia of "Anatomical abnormalities of the anterior Companion to Augustine . Eds. Eleon- Philosophy . Retrieved from http:// cingulate cortex in schizophrenia: bridg- ore Stump and Norman Kretzmann. plato.stanford.edu/entries/descartes- works. 12 Volume 18, Number 2 2011

Smith D. (2010). The Antipsychia- Zacher P. and K.S. Kendler. mental illness, or of ‘disease’ in the try Coalition . Website. Retrieved from (2007). “Psychiatric Disorders: A abstract.” They argue that “what mat- http://www.antipsychiatry.org. Conceptual Taxonomy.” The Ameri- ters to clinicians in both general medi- Solomon, RC. (1996). “Nietzsche can Journal of Psychiatry. 164: 557- cine and psychiatry is the recognition ad hominem: Perspectivism, personal- 565. of specific illnesses , and how they af- ity, and ressentiment.” The Cambridge fect particular individuals in concrete Companion to Nietzsche. Eds. Bernd *** ways” (Italics in the original). Further, Magnus and Kathleen Higgins. Cam- the recognition of these specific ill- bridge: Cambridge University Press; nesses is not dependent on the known 180- 223. existence of specific “’pathological Spiro, M. E. (1996). alteration of cells, tissues, and organs’” "Postmodernist Anthropology, Subjec- Does the Center Hold?: A but may be based on concepts of tivity, and Science: A Modernist Cri- Commentary on “Getting It “dysfunction, incapacity, phenomenol- tique." Comparative Studies in Society from Both Sides: Founda- ogy, or biological disadvan- and History. 38(04): 759-780. tage ” (Italics in original). Stephens, M. (1994). "Jacques tional and Anti-Foundational While a notion of psychiatric ill- Derrida." New York Times Magazine . Critiques of Psychiatry” ness that is based on the concept of 23: 22-25. Retrieved from http:// dysfunction is attractive, I am not sure www.nyu.edu/classes/stephens/ Jeffrey Bedrick, M.A., M.D. that it would satisfy those in the foun- Jacques%20Derrida%20-%20NYT% dational camp. One reason for this is 20-%20page.htm. Whether one thinks the that many foundationalists are what we Stevens, L. (2003a). "Does mental “foundational/antifoundational may call strict foundationalists, who illness exist?" A Comprehensive 12 schema…will provide a useful heu- believe that higher order phenomena Part Critique of Psychiatry . The Antip- ristic model” for understanding cri- are founded on lower order phenomena sychiatry Coalition. Retreived from tiques of psychiatry, as the authors of and can be reduced to them. Thus the http://www.antipsychiatry.org/ “Getting It from Both Sides: Founda- Vienna Circle believed in the unity of exist.htm tional and Anti-Foundational Cri- the sciences, and they had the dream of Stevens L. (2003b). tiques of Psychiatry” hope, will de- a unified encyclopedia of the sciences, “Schizophrenia: A Non-existent Disea- pend on whether one thinks such which would show how sciences like se.” A Comprehensive 12 Part Critique broad characterizations are useful, or biology rested upon and could be re- of Psychiatry. The Antipsychiatry Coa- whether one thinks the differences duced to physics. lition. Retreived from http:// between the various thinkers that are Further, even those foundational- www.antipsychiatry.org/schizoph.htm said to be in each camp are as impor- ists who are not reductionists might, I Szasz, T. (1961). The Myth of tant as their similarities. I do not suspect, be unhappy with our authors’ Mental Illness . New York, Paul B. want to focus here, however, on move here. For the authors go on to Hoeber. whether such broad dichotomies are say that “to this day, we recognize Szasz, T. (2009). Antipschiatry: useful. Instead, I will focus on the many conditions as ‘diseases’ (or disor- Quackery Squared . Syracuse: Syracuse defenses of psychiatry that the au- ders) without understanding much at all Univ Pr. thors make in their response to what about their causes or underlying patho- Szasz, T. (2010). Preface. The they see as the criticisms advanced by physiology,” citing the case of amyo- Myth of Mental Illness . 50 th Anv Ed. the two camps. If the dichotomy has trophic lateral sclerosis. The particular By Szasz. New York: Harper Perennial. provoked sound defenses of psychia- case is in some ways both unfortunate Wittgenstein, L. (1953). Philoso- try, then perhaps it has already and instructive. This past week a paper phical Investigations. Trans. by GEM proved itself useful. was published that claims to have Anscombe. Malden: Blackwell Publis- The defense presented of psy- found a pathology that underlies amyo- hers. chiatry against the “foundational cri- trophic lateral sclerosis (Deng et al Wakefield JC. (1994). “Is the tiques of Psychiatry” seems to rest on 2011). Pies, Thommi, and Ghaemi concept of mental disorder culturally several main claims. The main claim could certainly say that they could have relative? No.” Controversial issues in is that those making the critique have picked any number of other examples, mental health . Eds. S.A. Kirk and S.D. embraced a view of science and and the pathophysiology of the illness Einbinder. Boston: Allyn & Bacon. medicine that is artificial and overly would still be unknown. This is true, Wicks R. (2008). “Friedrich Nietz- narrow. (I will leave aside, for the but I think does not catch an important sche.” Stanford Encyclopedia of Philo- most part, the discussion of the new point. I think even before the recent sophy . Retrieved from http:// preface to The Myth of Mental Illness paper, any neurologist would have been plato.stanford.edu/entries/nietzsche/ as I think it takes us away from the extremely uncomfortable if we had said Yaffe, G. and R. Nichols (2009). central argument about foundational to them that the underlying pathophysi- "Thomas Reid." Stanford Encyclopedia critiques.) Thus, the authors write ology of ALS could never be discov- of Philosophy . Retrieved from http:// that “we very much doubt there is any ered, or even further, that there was no plato.stanford.edu/entries/reid/#Epi. ‘essential’ definition of physical or underlying biological pathophysiology

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to be discovered. Do we feel the same “victims” and their suffering, or to arguments of the anti-psychiatry way about schizophrenia? About post- alleviate it? If the latter, then there movement. While they focus on the traumatic stress disorder? Borderline are grounds for considering whether writings of Michael Foucault and personality disorder? Fetishism? The identifying with the “victim” or treat- Thomas Szasz, one other writer of the authors write that “the notion that only ing those with psychiatric disorders period also needs to be included; R.D. specific biological abnormalities can provides greater relief for their suffer- Laing. During the 1960’s, when anti- elevate a condition to the status of ing. If we do this, I think we would establishment rhetoric was at an all ‘disease’ is a gross misapplication of a discover that treatment (good treat- time high, these three writers laid the long-discredited logical positivism.” I ment, of course, whatever that is) intellectual foundation for the think there might be a difference be- does more to alleviate suffering than antipsychiatry movement (Rissmiller tween psychiatric disorders and other does just identifying with the suf- and Rissmiller 2006). Pies and medical disorders here, however. The ferer. To paraphrase Marx, the goal colleagues describe Szasz’s arguments authors go on to say that “’disease’ is is not just to understand the suffering as foundational and Foucault’s as anti- properly predicated of persons but to change it. This argument, I foundational. While this description is (‘people’)—not of minds, brains, bod- think, would potentially be a strong partly accurate it tends to obscure the ies, tissues or organs.” I would imag- defense of psychiatry. more important fact that the arguments ine that those who study the diseases of I think psychiatry can be de- of Szasz and Foucault (as well as plants might find this a strange claim. fended against its critics. Doing so, Laing) are very similar at a Those of us who are psychiatrists do however, I think entails acknowledg- fundamental level. They all involve an not for the most part, I think, find it a ing some differences between psy- extreme form of ontological strange claim—but I think that is be- chiatry and other branches of medi- skepticism: what lies at the heart of all cause we are dealing with psychiatric cine. That there are such differences their arguments is an outright denial of diseases, mental disorders (if I can bor- is not a weakness for psychiatry. It is the objective existence of mental row some italics from our authors). rather a strength of psychiatry as a illness. Let us now turn to the authors’ branch of medicine that does deal Foucault sought to explain away response to the antifoundational cri- with persons, both in their physical mental illness by questioning the tique. Here they say “whether or not and mental aspects. There is much in motives of psychiatrists. He argued in we regard either condition—coronary the paper to commend it, but I think it Madness and Civilization that artery disease or schizophrenia—as an weakens its own arguments by the psychiatrists were sadomasochists instantiation of disease depends, in the refusal to consider the differences conspiring to keep conventional final analysis, on certain kinds of value between psychiatry and other bourgeois morality in place (Foucault judgments.” Again, I think many psy- branches of medicine, and not just 1965). Szasz (1960) claimed that chiatrists would not object to the notion their similarities. There is a reason mental illness could never be linked to that values enter in to our distinguish- why psychiatry and neurology are dysfunction in the brain. Instead, he ing between the normal and the patho- different branches of medicine. We argued that the category of mental logical. The authors, rightly I believe, do not need to be afraid of this differ- illness was an arbitrary judgment on cite approvingly the authors of the Ox- ence. the part of the psychiatrists who did not ford Textbook of Philosophy and Psy- realize that mental illness was simply a chiatry to the effect “that ‘adding val- References disease of communication. Laing ues’ does not entail ‘subtracting facts.’” (1960) argued that mental illness may But what are we to make of the claim Deng, HX, et al. (2011). be an alterative and more authentic way that “In a society that greatly valued “Mutations in UBQLN2 cause domi- of existing. Mainstream psychiatrists paralysis and devalued walking, para- nant X-linked juvenile and adult- quickly provided effective rebuttals to plegia would not constitute onset ALS and ALS/dementia.” Na- the arguments at the time (Kelly and ‘pathology’?” It is a topic for another ture 2011. DOI:10.1038/nature Feeney 2006), but what really mattered place, but I think there might be 10353. was that the public, and specifically the grounds in this latter case for saying mental health reform movement, that there was something pathological quickly lost interest in these extreme in the culture, just as I think the authors positions (Rissmiller and Rissmiller might take their argument with Fou- 2006). Psychiatric patients and their cault to him, on his own ground. Quot- The Psychiatry Hoax advocates began to demand the reform ing Harland, the authors note that Fou- of rather than the disbanding of cault “’identifies with the victims. He Michael A. Cerullo, M.D. psychiatry. This was the beginning of identifies with them not because their the consumer movement and modern discourse would be more true, but be- In their article, “Getting it from patient advocacy groups. These groups cause it would be no less true, and yet both sides: Foundational and anti- supported patient rights, they are made to suffer for it ’” (Italics foundational critiques of psychiatry,” deinstitutionalization, community added by Pies, Thommi, and Ghaemi). Pies, Thommi, and Ghaemi do an mental health, and evidence based But is our goal just to identify with the excellent job of analyzing the medicine (Dain 1994; Rissmiller and

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Rissmiller 2006). They had little Those who espouse these arguments psychopharmacology industry and interest in naïve arguments denying the are more likely to quote Carl Elliot, concerns over conflict of interest and existence of psychiatry. Peter Kramer, and David Healy rather warps them into a radical skepticism. After the reform in nosology with than Foucault, Laing, or Szasz. Here I These arguments fit the post-modern the DSM-III and the explosion of will briefly review two of these neo- (or anti-foundational) mold in that they research in biological psychiatry, the antipsychiatry arguments. Ironically, play on the fact that nothing is ever traditional antipsychiatry arguments the first idea crystallized with the completely certain. Overwhelming finally became intellectual indefensible writings of a contemporary evidence is ignored in favor of trivial and whatever benign motivations that psychiatrist, Peter Kramer. Kramer uncertainty. Post-modern arguments were once associated with them have (1993) was concerned that selective also tend to banalize opposing long past. Mental illness is the number serotonin reuptake inhibitors might viewpoints and those who hold them. A one cause of disability in the world be altering personality and acting as good illustration of these arguments is (http://www.who.int/healthinfo/ general mood brighteners in those the recent claim that many mental global_burden_disease/ without depression. Kramer based his illnesses are the creation of “disease GBD_report_2004update_part3.pdf)! arguments on several patients he was mongering.” This derogatory label What more do we need to debunk these treating in his private practice and refers to the creation of disease extreme skeptical claims? In fact these published his musings in the book categories purely for profit. If you arguments are so obsolete that labeling Listening to Prozac (Kramer 1993). follow many of these arguments closely them “anti-psychiatry” gives them too While the arguments in Kramer’s they start with a reasonable concern much credit. Instead I would argue that book have been shown to be incorrect about the excesses of industry and then they are better grouped with other (Cerullo 2006) the idea that modern finish by casting doubt on a large conspiracy theories of the late 20 th psychopharmacology is serving as portion of psychiatry. Moynihan and century. In honor of my favorite enhancement rather than treatment colleague’s illustrate this tactic in a conspiracy theory, the moon hoax (the resonated with the many intellectuals series of articles (Moynihan et al. 2002; US faked the moon landings and they and led to a new generation of Moynihan et al. 2008). In their initial were filmed in the American skepticism towards psychiatry. The article published in a mainstream southwest), I propose to label these cosmetic psychopharmacology myth psychiatry journal they claim that “The radical ontological arguments the drifted into mainstream bioethics social construction of illness is being “psychiatry hoax”. Given the culminating with its acceptance by replaced by the corporate construction overwhelming amount of evidence for The President’s Council on Bioethics of illness” (Moynihan et al. 2002). The the objective existence of mental illness (The Presidents Council on Bioethics authors then claim that: the only way to deny this is to 2003; Elliot and Chambers 2004). Within many disease perpetuate a world wide conspiracy Prozac was seen as SOMA from categories, informal alliances have dedicated to generating the myth of Brave New World (SOMA was the emerged, comprising drug company mental illness. mind dulling medicine given to keep staff, doctors, and consumers. Unlike the moon hoax, which the masses unaware of the horrible Ostensibly engaged in raising public doesn’t seem to have that many serious reality surrounding them). It was awareness about underdiagnosed negative consequences (other than argued that psychiatrists were and undertreated problems, these perhaps encouraging more medicating the angst and difficulties alliances tend to promote a view of conspiracies), antipsychiatry of our stressful modern society away their particular condition as encourages the persecution of a (The Presidents Council on Bioethics widespread, serious, and treatable vulnerable minority of the world’s 2003; Elliot and Chambers 2004). … Alternative approaches — population. History clearly shows that This myth conveniently allowed for emphasizing the self limiting or one dark aspect of human nature is to the acceptance of the reality of relatively benign natural history of a marginalize minority groups. The way mental illness (and hence avoidance problem, or the importance of to fight this is not use more rational of any association with traditional personal coping strategies — are arguments to debunk ridiculous claims, antipsychiatry) but the denial of played down or ignored (Moynihan but instead to focus on decreasing the “mild” illnesses like depression, et al. 2002, p 886). stigma of those with mental illness. anxiety, and ADHD. While the What is the evidence for these Think of the difference in public traditional antipsychiatry at least informal alliances? Five examples are reaction if Tom Cruise had ranted didn’t blame the victim, these newer discussed: baldness; irritable bowel about the non-existence of cancer as arguments are not so kind. syndrome; social phobia; osteoporosis; opposed to mental illness. It is fair to Depression is once again seen as a and erectile dysfunction. The evidence say he would have received more than weakness and character issue and provided for the informal alliance to the mild rebuke he was given. taking medicines is seen as a crux create social phobia centers on a While the radical ontological that simply masks the “real” issues. marketing campaign in Australia. skepticism of antipsychiatry has lost all A second class of neo- Roche was promoting moclobemide, respectability, a new generation of antipsychiatry arguments take the one of its antidepressants, as a arguments has arisen to take its place. reasonable concern of biases in the treatment for social phobia and they put

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advertising money into an awareness Rissmiller, D. & Rissmiller, J. campaign. The authors claim that 1.In this article Healy (2006) (2006). Evolution of the antipsychiatry Roche exaggerated the prevalence of wasn’t technically arguing that movement into mental health social phobia in a press release. While bipolar disorder doesn’t exist but consumerism. Psychiat Serv . 57:863- this may be true, no referenced data is instead that the prevalence of the 866. given by the authors to refute the disorder is being greatly exaggerated The Presidents Council on numbers given by the company. Even if (again by the conspiratorial trinity). Bioethics. (2003). Beyond therapy: the prevalence of the illness was My favorite piece of evidence from Biotechnology and the pursuit of greatly exaggerated this would the paper was Healy’s accusation that human improvement. Washington, DC: implicate only one arm of their the creation of the journal Bipolar Dana Press. conspiratorial trinity. There was no Disorders supported his case for Szasz, T. (1960). The myth of evidence given to support the disease mongering. Thus as a mental illness. Am Psychol . 15;113- involvement of psychiatrists or patient researcher in the field of bipolar 118. groups. Yet “disease mongering,” as a disorder and a reviewer and publisher post-modern argument, does not in the journal Bipolar Disorders I *** require it. Only the most minimal of should be classified as a disease evidence is required for the argument mongerer. Taking Psychiatric Critique to count as an equally valid alternative. Once the reality of social phobia is References: Seriously: A Role for doubted then the post-modern Narrative Philosophy argument can freely generalize to other Cerullo, M. (2006). Cosmetic areas of psychiatry. In a subsequent Psychopharmacology and The Bradley Lewis M.D., Ph.D article Moynihan et al. (2008) President’s Council on Bioethics. classified bipolar disorder as another Persp in Biol and Med. 49(4):515- I very much appreciated Pies, creation of disease mongering. The 523. Thommi, and Ghaemi’s (PTG’s) efforts only evidence provided was a reference Dain, N. (1994). Reflections on to understand important and influential to an article by Healy without antipsychiatry and stigma in the critics of psychiatry. The writings of discussion of its content. 1 Notice we history of American Psychiatry. Hosp Thomas Szasz, Erving Goffman, Mi- have gone from an unsupported but Community Psych . 45:1010-1014. chel Foucault, Franco Basaglia, Ronald believable claim that a drug company Foucault, M. (1965). Madness D. Laing, David Cooper, Peter Breggin, may have exaggerated the prevalence and Civilization: A history of insanity and Bruce Levine do not often show up for a much understudied disorder to in the age of reason. New York: in psychiatric journals. This is a loss denying the existence of a disease Random House. for psychiatry because some of these which is the eighth leading cause of Kelly, B. & Feeney, L. (2006). authors have had major influence in the disability in the world (http:// Psychiatry: no longer in dissent? humanities and social sciences www.who.int/healthinfo/ Psychiat Bull . 30:344-345. (particularly Goffman, Foucault, and global_burden_disease/ Kramer, P. (1993). Listening to Laing) and others have had major im- GBD_report_2004update_part3.pdf). Prozac . New York: Penguin. pact in popular culture (such as Szasz, Antipsychiatry is still alive and Healy, D. (2006). The latest Breggin, and Levine). What makes well in the twenty-first century. mania: Selling bipolar disorder. PLoS PTG’s article valuable is that they work Traditional antipsychiatry arguments Medicine . 3(4):441-444. to make sense of psychiatric critics continue to flourish and have found a Laing, R. (1960). The divided within the psychiatric literature. By place among conspiracy theories which self: An existential study in sanity and writing the article, they argue that it is prosper even in the face of madness. Harmondsworth, England: worthwhile for psychiatry to under- overwhelming contradictory evidence. Penguin. stand its critics and to bring that under- As tragic as these theories are at least Moynihan, R., Heath, I. & standing inside the knowledge base of they were originally well meaning and Henry, D. (2002). Selling sickness: psychiatry. The more psychiatry fol- helped to initiate the reform movement the pharmaceutical industry and lows their lead, the more it will stay in psychiatry. Unfortunately the neo- disease mongering. BMJ . 324:886- alive to the limits of psychiatric knowl- antipsychiatry arguments supplanting 891. edge, aware of the many roads not them share more with the pre- Moynihan, R., Doran E., & taken, and appreciative of alternative enlightenment views of mental illness. Henry, D. (2008). Disease mongering points of view. Those with mental illness are not is now part of the global health Staying open to alternatives is par- viewed as having a disease but instead debate. PLoS Medicine . 5(5):684- ticularly important for psychiatrists are seen as the modern equivalent of 686. because many of the people who dis- being evil, i.e. having severe character Elliot, C., Chambers, T., eds. agree with us are also our patients or flaws and moral weaknesses. (2004). Prozac As a Way of Life . the loved ones of patients. Critics of Chapel Hill: The University of North psychiatry, in other words, do not stay Endnote Carolina Press. in books, on the internet, or in activist

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meetings. Like everyone else structuring their history of philosophy core categories (foundationalism or (including psychiatrists) they come to and the world-views of psychiatric antifoundationalism) you can ignore private offices, mental health clinics, critics through a sharp foundational- the many subtleties of the philosophers and to emergency rooms in need of ist/antifoudationalist dichotomy, PTG and the many complaints of the critics. psychiatric assistance. When they do, create a classification system that You can go back to business as usual in they should meet psychiatrists who divides more than it connects. That is psychiatry. No need to disturb your have thought through in advance some not because classifying is bad thing in psychiatric slumber. PTG’s classifica- of the key reasons people are unhappy itself. Language users routinely make tion also creates a stereotypical split- with psychiatry and why many believe sense of the world using broad cate- ting that makes critics of psychiatry psychiatry can be harmful. Otherwise gories of people and things with com- “Other” because critics, according to psychiatrists are likely to more defen- mon characteristics, and we may be PTG, use discredited philosophies. sive and argumentative than helpful able to salvage PTG’s efforts. But PTG do not make it clear what their when working with critical clients and classification can also become ex- own philosophy is, but they do make it family members. tremely divisive when it slides from clear that they do not fall into either The first step in approaching dif- helpful heuristic to a cultural stereo- foundationalist or antifoudationalist ferent psychiatric worldviews is not so type . Before we can salvage PTG’s traps. PTG have a philosophy that com- much philosophical as it is ethno- efforts, we have to work through the bines foundationalist facts with anti- graphic. The first step is to understand way their article slides into problem- foundationlist values. The result is that psychiatric worldview differences are atic stereotyping. that critics of psychiatry have a bad sub-cultural differences that are not Cultural theorist Stuart Hall ar- philosophy , while PTG have a good unlike cross-cultural differences. As we ticulates three toxic features of a clas- philosophy (albeit an unspecified one). have learned from cross-cultural medi- sification system that has become a And, finally, the power differential cine, lots of people in the world do not cultural stereotype: rigidity, splitting, between mainstream psychiatry and its see things the way western healthcare and inequalities of power (Hall critics means that PTG’s stereotypical workers do. Clinicians who lack aware- 1997). Stereotypes rigidly reduce classification of psychiatric critics risk ness and skill in the face of cultural people to simplified and exaggerated not being challenged within psychiatric difference cause tremendous disruption characteristics. Complexity is ignored circles. for their clients and themselves. The and denied, and it is implied that eve- Uncannily, PTG’s classification example PTG reference, When the rything that is necessary to know system creates the very thing that crit- Spirit Catches You , dramatically por- about the person can be known by ics from a variety of philosophic back- trays how not to act in cross cultural referring to the traits of the stereo- grounds most complain about with re- situations. The basic wisdom is the type. A stereotype declares ‘this is gard to psychiatry’s diagnostic prac- same in cross sub-cultural differences. what you are, and this is all you are.’ tices. Critics of psychiatry’s diagnostic Many critics of psychiatry come from In addition, stereotypes create split- manual complain that it too often be- different sub-cultural communities than ting when those who do not fit soci- comes a stereotyping devise. By giving psychiatrists. They may be from the ety’s norms are excluded, and their a diagnosis (and particularly by essen- same country and speak the same lan- exclusion is fastened by fitting them tializing that diagnosis), clinicians split guage, but when it comes to psychiatry to a set of characteristics deemed the normal from the pathological. The they read different literature, listen to unacceptable – the ‘Other’. This de- rigidity of this split means that there is different podcasts, and go to different nies the possibility of any meaningful not an option of complex and intertwin- gatherings. The task of cross sub- discourse about them or with them, ing mixtures of “normal” and cultural difference, like with cross- and ensures their continued exclu- “pathological” experiences shifting cultural difference, is to find common sion. Finally, this rigidity and split- from time to time. Nor is there an op- ground and to look for opportunities for ting proves most effective when gross tion of having understandable (not diplomacy and negotiation. The thing inequalities of power allow the domi- “pathological”) reactions to a sick soci- not to do, as happened in Spirit Catches nant group to employ the strategy ety. And certainly there is not an option You , is get involved in an ethnocentric without challenge. that “pathological” symptoms are a gift insistence of your sub-culture’s world PTG’s turn to philosophy ends that can motivate generative spiritual, view. Instead, clinicians need to be up too close to the stereotyping Hall political, or artistic consciousness and adept at understanding different points describes. The rigid dichotomy they social movements. Critics argue that of view and finding diplomatic alterna- use to organize the article loses com- once you become a pathological patient tives—rather than going against differ- plexity and makes it seem that the you risk becoming “Other” to normal ences head to head. many philosophers and critics of psy- clinicians and normal society. Your Philosophy’s role arguably comes chiatry are either foundationalist or voice is the voice of the mad. You are next because returning to basic philoso- antifoundationalist. The impression rigidly split off from the normal. To phical assumptions can be a good way the article leaves is that which cate- take you seriously would be ridiculous. to find common ground. But, unfortu- gory philosophers and critics fit is And this dividing practice works across nately, the way PTG turn to philosophy more or less all you need to know a power differential that too often sets reinforces the differences between about them. PTG seem to say to psy- up structures of oppression and subor- themselves and psychiatric critics. By chiatrists that if you can recognize the dination. We call this racism or sexism 17 Volume 18, Number 2 2011

in the case of racial or sexual stereo- A less rigid way to get at the psychiatric critique. I have found that types. We can call it sanism in the case difference PTG are trying to make is work in narrative theory can create a of psychiatric stereotyping (Lewis to use a more simple and descriptive philosophy for psychiatry that provides 2006). distinction between critics who rely a helpful way to do this (Lewis 2011). Still, despite the heavy handedness heavily on science and those who do By standing on the shoulders of narra- of PTG’s philosophic turn, there is not. Using this distinction, particu- tive medicine, narrative psychotherapy, promise in their effort. The spade work larly with regard to contemporary and narrative philosophy, psychiatrists they begin may be a useful starting critics, we can see that some critics can recognize that there are many ways point if we can loosen their categories a argue that psychiatry is not scientific to tell the story of psychic pain and little. PTG are certainly right that al- enough and other critics argue that difference. All the stories people tell though there are similarities critics of psychiatry is too scientific . Many mix intertwine facts and values. Dominant psychiatry are not all the same. Some the two concerns together, but we can stories rely on science centered models critics come at it one way, some come heuristically describe two groups. common in today’s psychiatric sub- at it other ways. On first pass, the two The first group of critics argues cultures, but other stories are critical of main examples PTG discuss, Szasz and that there needs to be more science in dominant models and prefer alterna- Foucault, do seem to be roughly divid- psychiatry. There is not enough sci- tives (such as psychoanalysis, existen- able along the lines PTG articulate. But entific funding to create an evidence tialism, creativity, or spirituality just to PTG become too rigid when they use base for psychiatry. The science we name a few). Most use hybrid combina- high-falluting philosophic categories of do have is not rigorous enough and is tions of a variety of approaches. foundationalism/anti-foudationalism too often overly shaped by pharma- All the models and hybrid combi- and try to essentialize these categories ceutical interests. For these critics, nations bring together facts and values. through a forced reading of Western what the field needs is a much more Narrative psychiatrists have a philoso- Philosophy. PTG are closer to the right and much better science. The second phy that allows them to embrace this track when they historically connect group of critics comes from the other diversity and multiplicity of options. Szasz with logical-empiricism and Fou- direction. These critics argue there is As a result, when narrative psychia- cault with postmodernism. Logical- too much science in psychiatry. They trists meet people in the clinics who empiricism and postmodernism are complain that psychiatry seems to have had bad experiences with psychia- more flexible than foundationalism and forget that humans (including scien- try or who are deeply critical of the antifoundationalism because they come tists) have complicated mental lives field, they need not be defensive. If closer to cultural/historical/contingent and are located in dense cultural, his- they are told, coming from one direc- intellectual formations rather than es- torical, and political contexts. They tion, that psychiatry is an immature sential timeless philosophical catego- argue that psychiatry’s over idealiza- science and that its categories are ries. To contextualize someone as a tion of science mystifies and natural- sloppy and destined to be the laughing logical empiricists or a postmodernist is izes approaches to humans in favor stock of history, narrative psychiatrists to talk about complex and often contra- powerful players (such as the phar- need not react. They can simply say: dictory intellectual traditions which maceutical industry or consumer so- “yes, the field does have its limits. We inform aspects of their work, not to ciety). do not have the kinds of hard scientific classify them for all time. The philosophic question for data and consensus to work with that But logical empiricism and post- psychiatry is this: “Can the field live other areas of medicine seem to have. modernism are also problematic be- with the fact that it is vulnerable to Many people in the field are concerned cause they are too dated for contempo- these two serious critiques?” From about this and are trying hard to de- rary critics of psychiatry. It is important one point of view, the science of psy- velop psychiatric science along these for psychiatrist to know that serious chiatry is insufficient and incomplete. lines.” When they are told, coming and deep critique of psychiatry did not We need much more science in psy- from the other direction, that psychiatry stop with Szasz and Foucault. More chiatry. From another point of view, relies to too heavily on science and has and more scholars from humanities, the field is too dominated by science become the scientistic handmaid of the social sciences, and the clinics are writ- and neglects many other areas of hu- pharmaceutical industry and overcon- ing complicated and persuasive cri- man inquiry such as literature, phi- sumptive society, narrative psychia- tiques of mainstream psychiatry losophy, history, cultural studies, trists need not rebut the claim. They (Angell 2011a, 2011b, Lewis 2009). disability studies, the arts. We need to can simply say: “yes, that is a real For these new critics, neither founda- open psychiatry to areas of study be- problem. Many people agree with this tionalism/antifoundationalism (terms yond science. From my perspec- critique. They are trying to find solu- which are way too blunt) nor logical tive, there are not necessary philoso- tions to powerful influences that shape empiricism/postmodernism (terms phic reasons psychiatry can not stay the field and are trying to open the psy- which no longer reflect today’s intel- open to both of these critiques. In- chiatry beyond the sciences. In the lectual styles) make a lot of sense. Yet, deed, the clue that PTG give us to mean time, let’s see how we can be of even though none of these categories their philosophy—that psychiatry help in your situation and make sure work very well, there is still an echo of must be open to facts and values— not to be overly attached to contempo- the distinction one can detect. seems to be a step in the right direc- rary psychiatric worldviews.” tion for coping with this double sided 18 Volume 18, Number 2 2011

Psychiatrists, in summary, would article. Anomalies that interrupt the standard-bearer, the insurance industry, be wise to follow PTG’s lead to take ‘flow’, things like grammatical er- is wholly ignored in this piece. For it is psychiatry’s critics seriously. But, as rors, spelling errors, punctuation er- surely no coincidence that the rise of we do this, our task is not to categorize rors, leap out at me like pathology to anti-psychiatry parallels the explosive our critics and dismiss them. Our task an experienced radiologist. Or, per- invasion of the private insurance lobby. is to learn from alternative world views haps, this linguistic hyperawareness I will address Stevens briefly later and subcultures, to recognize our many has more to do with my strict twelve in this commentary, but for now Szasz vulnerabilities, and to go humbly for- years of primary Catholic grammar then is really the only ‘Foundational’ ward in the face of these vulnerabili- schooling. Whatever the etiology, example of anti-psychiatry presented. ties. One way to do this is to go back to split infinitives, dangling participles, The authors do take pains to attack the drawing board and rethink our basic enclitic relative clauses all set off tiny Szasz’ arguments as distilled down to philosophic assumptions. When we do ‘neuro-shocks’ in my language- his assertion of ‘analytic truth’ deter- that, we see that we are in a field (like addled brain. And so in this paper by mining the existence of illness. More other fields) where facts and values get Dr. Pies, Ms. Thommi, and Dr. broadly, Szasz’ whole argument is one all mixed up. That means we need to be Ghaemi, where early on there is a of negation, one might even say denial. smart about both facts and values and parenthetical reference to “the section Mental illness plainly and simply does about the different ways that facts and entitled ‘Foundational Critiques of not exist. Evidence is not produced values can be combined for living with Psychiatry’”. At first I was sure this against the existence of mental illness. and through psychic difference. Narra- was simply an oversight, that the edi- Rather, lack of, literally, microscopic tive psychiatry is a particularly helpful tors meant to correct this to read “the evidence in support of the existence of way to do this and a valuable philoso- section titled ...” After all, it is diffi- mental illness is the crux of the argu- phical scaffold for organizing our re- cult to imagine something as inani- ment. This lack of evidence is defined search, education, and practice with mate and inert as a ‘section’ to be as mental illness’ distinct lack of this kind of subtlety. worthy of ‘entitlement’. But as I “pathological alteration of cells, tis- thought about it, I more and more sues, and organs”. Utterly ignoring the References came to appreciate, whether intended forest for the trees, Szasz then wraps up or not, the double entendre of the this assertion with the at worst, contra- Angell, M. 2011a. The epidemic of phrase on the paper; that is, that dictory, and at best, bizarre, claim that mental illness. New York Review of somehow that section of the paper, on “mental illness is a metaphor...an ana- Books. June 23. ‘Foundational Critiques’, was either lytic truth, not subject to empirical fal- Angell, M. 2011b. The illusions of to be considered as having been af- sification”. Again, the philologist in me psychiatry. New York Review of Books. forded pre-eminence among theories, is drawn to the striking use of the term July 14. or as nothing more than a lexical mis- ‘metaphor’. A metaphor, of course, is a Hall, S. 1997. The spectacle of the take. This interpretation grew even comparison between two things, or in ‘other.’ In S. Hall ed. Representation: more appealing given that only two Aristotelian terms, “the application of a Cultural representations and signifying examples of foundational anti- word that belongs to another thing”. practices . London: Sage Publications. psychiatry arguments are presented: ([1], p. 1457b) Szasz, by virtue of his Lewis, B. 2006b. A mad fight: Thomas Szasz, who, perhaps wisely, defining mental illness in terms of its Psychiatry and disability activism. In L. has eschewed the term ‘anti- negation, implies that since mental ill- Davis, ed. Disability studies reader , psychiatry’ as co-opted by a spec- ness is not a pathological phenomenon, 2cd ed. New York: Routledge. tacularly narcissistic ‘blogosphere’ he then it must be ‘something else’. In Lewis, B. 2009. Madness Studies could not possibly have seen coming, good old-fashioned postmodern terms, (Review). Literature and Medicine. 28. and the latter-day Renfield to Dr. it must be an ‘Other’. This interpreta- no 1: 152-171. Szasz’ Dracula, attorney, blogger, tion is the only way I see to resolve Lewis, B. 2011. Narrative psychia- and psychiatric ambulance chaser, Szasz’ strangely literary claim with his try: How stories can shape clinical Lawrence Stevens. And more, the otherwise odd appeal to “empirical practice . Baltimore: Johns Hopkins fact that Mr. Stevens is included in falsification”. In other words, the the same conversation with St. ‘Other’ that is mental illness can only Augustine, Descartes, even Thomas be conceived of as an ‘analytic truth’, On Being ‘Entitled’, or Reid, makes the whole endeavor, in and this plants Szasz firmly among the Why a Little Knowledge Is a the bewildered words, previously supposed ‘Anti-Foundationalists’, not Scary Thing quoted, of young, if perhaps some- the ‘Foundationalists’. This then re- what psychotic, Alice, ‘curiouser and duces the ‘meta’-categories of anti- Elliott B. Martin, Jr., M.D. curiouser’. (Of course I run the risk psychiatry proponents to one. now of the editors correcting this Attorney Lawrence Stevens thus As a former, though admittedly oversight in the meantime, and ren- finds himself, by virtue of his self- minimally paid, philologist I find my dering my little rant here irrelevant. promotional blogging, abandoned as own neural wiring unwittingly, often Che sará.) It should also be noted – the only ‘philosopher’ of annoyingly, attuned to ‘the little things’ emphatically noted – that the largest ‘Foundational’ anti-psychiatry. That is, when I read a newspaper, a book, an and most influential anti-psychiatry he and a laundry list of disillusioned 19 Volume 18, Number 2 2011

psychiatrists and psychologists who taste, I smell, all recede in the pres- cords hinting at the medically pre- continue to regurgitate the ence of Descartes’ sixth sense, ‘I scribed killing of the mad. ([4], pp. 14- ‘microscopic argument’ ad nauseam. think’. To be fair, Descartes does 15) Here I find myself more in agree- There is no new argument at all among consider the prospect that, by denying ment with Gauchet and Swain’s thesis them. They randomly regurgitate Szasz his own existence, he too might be that before the (late) Western assertion in the name of self-interest, for at no ‘mad’. But he quickly dismisses this that all men are equal what allowed for other time in history has there been contention in the context of his ability any supposed toleration of the madman doubt as to the existence of mental ill- to entertain the proposition at all, or, at all was in fact his ‘Otherness’. The ness. As is the case with any number of in his ability to use his ‘Cogito’. In madman, in this view, was somehow diseases across medical boundaries, Cartesian terms therefore, madness is different from other men. And in socie- there do not yet exist biological mark- not compatible with reason at all. The ties that recognized, and accommo- ers of mental illness. Therefore, mental underlying assumption here, of dated, certain people as slaves, or sub- illness does not exist. I can discern no course, is that the ‘madman’ then humans, and others as gods, or super- value in Stevens’ cataloguing of such lacks the ability to think, to reason. In humans, the madman might fall any- statements. One may as well appeal to other words, the madman’s distrust of where in between. As certain societies, every experiment that fails to yield any his senses is somehow pathological. typically in the West, became more pathological needles in the genetic hay- Both Foucault and Derrida famously egalitarian, so Gauchet and Swain stack of any number of diseases. More took issue with these conclusions, claim, what causes problems for the prevalent than the authors’ example of this in their efforts to conclude that relativists is that the madman then lost ALS, Alzheimer’s disease – and the madman indeed does not lack a his ‘Otherness’. He could no longer, in frankly a fair percentage of neurologic Cogito. Rather, according to Derrida, good egalitarian – or, in up-to-date disorders – by this logic, do not exist. he lacks the ability “to reflect it and parlance, politically correct – terms, be In other words, there is no serious retain it”. ([2], p. 58) The discovery thought of as an ‘Other’. By law now thoughtful ‘Foundational Critique of thereby – or perhaps more appropri- he had to be thought of as the ‘same’. Psychiatry’. (There are certainly profit- ately, the initial best expression of – Thus the madman was not necessarily able foundational critiques, and this the Ratio, of reason, from its incep- assimilated, but accommodated. Swain would likely go a long way in explain- tion necessarily implicated its himself never disputes that madness is ing the bull-headed, unimaginative ‘Other’. From the moment existence the ‘Other’ of reason, “but it is an other reiteration of the obvious.) The current was confirmed as a subjective self- that is somehow inside of it, and whose authors present evidence enough identity, so the possibility of the loss unexpected arrival is contained in the against such one-dimensional claims. of self-identity emerged, i.e. reason’s very logic of its development”. ([5], p. And in so doing, they have essentially Other, madness. This certainly did 94) Madness is not an opposite of rea- rendered insignificant their one pre- not establish madness as a distinct, son, but an ‘Other’. In democratized sented case of a ‘Foundational Critique verifiable entity per se. Rather, in society then, madness and reason must of Psychiatry’. good constructivist fashion, it merely coexist. The development of moral There really is no double-barreled marked the initiation of discourse on treatment in this regard was essentially assault on psychiatry. This is not to the subject. the forced belief that there was in fact claim that anti-psychiatry does not ex- This is overlooked in the overall present a Pathology (madness) as op- ist. Rather, the proponents are of the lack of historical context in this arti- posed to Healthy (reason). The door single barrel variety, and firmly en- cle by Dr. Pies et al. Anti-psychiatry thus stood wide open for the psycho- trenched in constructivism alone. The has become an all-encompassing term analyst. authors do provide brief historical out- only over the last forty to fifty years, Of course the anti-Oedipus crowd line of thinkers they classify broadly as coinciding with the development of has praised the madman in various in- either ‘Foundationalist’ or ‘Anti- antihumanism. Madness, however, or carnations as the last rebel, the staunch- Foundationalist’, but none of this typo- reference to such a pathology in the est of resistance fighters, less against logical scheme is presented as bearing medical literature dates back at least democratization per se than against on the question of psychiatry or mental to the Babylonian and Egyptian eras. rampant capitalism. ([6], pp. 1-50) In illness in any way. Assuming a dia- (3) In broader historical terms, Fou- this context the postmodern pendulum logue is implied, to return to the prof- cault’s premise that madness is a so- has swung the other way, and ideology fered examples of Augustine and Des- cial construct requiring the segrega- is inextricably woven into the fabric of cartes, that these thinkers would start tion of the mad as a logical conse- the ‘Other’, of madness. As a socio- with a premise that questioned the very quence of increasing egalitarianism is political martyr, he-who-is-mad then existence of the material world and difficult to maintain. Though histori- flies in the face of Hegel’s concept that themselves, I would contend, is very cally unproven that the mad were notions are the result of themselves. much akin to ‘Madness’ (to borrow a otherwise ‘contained’ before the sev- The madman is no more motivated to favorite synonym of the relativists). To enteenth century, it is equally un- fight for a principle than he is moti- question one’s very existence, after all, proven that the mad were assimilated vated at all. Left to a world of madmen, is to deny the evidence of one’s own in any functional way into day-to-day there would be no notions. Psychopa- perceptions. I see, I hear, I touch, I life. In fact there are Babylonian re- thology, though a necessary condition

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for the anti-Oedipeans, is greatly di- Lastly, I would like to re-assert Sources, Translations, and Modern minished thereby, and here is where, Slavoj Žižek’s point regarding how Medical Analyses . Trans. and with despite his optimistic stance, I must properly to judge thought in an his- commentary by J. Scurlock and B.R. take issue with Dr. Schramme’s belief torical context. Žižek rails against Andersen, Champagne, IL: U. of Illi- that anti-psychiatry is a misnomer. It is arrogantly judging the past with nois, 2005. my understanding, from my reading of twenty/twenty hindsight. Rather, he 4. Stol, M: Epilepsy in Babylonia . their discussions and interpretations, states “when we are dealing with a Groningen, Neth: Styx, 1993. that the anti-psychiatry crowd in fact truly great philosopher the real ques- 5. Quoted in Ferry, L; Renaut A: advocate nothing less than the aban- tion to be raised concerns not what An Essay on Antihumanism . Trans. by donment of the mentally ill to their own this philosopher may still tell us…but M.H.S. Cattani, Amherst: U. of Massa- devices. Indeed I often wonder if any rather the opposite…how our epoch chusetts Press, 1990. of the steadfastly anti-psychiatry would appear to his thought”. ([7], p. 6. Deleuze, G; Guattari, F: “The crowd, Dr. Szasz included, has ever 6, author’s italics) The current au- Desiring-Machines” , in Anti-Oedipus: been face-to-face with a floridly psy- thors do indeed provide two cursory Capitalism and Schizophrenia . Trans. chotic or manic individual, with an histories of what they respectively by H.R. Lane, R. Hurley, and M. Seem, acutely suicidal or homicidal individ- call ‘Foundational’ and ‘Anti- New York: Penguin, 2009. ual, with a catatonic individual. To Foundational’ thought. But they fail 7. Žižek, S: First as Tragedy, Then return once more to the issue of histori- to engage in any meaningful dialectic as Farce . London, New York:Verso, cal context, it should be remembered between the past and the now. In fact, 2009. how easy it is to forget just how hor- they fall into the historical trap both rific, how terrifying, was the course of of creating new terms, and even more *** untreated ‘madness’, the type of mad- egregiously, propagating the new ness that faced medical professionals terms of others, i.e. ‘Foundational’, prior to the advent of anti-psychiatry. ‘Anti-Foundational’, ‘Scientism’, Reform or Revolution: (Indeed, a disease so horrific as to have ‘Skeptical Psychiatry’. Generating Response to Pies, Thommi, medical professionals prescribe, at novelty terms, again thinking as a and Ghaemi’s “Getting It times, death as the only recourse.) Cer- philologist, only removes one further From Both Sides: Founda- tainly one can easily praise the from any meaningful dialogue with ‘rebelliousness’ of these ‘free thinkers’ the past. (I think of this less as an tional and Antifoundational from an intellectual distance. But the infinite regress, than an infinite pro- Critiques of Psychiatry” simple fact is that there is no conscious gress: modernism begets postmodern- rebellion there. The schizophrenic no ism, which begets post- Marilyn Nissim-Sabat, M..S.W., Ph.D. more chooses to rebel against society postmodernism, et cetera, ad infini- than the paraplegic chooses not to tum, ad nauseam.) The question per- The authors of “Getting It from walk. haps the authors should be asking is Both Sides” maintain that, “in order to Even more plainly and simply I not whether critics of psychiatry have defend itself—and, indeed, to reform suppose the best way to disprove any foundational or anti-foundational itself—psychiatry must understand the ‘Foundational’ attacks on psychiatry bases – terms both so ‘meta’, by the nature of the arguments arrayed against would be to gather the adherents in a way, as to encompass the whole of it” [authors’ ital.]. Manifestly, then, the room, then present to them a floridly intellectual history – but whether authors believe that psychiatry is in impaired individual, very much like I psychiatry itself remains relevant need of reform. However, the authors would imagine presenting a captured when viewed through the eyes of “the see psychiatry as very much embattled, Bigfoot to a gathering of skeptics. I’m truly great philosopher”. threatened by the barbarians at the gate sure there would be those steadfast few (my metaphor). Interestingly, then, the willing to deny the evidence before References entire body of their paper is given over their eyes, to deny their own sense per- to presenting and critiquing the “anti- ception, but at that point the objection 1. Aristotle: Poetics ; Longinus: psychiatry” movement, “the arguments could no longer lie on Foundational On the Sublime ; Demetrius: On Style . arrayed against” psychiatry, which the grounds. True, the ‘Anti- Trans. by S. Halliwell, Loeb Classical authors categorize under the rubrics of Foundationalists’ would more likely be Library, No. 199, Cambridge: Har- “foundationalist” and “anti- among those disputing the evidence vard University Press, 1996, 1457b. foundationalist” (loosely equated, re- before their eyes, but this claim would 2. Derrida, J: “Cogito and the spectively, with logical positivism and present an interesting contradiction to History of Madness”, in Writing and postmodernism). It seems, then, that relativist thought in general: that is, Difference . Trans. by A. Bass, Chi- their advocacy of reform is related to creating a social construct around evi- cago: University of Chicago the authors wish to stave off revolution. dence presented to everyone, at the Press,1978, p. 58. (The authors do not use the term same time, despite any one individual’s 3. Diagnoses in Assyrian and ‘revolution’ in their paper. Neverthe- cultural context. Babylonian Medicine: Ancient less, as I will attempt to show, I believe

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it is indeed what they are arguing the classical aims of liberalism: as revolutionary (my term) in their im- against.) “There are also many areas of psychi- plications and for this reason wish to The authors find all of the posi- atric practice that must be examined dissociate them from critical claims tions under the rubrics of foundational- from the standpoint of civil liberties that they, the authors, deem to be ism and anti-foundationalism, and equitable, humane treatment of within the scope of their own, liberal (including those in a lengthy philoso- psychiatric patients.” In the previous (my term), critique of psychiatry. Let phical excursus), to be deeply flawed. paragraph they had pointed out the us see how this plays out in their dis- What, then, we may ask, is the relation importance of concerns such as “ the cussions of such epistemological and between, on one hand, their belief that legal and ethical treatment of those ontological claims. In what follows, I reform is needed, and, on the other diagnosed with serious psychiatric will point out that the authors, while hand, their intensive, albeit “heuristic,” disorders.” In contrast, from a radical, themselves pointing to the epistemo- critique of the arguments of the anti- as contrasted with a reformist, stand- logical and ontological stances of some psychiatry thinkers? (The authors ac- point, one would ask, rather: How is critics of psychiatry, nevertheless elide cept the term “anti-psychiatry” to des- it that abuse of psychiatric patients, any discussion of these as such, nor do ignate the leaders of the “assault” (a including racism and sexism, has they indicate that their own stance im- term they do use) on psychiatry, though been endemic to psychiatry and the plicitly posits an epistemology and they differentiate it from the earlier, treatment of people with mental dis- ontology. Moreover, while they claim, Laing inspired version.) Clearly, the orders from the beginning and how is and I agree, that a scientific view of authors do not aim to pose a fundamen- it that the problem remains intracta- psychiatry does not require a material- tal challenge to the psychiatric estab- ble? In this regard, we can ask, also: ist ontology or an epistemology that is lishment that uses DSM (and will use Is it possible that failure to eliminate grounded in a materialist ontology, on the forthcoming DSM-5) as its noso- psychiatric abuse of patients is related the other hand, they do not provide any logical bible; rather, they aim to de- to the way certain perspectives in other rationale or grounding for the bunk any view they determine advo- psychiatry, e.g., the medical model, scientificity of their approach. cates for, not reform , but rather the (which the authors critique for its The primary representative of view that psychiatry is in need of a pretensions to value neutrality) facili- foundationalist claims against psychia- radical, or even revolutionary transfor- tate, or fail to raise consciousness try that the authors focus on is Thomas mation (again, these terms are not used regarding, dehumanization of pa- Szasz. They reduce Szasz’s perspec- by the authors). Such a transformation tients? How then do the authors con- tive, not unreasonably, to four principle would probably entail, one way or an- strue what I have referred to as a radi- tenets, one of which has direct bearing other, a radical transformation of psy- cal critique of psychiatry and the on ontology. Szasz’s stance, they main- chiatric nosology possibly leading to DSM, the sort of critique that, as we tain, “implies that there is a single, uni- rejection of the DSM approach to shall see, they clearly reject and from vocal ‘materialist-scientific definition nosology tout court . Certainly, this which they apparently seek to shield of illness’ [quoting Szasz] to which one would be true of two of the anti- psychiatry? can appeal, and which then can be used psychiatry critics the authors focus on: In their conclusion, the authors unambiguously to compose an the foundationalist Szasz, since Szasz register the nub of their critique of the ‘analytic’ truth.” Indeed, Szasz is un- denies the existence of mental disease; philosophical/psychiatric foundation- ambiguous regarding his commitment and, the anti-foundationalist Foucault, alist and anti-foundationalist critiques to scientific materialism and to an al- since he viewed mental illness as an of psychiatry that they discuss in their leged “scientific-materialist definition instrument of oppression by the ruling paper: of illness as a ‘pathological alteration classes. (I am here just explicating the Many critics of psychiatry of cells, tissues, and organs’” (authors authors’ views of these critics.) have persistently conflated episte- quoting Szasz). Scientific materialism That the authors reject radical mological and ontological claims is indeed an ontological standpoint that transformation of psychiatric nosology regarding the nature of “disease “ avers, as the authors point out in their and seek to neutralize such tendencies with hortatory arguments regard- philosophical excursus, that “matter is is evident in their description of the ing the legal and ethical treatment the only thing that exists.” The authors types of reform they endorse. They of those diagnosed with serious go on to argue against Szasz’s views on signal their acceptance of the DSM psychiatric disorders. Such legal- many fronts, and much of what they when they write that, “Nonetheless, we ethical concerns are of great im- write is sound. All of this notwithstand- would acknowledge many weaknesses portance in their own right, but ing, to refute an ontological stance one and deficiencies in psychiatric are logically distinct from onto- must not merely point it out; rather, one nosology that warrant careful re- logical claims regarding the nature must address it directly and pose an assessment, as psychiatry faces the or treatment of psychiatric disease alternative ontology, or a rationale for daunting task of creating the DSM- categories. abjuring to posit an ontology. It is all 5…” They go on to provide their own It is, I will show, these “ episte- well and good to say that Szasz and list of improvements needed, and this mological and ontological claims” or others conflate ontology and epistemol- list is itself manifestly one that reflects potential claims that the authors see ogy with legal and ethical issues; it is

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quite another task to show that an on- it announces? The authors speak of subject to critique on this point because tology like scientific materialism is not “principles” of dysfunction, etc. What they themselves never address the philosophically adequate in general, is the nature of these principles drawn question of their own ontology. The and in particular, not adequate to pro- from, I assume, empirically observed authors’ central critique of both Fou- vide a philosophical foundation for regularities? What is their ontological cault and Stevens is that these writers psychiatry. Moreover, quite a few phi- status? The authors might argue that maintain that psychiatry is a method of losophers, Plato and Levinas, for exam- they are not obliged to discuss or oppression of those deemed by its ad- ple, would challenge the authors’ claim provide an answer to these questions herents to be misfits, to be people who that ontological and epistemological here because their evidence is empiri- fail to conform to societal expectations. issues are logically separable from ethi- cal and can be observed repeatedly In their discussion of Foucault, Derrida, cal and legal issues. Separability for the and systematically. But, their view in and postmodern thought, their point is sake of discussion, or, to use one of the no way rules out a materialist ontol- that the postmodern standpoint, that of authors terms, for “heuristic” purposes, ogy. For example, the “principles,” or Foucault in particular, is judgmental does not necessarily imply philosophi- the observed regularities from which and ipso facto unscientific. The sense cal or logical separability. they are inductively drawn can be of the author’s critique of anti- If scientific materialism were to construed as indicative of neural foundationalist attacks on psychiatry is be universally adopted as the one true pathways and thus as materially con- that their stance is both unscientific and philosophical, ontological foundation stituted. Why should we not so con- is an attack on the very possibility of for psychiatry, and, mutatis mutandis , strue them or attempt to show this as science, and on the very existence of for all other disciplines, (a situation some neuroscientists do? My point is ‘reason.’ They reject psychiatry on that I for one, a devotee of Husserlian not to promote a materialist ontol- political and ideological grounds. From phenomenology, would strongly op- ogy—indeed, as just noted, it is not at this point of view, one might argue that pose, to say the least!), this would in- all the ontology that I favor! I only the postmodern anti-foundationalist deed have revolutionary implications. aver that if one rejects such an ontol- would indeed like to see a revolution— That is, it would have revolutionary ogy then one is obliged to explain the the complete abandonment of psychia- implications if it were acknowledged as basis for that rejection and provide an try. One might say (tongue in cheek) such. It would mean, for example, that alternate view. Why is scientific ma- that Szasz’s scientific materialism or all mental phenomena of either health terialism philosophically unsound? scientism suggests revolution from the or disorder would be held to be exclu- The authors say nothing. Nor do they ‘right,’ while Foucault et al represent sively phenomena of materiality, thus provide a rationale for non-materialist revolution from the ‘left’! rendering irrelevant all approaches to scientificity. More specifically, the As the authors clearly show, post- psychiatric nosology and treatment of authors are explicating a concept of modernism is a form of skepticism that adverse mental conditions whose theo- mental illness that accepts a notion of rejects any claim, not just to possess rists and practitioners deny the validity ‘disease’ broadly construed, but re- truth, but even to be seeking it since of materialism vis-a-vis reality and in jects scientific materialism. What these thinkers maintain (contrary to the their theory and practice. Scientific then is the ontology of disease that phenomenological standpoint) that any materialism, systematically construed, they wish to substitute for scientific notion of a truth as such or in-itself is would rule out any other ontology. Let materialism, one that will enable both ipso facto foundationalist and has the us see how the authors dodge this prob- scientificity and “reform” of DSM? potential to lead to totalitarianism and lem. The authors next take on what authoritarianism. However, the authors They write: they deem, quite correctly, to be anti- do not bring to bear on their discussion Finally, we would argue— foundationalist critiques of psychia- a question that is relevant to their per- contra Szasz—that a “materialist” try. The authors do not at all discuss spective, and which, in my view, view of disease is by no means the ontological aspects of the two cri- strikes at the heart of postmodern only one that may be called tiques of psychiatry they focus on, thought: the question of relativism. “scientific.” For example, we see those of Foucault and Anthony Law- Perhaps we can discern in their own no logical reason why one could rence Stevens, who (Stevens) has views an explanation of the elision of not construct a legitimately posted articles on the antipsychia- the problem of relativism, which is an “scientific” view of disease based try.org website and who is associated epistemological problem regarding the upon principles of dysfunction, with the Antipsychiatry Coalition. nature of truth. incapacity, phenomenology, or However, in their philosophical ex- The authors conclude that, biological disadvantage —not nec- cursus they do make clear that the “Indeed while Foucault and Szasz pro- essarily upon the “pathological anti-foundationalists reject all ceed from quite different initial as- alteration of cells, tissues, and or- “absolutes.” These thinkers project a sumptions, both advance arguments gans…. profound epistemological skepticism against the activities of institutional In what sense does this statement regarding truth; however, their views psychiatry that are fundamentally hor- even suggest a rationale for the non- on ontology are exceedingly unclear. tatory and value based —not scien- materialist scientificity of the approach Nevertheless, their work should be tific—in nature.” Interestingly, the au-

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thors then bring forth their own per- thors elide discussion of the ontologi- are relative, what motivates psychia- spective which is also most insistently cal and epistemological issues that trists who are scientists to prefer one values based, but, they argue that their one would engage in a critique of judgment to another, as to what, for stance, contrary to those of Szasz, Ste- mainstream psychiatric theory and example, constitutes health? The au- vens, and Foucault, is both values practice, including the nature and thors provide the example of someone based and scientific. How do they jus- relevance of the DSM to that theory who is diagnosed with “spinal disease,” tify this stance? To pursue this ques- and practice. As is well known, DSM specifically a “fracture-dislocation of tion, we turn to the next section of was originally inspired by the logical the lumbar vertebrae.” The effort to “Getting It From Both Sides.” empiricism of Carl Hempel and the restore this patient’s ability to walk The next section is called “Facts operationalism of A. Rappaport. reflects the judgment that it is better to and Values in Psychiatry: Some Quali- Above, I stated that the authors be able to walk than not to be able to fications.” This section, to a greater do not raise the question of relativism walk. This judgment is fused with the degree than the next one, their conclu- as a critique of postmodern thought. facts that will enable efforts to restore sion, presents the authors own views Why not? Perspectival relativism, the patient’s ability to walk. Thus, the regarding the future of psychiatric narrative relativism, or relativism in goal is to restore the patient’s function- nosology. The authors argue that any form, if valid, renders science ing to normalcy. The authors maintain though they acknowledge the necessity and reason irrelevant at best. The that this example is generalizable to for a values based psychiatry, they de- authors do point out in their discus- mental disorders like schizophrenia. part from anti-foundationalism of Fou- sion of Foucault that for him, The goal would be to restore the patient cault and others in insisting that a val- “’Truth’ therefore, cannot be absolute to health, to the ability to function nor- ues orientation in no way conflicts with and claims of objectivity are impossi- mally or as close to normally as possi- the necessity to ascertain facts about ble.” However, nowhere in their arti- ble. mental disorders. cle do the authors indicate that they The problem with these formula- In the context of the present dis- believe that psychiatry should seek a tions is that if one wants to develop a cussion, the most salient aspect of this truth that is “absolute,” nor do they philosophically rigorous standpoint, section is that the authors simply pre- discuss the problem of relativism. 2 and it seems to me that without such an suppose the concept of “fact” as phi- They do indeed believe that ‘facts’ effort, there is no philosophy at all—it losophically clear and distinct and are ‘objective,’ certainly in the sense is either rigorous or it is not philoso- therefore as a valid construct for psy- that they are based on empirical ob- phy—and this is the fundamental ho- chiatry. And yet, the coherence of the servation allegedly unclouded by mology between philosophy and sci- concept of fact is one of the most dis- ideology. Be this as it may, the ques- ence —then one cannot sidestep the cussed and debated notions in philoso- tion of relativism is most germane to problem of relativism. Why are my or phy of science and in philosophy in its the authors’ discussion of the role of anyone else’s judgments regarding entirety. Philosophy of science, includ- values in their effort to “reform” psy- what is good and bad with respect to ing the work of Popper and Kuhn, has chiatric nosology. health more worthy than anyone else’s shown that facts are always theory The authors rightly focus on the judgments? laden and cannot be understood decon- fundamental value of the medical and The authors themselves cite an textualized from a theory, whether mental health professions: health. In example of a hypothetical group who physicalist, materialist, hybrid, idealist the following discussion, I should not “valued paralysis and devalued walk- or whatever. 1 The authors point out and be taken at all to be questioning the ing” so that for them paraplegia would accept that, contrary to the claims of view that psychiatry is grounded in not constitute ‘pathology.’ Or, to put supporters of the medical model, there the value of health. On the contrary, I the point another way, why does para- is no value free science; but science fully support this view and consider it plegia violate our sense of the meaning also can never be theory-neutral. Yet, to be vital to the continuance and of health but not theirs? Are the views the authors write with remarkable theoretical and practical development ethically and morally equivalent? And, aplomb that their theory is scientific of psychiatry and all of the mental most importantly, is our concept of because, while it recognizes the insepa- health professions. Of course, what is health intrinsically different from rability of value theories and value considered to be “health” is, as the theirs? judgments from psychiatric diagnoses authors point out, a judgment. The Philosophically considered, there and treatment, unlike postmodernist authors also point out that the “DSM- are two aspects to the refutation of rela- anti-foundationalist theories it recog- IV-TR appendix, the Global Assess- tivism: first, relativism, the view that nizes the necessity of facts. Yet, at no ment of Relational Functioning Axis everything is relative, is false because point in their essay do the authors even (5) can be seen as an attempt to op- it is self-contradictory in excluding the hint that the nature and existence of erationalize psychiatric values…” principle of relativism itself from being facts is itself a very charged and pro- The question arises then, if psychiat- relative. Second, the only way to pre- found philosophical question, one that ric values are based on judgment, are clude relativism, that is to say, to pre- engages ontology and epistemology, as they not relative to, for example, cul- clude holding an inherently self- well as ethics. In this way, too, the au- ture or historical period? And, if they contradictory position, is to show that,

24 Volume 18, Number 2 2011

in this case the concept of health, is this thing called science? Queen- relative to that which is not itself rela- sland: University of Queensland by the objective rational self is tive —that is to say to a transindividual, Press. The revised edition was pub- "science," which can provide univer- transcultural, transhistorical universal lished in 1999, but I prefer the earlier sal truths about the world, regardless value that obtains for all in virtue of editions. of the knower’s perspective. our existence as human beings. We do 2. I discuss the problem of relativ- not know the ultimate meaning of the ism in philosophy of psychiatry and 4. Such knowledge and truth pro- concept, but we seek to know that psychoanalysis extensively in: duced by science will inevitably lead meaning and cannot not seek to know. Marilyn Nissim-Sabat (forthcoming, toward progress and improvement. However, the authors discuss health as 2013) “Race and Gender in Philoso- the fundamental value of psychiatry, phy of Psychiatry: Science, Relativ- 5. Language is rational, in that it but they do not ask whether or not the ism, and Psychiatry” in: Handbook of represents the real/perceivable world concept of health as such, as a concept, Philosophy of Psychiatry , ed. by K. which the rational mind observes can be relative in the sense of relativ- W. M. Fulford and R. Gibbs, Oxford: . ism and therefore be devoid of univer- Oxford University Press. 6. Language embodies a firm and sality. What is the relevance of Husser- 3. Though all of Husserl’s works are objective connection between the lian phenomenology to the question or germane to this issue, his last, and objects of perception and the words problem of relativism? greatest work is the best starting used to name them (between signifier Phenomenologically, philosophy is point: E. Husserl (1970) The Crisis of and signified). a rigorous science that begins with the European Science and Transcenden- understanding that we as finite beings tal Phenomenology , trans. by David In the unqualified way in which cannot know the ultimate ontology of Carr (Evanston, IL: Northwestern these ideas are presented, I would dis- the world, and therefore we adopt the University Press). agree with every one of them. What standpoint of radical empiricism and does this mean? That I’m a post- investigate the world, including our- *** modern relativist? That I’m an anti- selves, just as it gives itself, with no foundationalist? That I’m not a logical ontological presuppositions. The phe- Critiquing Psychiatry: positivist? I certainly don’t think of nomenological attitude is not tanta- myself as a post-modern relativist. I mount to sidestepping the question of How We Do It also don’t think of myself as a logical ontology. Much the rather, it is the positivist. And while I might qualify fully conscious, intentional acknowl- James Phillips, M.D. myself as an anti-foundationalist, I like edgement of human finitude in just this to think that my anti-foundationalism sense: since whatever we know or can A Predicament doesn’t carry the baggage the designa- know must be known in and through tion does for the authors. That may be our minds, subjectivity, or conscious- In Getting it From Both Sides, the crux of my discomfort. ness, we cannot know whether or not the authors have given us a thorough In their introduction the authors anything exists independently of us; review of critiques of psychiatry, a state that “The aim of the present paper therefore, the most rational standpoint proposed division of the critiques into is to place the critics of psychiatric is to suspend judgment regarding the foundational and anti-foundational theory and practice in the broader ultimate ontology of the world. From camps, and an admirable effort to framework of two philosophical tradi- this point of view, everything is not refute the critiques. In this commen- tions: logical positivism and post- relative in the sense of relativism which tary I focus on my personal difficul- modernism ." They fold these into the denudes everything of meaning; rather, ties locating myself in these divi- larger categories of foundationalism everything is relative to the a priori of sions, and what that may suggest and anti-foundationalism – leaving us possible meanings for us as human about a need to broaden the divisions with a question. Is the implicit, un- 3 beings. For psychiatry to adopt this Let me hone in on my difficulty stated, theme of the paper that there are standpoint would be revolutionary, and, by citing the authors’ (cited) list of two choices available to us: recognition it would be a bloodless revolution! Ac- “underlying” ideas of the Enlighten- of the reality of psychiatric disorders tually, it seems to me that the authors ment. based on a philosophical position of of the paper under discussion here foundational logical positivism, versus would find a home in phenomenology 1. There is a stable, coherent, rejection of the reality of psychiatric for their approach. I say this because knowable self that is conscious and disorders based on a philosophical po- they seem to be in crisis regarding the rational. sition of post-modern relativism? The problem of ontology. issue here is to what an extent the cate- 2. This self knows itself and the gories of logical positivism and port- Endnotes world through reason, which is the modernism map onto the other catego- highest –and only “objective”— ries of foundationalism and anti- 1. The best summary of the modern form of mental functioning. foundationalism. Can one be a founda- history of philosophy of science is A. tionalist but not a logical positivist?

F. Chalmers’ bestselling book , What is 3. The mode of knowing produced And can one be an anti-foundationalist 25 Volume 18, Number 2 2011

but not a post-modernist? And to bring the subject, but from a subject which bothered a number of my critics. these questions directly to bear on the is nothing but a project of the world, They find my viewpoint relativistic, theme of the article: where in all this is and the subject is inseparable from particularly as it is developed in the there room for an acknowledgment of the world, but from a world which it last section of this book….Later sci- the reality of psychiatric disorders that projects itself” (Merleau-Ponty 1962 entific theories are better than earlier is not logical positivist and not founda- [1945], p, 430). Is this foundationalist ones for solving puzzles in the often tional? That is the question I raise in or anti-foundationalist? Both and quite different environments to this commentary. neither. which they are applied. That is not a Let me turn to Gadamer relativist’s position, and it displays Foundationalism and Anti- (Gadamer 1975 [1960]), another phi- the sense in which I am a convinced foundationalism losopher who challenges the founda- believer in scientific progress. tionalist-anti-foundationalist division. Compared with the notion of According to the authors, He is also of interest because he progress most prevalent among both “foundational philosophies and phi- brings the topic of hermeneutics into philosophers of science and laymen, losophers hold that we can reliably the discussion. Gadamer’s position is however, this position lacks an es- describe a coherent, objectively- that we always approach an issue – sential element. A scientific theory is measurable ‘reality ’ or ‘ truth ’, whether e.g. a historical event, a philosophical usually felt to be better than its one considers the world as a whole, or question – with preconceptions—our predecessors not only in the sense specific aspects of it, such as the classi- “horizon of understanding”—and that that it is a better instrument for dis- fication of disease. Anti-foundational we oppose our horizon to that of the covering and solving puzzles but also philosophies and philosophers deny interpreter at the time of the event or because it is somehow a better repre- this claim, asserting that there are no earlier discussion, the result being a sentation of what nature is really like. objectively demonstrable ‘truths’, – fusion of horizons in which our own One often hears that successive theo- only various ‘perspectives’ or perspective or preconception is al- ries grow ever closer to, or approxi- ‘narratives’ that cannot be privileged as tered and our understanding deep- mate more and more to, the truth. uniquely or objectively ‘true’.” ened. The “truth” is a historically Apparently generalizations like that Although the authors invoke an- conditioned and ever evolving proc- refer not to the puzzle-solutions and cient examples of skepticism, as well as ess. In the language of the authors the concrete predictions derived from Augustine, as defenders of foundation- this is of course an issue of a theory but rather to its ontology, to alism, would it be fair to argue that the “perspectives” or “narratives,” and the match, that is, between the enti- foundationalism debate is an affair of thus anti-foundational. But that is not ties with which the theory populates the modern era, with its origin perhaps a fair representation of the hermeneu- nature and what is “really there.” in late medieval nominalism, its first tic approach. Or it only anti- Perhaps there is some other way dramatic expression in Descartes, and foundational if your standard is some- of salvaging the notion of ‘truth’ for its flowering in reactions to 17 th ration- thing like: either verifiable, no-holds- application to whole theories, but this alism and the Enlightenment? But then barred objective truth, or hopeless one will not do. There is, I think, no who are the foundationalists and who relativism in which all perspectives theory-independent way to recon- are the anti-foundationalists? The au- enjoy equal status. Nietzsche may be struct phrases like ‘really there’; the thors name the easy candidates: Des- the one philosopher who mischie- notion of a match between the ontol- cartes and the logical positivists repre- vously argued for unassailability of ogy of a theory and its ‘real’ counter- senting the rationalist and empiricists perspectives, but he is not representa- part in nature now seems to me illu- wings of foundationalism; post-modern tive of the Gadamerian hermeneutic sive in principle. Besides, as a histo- figures like Foucault and Derrida repre- tradition, in which knowledge ad- rian, I am impressed with the implau- senting anti-foundationalism. What vances through dialogue and the con- sibility of the view. I do not doubt, about Kant? Is he a foundationalist or frontation of perspectives. for example, that Newton’s mechan- anti-foundationalist? The apriori cate- Invoking Gadamer and herme- ics improves on Aristotle’s and that gories are foundational, but the thing- neutics of course brings me to Tho- Einstein’s improves on Newton’s as in-itself is an unknowable reality. How mas Kuhn, who wrote that “…the instruments for puzzle-solving. But I about Hegel? In the phenomenological discovery of hermeneutics did more can see in their succession no coher- tradition, Husserl’s goal was certainly than make history seem consequen- ent direction of ontological develop- foundational, but Merleau-Ponty stands tial. Its immediate and decisive effect ment. On the contrary, in some im- out for rejecting that position, insisting was instead on my view of sci- portant respects, though by no means that our contact with the world involves ence” (1977, p. xiii). The authors in all, Einstein’s general theory of a realist (?foundational) and an idealist place Kuhn in the anti-foundational relativity is closer to Aristotle’s than (?anti-foundational) dimension, and camp, keeping company with either of them is to Newton’s. that either fails on its own. His philoso- Nietzsche, Foucault, and Derrida. Though the temptation to describe phy is developed around the core in- Let’s allow Kuhn to address that as- that position as relativistic is under- sight that consciousness and world signation: standable, the description seems to form an indissoluble unity. As he One consequence of the posi- be wrong. Conversely, if the position writes: “The world is inseparable from tion just outlined has particularly be relativism, I cannot see that the 26 Volume 18, Number 2 2011

relativist loses anything needed to but rather in that of the hybrid of and trying to defend psychiatry from account for the nature and develop- Kuhn and others. This is manifest in both kinds of attack. My only response ment of the sciences. (Kuhn 1970, the current DSM-5 debates. If you to such a retort would be that I have pp. 205-207). want a model of the modernist/ tried to take the discussion in a differ- I think it’s fair to say that Kuhn positivist position, you have it in the ent direction, with an argument that the jumbles the authors’ categories. He’s Robins/Guze criteria for diagnostic foundationalist/anti-foundationalist anti-foundationalist, but not relativist. validity and their instantiation in division is unsatisfactory, and that a He believes in scientific progress, and DSM-III and DSM-IV. Now we of defense of psychiatry will stand on in the notion that one scientific theory course know that DSM-III/IV diagno- firmer ground if based on what I have is better than another, but not in the ses have failed the validity tests, and been calling a hybrid model than on a notion that science reaches some kind with that failure we have witnessed foundationalist or positivist model. of final, uninterpreted, unmediated the collapse of the dream of neat truth. Or I could say that he’s founda- positivist diagnostic boxes: disorders References tionalist, but not in the sense of reach- with clean genetic and physiological ing an unvarnished, bedrock reality foundations. We are moving in fact to Gadamer, H.-G. (1975 [1960]). through science. something very different: diagnostic Truth and Method . New York, Contin- categories that will probably require uum Press. Psychiatric Reality understanding in the language of Kuhn, T. (1970). The Structure of complexity theory. To take the king Scientific Revolutions . 2nd Edition. Let me now break off from invok- of diagnoses, schizophrenia, how will Chicago, University of Chicago Press. ing this gallery of foundationalist/anti- we understand it? Will it be one cate- Kuhn, T. (1977). The Essential foundationalist hybrids (I have, after gory or 50 categories related in a va- Tension: Selected Studies in Scientific all, spared you Heidegger and Wittgen- riety of ways? Will it merge on a Tradition and Critique . Chicago, Uni- stein), and get to the matter of psychia- spectrum with bipolar disorder, and versity of Chicago Press. try. The authors divide the strong crit- in what ways? Most importantly, will Merleau-Ponty, M. (1962 [1945]). ics of psychiatry (strong enough to be we understand it in different ways for Phenomenology of Perception . London, labeled anti-psychiatrists) into founda- different purposes? If our goal is ho- Routledge & Kegan Paul. tionalist and anti-foundationalist camps mogeneous genetic or physiological (or logical positivist and post-modern grouping, we may aggregate the vari- *** camps). This division leads to an im- ous phenotypic expressions in one plicit conclusion that defending the way; if on the other hand, our interest Psychiatric Reform: Mining reality of psychiatric disorders involves is response to treatment, that might Critique for Philosophical some kind of modernist and logical require a different aggregation. There Resources positivist stance. Just as I am uncom- is simply no reason to expect that in fortable with the foundationalist/anti- the vast population we now label Douglas Porter M.D. foundationalist division, so I am un- schizophrenia, the aggregations dic- comfortable with the implicit conclu- tated by different purposes will map The authors of “Getting It from sion that defending psychiatry requires onto one another. If this is the case Both Sides: Foundational and Anti- Enlightment modernism plus logical we will be left with the question: Foundational Critiques of Psychiatry” positivism. (I may be misrepresenting what do we call schizophrenia, and do the philosophy of psychiatry a ser- this as the implicit position of the au- for what reason, and can we even vice with their article. They wisely thors, but then I’m not sure what their define a superordinate category that caution against the “if you are not with position is.) justifies retention of the diagnostic us, you are against us” attitude that I wish to draw a different conclu- category? What we now call schizo- equates critique of psychiatry with be- sion from that which I am attributing to phrenia spectrum disorders is simple ing “anti-psychiatry”. Such an attitude the authors, and I begin with the last flag-waving for what we don’t know. prevents appreciation of beneficial sentence in the citation by Kuhn: I add forcefully that this line of think- teaching moments in critique that have “Conversely, if the position be relativ- ing is not remotely to be confused the potential to stimulate progressive ism, I cannot see that the relativist loses with anti-psychiatry. It is simply a psychiatric reform. Indeed, it is con- anything needed to account for the na- recognition of the complexity of the cern for the content and meaning of ture and development of the sciences.” very real psychopathology we deal critical arguments that leads the authors In other words, is anything lost in de- with. to carefully unpack and differentiate fending psychiatry with the hybrid phi- I am aware that in their response the philosophical assumptions that losophical position represented by to this commentary the authors might guide Foucault and Szasz, while less Kuhn and others mentioned above. I retort that I am imputing to them a careful analysis would lump them to- would in fact take this a step further point of view that they don’t lay gether as just so many equivalent in- and argue that the movement of con- claim to, that all they are doing is stantiations of anti-psychiatry. temporary psychiatry is not in the di- dividing anti-psychiatry into logical The authors note that while Szasz rection of modernist/positivist position positivist and post-modern positions, contributes to psychiatry by pointing 27 Volume 18, Number 2 2011

toward the very real potential for abuse against the reification of our prag- by psychiatry is properly regarded as of power in the practice of psychiatry, matic diagnostic constructs, in which therapeutic as opposed to pathological. he ultimately undermines the signifi- case postmodernism has become a Alas, in terms of providing philosophi- cance of his critique by stubbornly kind of common sense amongst cur- cal resources to guide the development clinging to a positivist philosophical rent practitioners of the philosophy of of a more therapeutic and less patho- orientation. This philosophical orienta- psychiatry (and hopefully amongst logical psychiatric discourse, the cri- tion ignores the implicit value judg- current practitioners of psychiatry). tiques provided by Szasz and Foucault ments associated with biological medi- But, less generously, the portrayal of appear very limited. cine and, as the authors point out, per- alternative discursive formations as petuates the myth that adding values just so many equivalent instantiations References entails subtracting facts. Foucault, on of knowledge/power can be seen as the other hand, could certainly not be an invitation to the type of moral (1) Foucault, M (1973) The Birth accused of adopting a positivist phi- skepticism and relativism that ulti- of the Clinic: An Archaeology of Medi- losophical orientation. Within Fou- mately undermines progressive re- cal Perception. New York: Vintage cault’s “archeology” of knowledge, form. I think Foucault can be inter- Books. traditional biologically oriented medi- preted as joining ranks with Szasz in (2) Foucault, M (1972) The Arche- cine becomes just another discursive implying that evidence that psychiat- ology of Knowledge. New York: Pan- formation of knowledge/power that ric discourse is value-laden is tanta- theon Books; p. 185. does not differ substantially in form mount to evidence of its illegitimacy. (3) Foucault, M (1965) Madness from that of psychiatry (1). In fact, this The complex interplay of facts and and Civilization: A History of Insanity kind of “anti-foundational” leveling of values that eventually become en- in the Age of Reason . New York: Vin- the discursive playing field can be seen twined in psychiatric discourse can be tage Books. as undermining the kind of normative resolved for the better or for the (4) Caputo, J. (1993) “On Not foundation that is required for progres- worse. Not only can psychiatric dis- Knowing Who We Are: Madness, Her- sive form. The questions Foucault self- course be more or less factual, it can meneutics, and the Night of Truth in consciously asks of science are not, be more or less ethical. The power Foucault.” Foucault and the Critique “the possible use or misuse to which it evinced by psychiatric discourse may of Institutions. Eds. John Caputo and can be put”, but instead merely, “the be more or less in the service of those Mark Yount. University Park, Pennsyl- question of its functioning as a discur- who are living with mental illness. vania: The Pennsylvania State Univer- sive practice and of its functioning This does not appear to concern sity Press; p.249. among other practices” (2). Szasz or Foucault. Nonetheless, Foucault’s concern A responsible medical response *** about the repressive aspects of societal to the suffering created by illness exclusion of the mentally ill is evident entails maintaining a normative in his book “Madness and Civiliza- stance; there is simply no room for a tion” (3). Foucault’s concerns in this stance of moral skepticism. It is per- regard and the more general postmod- haps, then, not so ironic that when Why Taxonomise ern celebration of difference can be Foucault does take a normative stance Anti-psychiatry? seen as a progressive philosophical about the misuse of power he em- influence in certain civil rights move- ploys medical metaphors. He makes Tim Thornton, Ph.D. ments. These movements underscore reference to “pathological forms” of the fact that much of the suffering asso- power and even “diseases of Of all disciplines, psychiatry is ciated with mental and other forms of power” (4). Taking a normative particularly keenly aware of the impor- chronic illness does not result directly stance about pathological forms of tance of a good taxonomy. Whilst in from the illnesses but rather from soci- power is laudable, but it appears awk- some scientific disciplines the explicit ety’s response to, and failure to accom- ward within Foucault’s philosophical focus is on explanatory theories and modate, differences associated with the system which limits itself to unpack- there is only implicit attention to the illnesses. But, in terms of the suffering ing the historical formation of scien- taxonomies they presuppose, in psy- inherent in illness and the fact that the tific objects of discourse while ab- chiatry, getting the taxonomy right is discourses of medicine and psychiatry staining from judgments about their one of the key foci of intellectual en- may be more or less in tune with the proper use or misuse. The authors of deavour. This attention has helped re- call to action that is created by that “Getting It from Both Sides: Founda- veal different virtues of taxonomies. suffering, it seems to me that Fou- tional and Anti-Foundational Cri- Thus until recently, the key virtue cault’s archeological method can most tiques of Psychiatry” recognize that a aimed at for the DSM taxonomy has generously be regarded as simply re- complex interplay of factual and been reliability: roughly, the non- maining mute. Perhaps the call to re- evaluative elements evolves in psy- collusive agreement in applications of sist the trap of objectifications created chiatric discourse. This recognition, the taxonomy in classificatory judge- by discursive formations in psychiatry dealt with responsibly, entails an ef- ments. can be seen merely as a cautionary note fort to insure that the power evinced For DSM-5, the key aim is, we are

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told, validity. But even validity can be barreled” assault on modern-day What is foundationalism? subdivided. It might mean, for exam- psychiatry… The paper suggests that founda- ple, any of these or others: A key theme is that psychiatry is tionalism has two key aspects. One is a criticised from both sides of a distinc- • traditional epistemological notion. Face validity : the extent to tion. This sets up a particular kind of Knowledge is based on a foundation which a classification appears to be of expectation about the significance of (of experience, or belief) which is not relevant features (which has conse- the duality that forms the taxonomy itself (inferentially) dependent on any- quences for the acceptability of tests to which I will illustrate indirectly. thing else. test users and subjects [Rust and One way to fail to meet the ex- Logical positivism in its various Golombok 1989: 78]). pectation would be to propose a tax- forms is a modern-day expression of • onomy of forms of anti-psychiatry Construct validity : roughly, the foundational world-view... [It] based on the position in the alphabet the extent to which it relates to underly- essentially held that all knowledge is of the first letter of the first author of ing theory. Kendell articulates this based on logical inference grounded in the attack. If this were a simple dual- thus: ‘the demonstration that aspects of observable fact… ity – of first half versus second half – psychopathology which can be meas- Foundationalism, in this traditional then (given the names ‘Foucault’ and ured objectively… do in fact occur in epistemological sense, is usually held ‘Szasz’, eg.), psychiatry would come the presence of diagnoses which as- to contrast with forms of holism which under fire from both sides, a ‘double- sume their presence and not in the pres- deny that any of our beliefs, such as barreled’ assault on modern-day psy- ence of those which assume their ab- perceptual beliefs, are privileged and chiatry if you like. In that hypotheti- sence’ [Kendell 1975: 40]. Anastasi instead each is potentially subject to cal case, there would, however, be no says it is ‘the extent to which the test revision. A belief in the theory depend- significance (such as, perhaps, a bitter may be said to measure a theoretical ence of observation is one reason to irony) that psychiatry were attacked construct or trait’ [Anastasi 1968: 114]. support holism in the philosophy of from both sides. Although the distinc- • science. Predictive validity : the extent tion is in one sense perfectly valid, The other aspect is expressed in to which the classification allows us to and cuts anti-psychiatry at the joints this way: predict future properties. of author nomenclature, it fails some- In simplest terms, foundational thing like construct validity. It fits no • Content validity : ‘the demon- philosophies and philosophers hold deeper theory of anti-psychiatry. stration that the defining characteristics that we can reliably describe a coher- So one test of the proposed tax- of a given disorder are indeed enquired ent, objectively-measurable “reality” or onomy is that it does have signifi- into and elicited before that diagnosis is “truth,” whether one considers the cance. The ideas of foundationalism made’ [Kendell 1975: 40]. world as a whole, or specific aspects of and anti-foundationalism should shed it, such as the classification of disease. So it is appropriate in thinking light on the nature of the anti- Anti-foundational philosophies and about a proposed taxonomy of forms of psychiatry in a way that mere sur- philosophers deny this claim, asserting criticism of psychiatry – forms of anti- names do not (because of the that there are no objectively demon- psychiatry – to examine the intellectual ‘arbitrariness of the signifier’ as Post- strable “truths”—only various virtue of the proposal in something of modernism, in particular, has taught “perspectives” or “narratives” that the same spirit as critical reflection of us to say). cannot be privileged as uniquely or psychiatric taxonomy itself. In this But there is a worry from a po- objectively “true.” case, my concern is not so much tential response to this. Suppose that (It may not be quite realism in a whether anti-psychiatry can be divided from anti-foundationalist premises, a standard form, however, since the most into forms which are foundational and form of anti-psychiatry were justified, obvious opposition to ontological real- forms which are anti-foundational if followed logically. And from foun- ism is idealism, whilst the authors take (although I do have worries about quite dationalist premises, another form of Berkeley to be a foundationalist: how this is proposed). It is rather anti-psychiatry were similarly justi- ‘Berkeley effectively dispensed with whether we learn anything from doing fied. Then on the assumption that the concept of material substance, but that. I am not sure that we do. either foundationalism or anti- most certainly was a foundational phi- foundationalism is true, some form of An initial requirement for the losopher: he merely argued that the anti-psychiatry would be justified taxonomy “foundation” of reality consisted of come what may. So, as far as a de- ideas in the mind of God!’ But even in I can illustrate one challenge to a fence of psychiatry goes, we had bet- this case, the idea may be that whatever taxonomy of this sort by looking at the ter hope that the relation of signifi- the substrate of the world, it is inde- business the paper sets itself. Called cance (between the category and anti- pendent of claims made about it. That ‘Getting it from both sides’ it says: psychiatry) is not implied. serves as a test of truth and thus stands The burden of this paper will be to Whatever the kind of signifi- in contrast with the anti- outline the historical roots of founda- cance turns out to be, at the very foundationalists’ mere interplay of nar- tional and anti-foundational philoso- least, some kind of light should be rative.) phies; describe how these philosophies shed on anti-psychiatry by seeing it in There is some danger in combining have provided the basis for a “double- the context of the taxonomy. 29 Volume 18, Number 2 2011

both these aspects – epistemological Quine is at pains to challenge; (2) It claims of “materialist” science. Yet any and ontological – under a single term appears to remove from the realm of putative “materialist-scientific defini- which can be illustrated by a philoso- scientific investigation the question of tion of illness”—to the extent we can pher mentioned in the paper: Quine. In whether schizophrenia or bipolar even specify one—did not arise ex ni- his famous paper ‘Two dogmas of em- disorder, for example, are diseases or hilo or out of some syllogism; but piricism’ Quine explicilty rejects the illnesses; (3) It conflates the terms rather, from specific empirical observa- idea of foundations when he rejects “disease”,“illness”, and “disorder” tions of cells, tissues and organs, by the’ dogma of reductionism’ which is without any attempt to discern con- pathologists like Virchow and von the ‘supposition that each statement, ceptual or clinical distinctions among Rokitansky. Thus, Szasz’s argument taken in isolation from its fellows, can them; and (4) It implies that there is a that “mental illness is a metaphor” admit of confirmation or infirmation at single, univocal “materialist- seems to us far from a straightforward all’. [Quine 1953: 41] But he continues scientific definition of illness” to “analytic” claim; rather, it appears to ‘My counter suggestion… is that our which one can appeal, and which be a pseudo -analytic claim that de- statements about the external world then can be used unambiguously to pends critically on a huge body of his- face the tribunal of sense experience compose an “analytic truth.” Also torical, synthetic and empirical claims. not individually but only as a corporate note that the hyphenated term One way of approaching this argu- body.’ So whilst he rejects privileged “materialist-scientific” implicitly ment is to think that it helps demon- epistemological foundations he does suggests that science and strate the value of the taxonomy. If not reject the idea that our beliefs an- “materialism”—roughly, the view Szasz is a typical foundationalist and if swer to something independent of us. that the only thing that exists is typical foundationalists presuppose the This is significant because that “matter”—are linked in some essen- analytic-synthetic distinction, but if that combination of ideas is the dominant tial way. is an invalid distinction (as Quine has view held by philosophers and self- In the context of a paper suggest- argued), then Szasz’ argument will fail conscious scientists alike. Epistemo- ing a categorisation of anti- and it will fail because he is a founda- logical foundationalism is dead. No psychiatry, I would expect that this tionalist. That would be a partial vindi- observation is thought to be free of its list would demonstrate how Szasz fits cation for the taxonomy. Putting him theoretical context and thus, like any his assigned place: foundationalism. into that camp helps shed light on why scientific statement, is fallible. But And indeed, pace my worries about he is wrong. rejecting that view does not commit Quine, the first point does. Szasz is But it is not clear that that is what one to a denial that our beliefs answer within a tradition of philosophy the authors intend here. The comment to a world largely independent of us, which accepts analytic truths and that Szasz’ claim is ‘far from a straight- nor to the embrace of mere shifting Quine, at least, has argued that this is forward “analytic” claim; rather, it ap- narratives. an important part of foundationlism. pears to be a pseudo-analytic’ suggests Given that the taxonomy is of- Point 2 does not obviously exemplify that an analytic claim might be in per- fered, not for philosophy as a whole, the category but, perhaps, neither fectly good order. The problem is not but rather for anti-psychiatry, it might does it contradict it. Point 3 seems to so much that Szasz is appealing to the be that no anti-psychiatrist fails to com- lie simply outside the terms of the notion an analytic truth, rather, he is bine the appropriate epistemological taxonomy. One might be guilty of doing that badly. If so, the problem and ontological views. But if the taxon- this which ever side one belonged to. with Szasz’ anti-psychiatry is not that it omy is to shed light on anti-psychiatry, Likewise, point 4 does not seem to be is foundationalist but that it is bad such correlations should be explicit and an effect of or have anything to do foundationalism. But if that is the case, subject to explanation rather than hid- with foundationlism. the taxonomy of anti-psychiatry into den in the taxonomy. That is a bit odd. Only the first foundationalism and anti- point helps locate Szasz on the foun- foundationism does not seem to be The application of the taxonomy dationalist side of the taxonomy. carving the nature of anti-psychiatry at Having set up the taxonomy, the There is then an argument the right – significant, informative – authors apply it to particular critics of against Szasz. In a paper outlining a joint. psychiatry. I will discuss just the first: taxonomy, such an argument is not It is also worth noting that if that is Szasz. Responding to a recent summary the main business. But it may illus- not the meaning of that phrase and that by Szasz of his original argument they trate what we learn from applying the any appeal to analyticity is misguided say: taxonomy and thus why the taxon- (thus preserving the point of the taxon- A full-blown critique of this argu- omy is helpful. The central argument omy for the foundationalist side), the ment is beyond the scope of this paper. runs: key architect of the downfall of analy- However, it is instructive to note some Szasz’s argument purports to rest ticity is Quine whom the authors call an of the key “properties” of Szasz’s upon an analytic statement—similar anti-foundationlist. So why would not claim: (1) It is based on an implicit in kind to “All bachelors are unmar- the failure of foundationalist anti- assertion that “analytic truths” are not ried males”—while implicitly draw- psychiatry be a partial argument, at empirically falsifiable—a claim that ing upon the historical and empirical least, for the success of an anti-

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foundationalist variant? In fact in the chiatry. For Bill Fulford (and the au- that the very idea of mental illness is a later parts of the paper, anti- thors of the paper), for example, it is normative notion – since values are foundationalist anti-psychiatry is criti- not. normative and have a good versus bad cised on grounds which do not even A second useful characterisation dimension – and for that reason cannot mention analyticity. Thus no light is links the debate about mental illness be reduced to plainly factual or realm shed on criticisms of anti- to other debates in philosophy about of law terms. foundationalists in virtue of their analy- the place in nature of problematic Using distinctions such as these ticity-eschewing position in the taxon- concepts. On this second construal, provides tools for the diagnosis of as- omy. In either case, at least one side of the question is whether mental illness sumptions made both by those who the taxonomy will not be informative. can be naturalised . That is, can men- oppose and those who support modern tal illness be accommodated within a psychiatry. In the paper, the authors A different taxonomy? satisfactory conception of the natural criticise one ‘foundationalist’ anti-

I think that it is a mistake to hope realm? psychiatrist in this way: Stevens’ foundational critique is that a binary opposition which locates The most common form of phi- built upon a scaffolding of selective forms of anti-psychiatry on both sides losophical naturalism is reductionism quotes from a large cadre of mental will, in itself, be very helpful. How which attempts to show the place in health professionals... all in the service could it? If a binary distinction ex- our conception of nature of puzzling concepts by explaining them in terms of showing that we cannot identify any hausts logical possibilities – if every- of, and so reducing them to, basic biological abnormalities in any of the thing is either in the one or the other concepts that are unproblematically major psychiatric disorders; and that, category – then all the positions we can take will be in one or the other. All natural. So on this second characteri- absent such physical “causes,” these forms of philosophical view which sation of the debate, a pressing ques- conditions cannot be considered bona . support modern psychiatry will be lo- tion is whether, or to what extent, the fide diseases cated rubbing up against the views concept of mental illness can be re- Whilst I agree with the criticism which oppose them. The taxonomy will duced to plainly factual concepts. If it they go on to make, I do not think that not shed light on the difference be- cannot be naturalised, to what extent it helps to characterise Stevens as a tween the pro- and anti- view. is it consistent with a scientific ac- foundationalist. The quotation does not I think that a more fruitful ap- count of the world.? imply anything about his epistemologi- What makes reductionism diffi- cal views nor would ontological real- proach is a taxonomy of approaches to cult is that different concepts can ism about an objective world help shed the nature of mental illness itself. Here seem to behave quite differently from light on his particular brand of anti- are two, related distinctions. One key disagreement is whether one another. Take, for example, a psychiatry. mental illness in particular, or illness distinction drawn from the work of What is picked out in the quotation more generally, is essentially evalua- the philosopher Wilfrid Sellars, and is an assumption that he has made tive. Does the analysis of mental illness repopularised by John McDowell about what counts as real: biological contain reference to values or not? [McDowell 1994] between the ‘realm abnormalities. And thus he counts as Some philosophers and psychiatrists of law’ and the ‘space of reasons’. both ‘values out’ and reductionist in the argue that at the heart of the idea of Whilst the space of reasons concerns two distinctions above. This is not yet illness is something that is either bad meaning-laden and normative phe- to provide an argument against his po- for a sufferer or is a deviation from a nomena that we take for granted in sition. But it does help outline the com- understanding minds, the realm of mitments he needs to maintain. He social or moral norm. Both of these are law concerns events that can be ex- owes an account of why biological ab- evaluative notions and hence both are ‘values in’ views. plained by subsuming them under normalities are all that can count as real Others argue that it is, what I will natural scientific laws. In the philoso- in this context. A biologically minded call, a plainly factual matter. Typically, phy of mind, reductionists attempt to reductionist supporter of modern psy- they argue that illness involves a failure show how the space of reasons can be chiatry will agree with Stevens on that of a biological function and function – completely explained using the re- metaphysical claim and will have to and hence deviation from, or failure of, sources of the realm of law. Anti- look elsewhere to disagree. But an anti- function – is a plainly factual, biologi- reductionists argue that the normativ- reductionist supporter of psychiatry can cal term couched in evolutionary the- ity of mental states and meanings – target that assumption. The assumption ory. Of course, disagreement about the the fact that beliefs can rationalise – and hence his reductionism – sheds and support one another, can be right light on his position. presence or absence of values in the or wrong – cannot be captured in In sum, I think it a mistake to aim analysis is just one aspect of the debate. terms, for example, of statistical laws a taxonomy at anti-psychiatry rather It is a further question, for example, what follows from this for the objectiv- of association. than at views of mental health and ill- ity of mental illness and the status of In fact, value theorists in the de- ness (or disease or disorder) in general. psychiatry as a science. For Szasz this bate about mental illness are making It will probably, at least, not be particu- is the basis of an argument against psy- a similar point to anti-reductionists in larly helpful. If the aim is, additionally, the philosophy of mind. They argue

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to attempt to undermine anti- Replies to Comments on there are many non-human contexts in psychiatry, then it seems doubly mis- which the term “disease” is used, and taken because it cannot work. If – and “Getting it from in which the term has coherent mean- this is a key assumption – we were to Both Sides” ing and utility. We were speaking in assume, from the perspective of a de- the context of human disease states, fender of contemporary psychiatry, that and following the general argument of anti-psychiatry were simply misguided Ronald Pies, SairahThommi, psychiatrist RE Kendell; i.e., “Neither then a helpful analogy might be with and Nassir Ghaemi minds nor bodies suffer from diseases. Tolstoy’s views of unhappy families in Only people (or, in a wider context,

Anna Karenina. There is little point in organisms) do so…” [see RE Kendell aiming to taxonomise arguments “…however much you deny the in Szasz Under Fire , op cit, p. 41]. against psychiatry because whilst valid truth, the truth goes on existing, as it Thus, contra Szasz and consistent with views in support of psychiatry are all were, behind your back…”-- George Kendell, we would deny that—in ordi- alike; every unhappy anti-psychiatric Orwell, from Looking Back on the nary language-- human cadavers can be argument is unhappy in its own way. Spanish War in a state of illness or “disease” (as in, But to evaluate that key antecedent “That cadaver has a very serious dis- assumption, we will need valid general We very much appreciate the ease!”), though a cadaver may indeed taxonomies of views of health and ill- thoughtful comments of our review- demonstrate organ, tissue or cellular ness and nature in general. ers. While we can’t respond to all the pathology . [See footnote on Vir- chow**] On linguistic grounds, just as References issues they raise, we hope the follow- a heart or brain cannot have “ease”, Anastasi, A. (1968) Psychological ing comments are at least a provi- neither organ--on our view and that of testing, New York: Macmillan sional response to some of the more Kendell--ought to be characterized as Kendell, R.E. (1975) The Role of salient points of contention. having “dis-ease.” We acknowledge, Diagnosis in Psychiatry, Oxford: however, that pathologists do some- Blackwell Reply to Jeffrey Bedrick, M.A., times speak of a “badly diseased heart” McDowell, J. (1994) Mind and M.D. and of “diseased brains” and that our World, Cambridge, Mass.: Harvard argument is itself subject to a counter- University Press Our thanks to Dr. Bedrick for argument from “ordinary language”— Quine, W.V.O. (1953) ‘Two Dog- raising some important and interest- at least, as ordinarily spoken by pa- mas of Empiricism’ in From a Logical ing questions regarding our paper. thologists! Nonetheless, we stand by Point of View, Cambridge, Mass.: Har- Dr. Bedrick writes, “I think even our position that the term “disease” is vard University Press before the recent paper [on ALS], any most useful in ordinary discourse—and Rust, J. and Golombok, S. (1989) neurologist would have been ex- in clinical psychiatry--when applied to Modern Psychometrics, London: tremely uncomfortable if we had said (human) persons. Routledge to them that the underlying patho- Dr Bedrick writes, “I think psy- physiology of ALS could never be chiatry can be defended against its crit- *** discovered, or even further, that there was no underlying biological patho- ics. Doing so, however, I think entails physiology to be discovered. Do we acknowledging some differences be- feel the same way about schizophre- tween psychiatry and other branches of nia? About posttraumatic stress dis- medicine. That there are such differ- order? Borderline personality disor- ences is not a weakness for psychiatry. der?” It is rather a strength of psychiatry as a But we would not make such an branch of medicine that does deal with argument. We would argue only that persons, both in their physical and we need not possess at this time such mental aspects. There is much in the pathophysiological knowledge in paper to commend it, but I think it order to defend the claim that schizo- weakens its own arguments by the re- phrenia or PTSD are instantiations of fusal to consider the differences be- “disease”. tween psychiatry and other branches of Dr. Bedrick writes, “The authors medicine, and not just their similari- go on to say that “’disease’ is prop- ties.” We do not disagree with Dr. erly predicated of persons Bedrick that there are certain technical, (‘people’)—not of minds, brains, methodological, and evidentiary differ- bodies, tissues or organs.” I would ences between psychiatry and other imagine that those who study the dis- branches of medicine, but we believe eases of plants might find this a these differences have been greatly strange claim.” Of course, we realize exaggerated by psychiatry’s critics;

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moreover, such differences as do dif- under the rubric of “anti-psychiatry”. other sciences of things must accord ferentiate psychiatry from other medi- And, if by “ontological skepticism”, the science of persons the right to be cal specialties mask many fundamental we mean that all three would likely unbiased in a way that is true to its own elements in common. To be sure, psy- answer “no” to the question, “Is there field of study." (italics ours; cited in chiatry, in some sense, partakes of sci- such a “thing” as mental illness, in Selected Works of R.D. Laing , vol 1, p. ence and art, objective and subjective the same sense that there is such a 24). elements [See Pies R: Can psychiatry thing as sodium?”, then, indeed—Dr. Furthermore, Laing did not deny be both a medical science and a healing Cerullo is probably correct. But we that the term “schizophrenia” (or art? Psychiatric Times , Oct. 19, 2011]. still maintain that Szasz and Foucault “schizophrenic” as a noun) could be But in this regard, it does not differ begin with very different epistemo- applied legitimately to certain persons fundamentally from much of general or logical assumptions and beliefs; that whose behaviors did not make sense to internal medicine, which also deals is, beliefs about what can be “known” others, and which were idiosyncratic in with “persons, both in their physical or claimed as matters of scientific certain characteristic ways. Rather, he and mental aspects.” As Osler put it, fact. In our view, Szasz is very much challenged the idea that schizophrenia ““The practice of medicine is an art, the logical positivist when it comes to was best conceptualized as a disease not a trade; a calling, not a business; a logical and epistemological claims process , in the way, say, that cancer is calling in which your heart will be ex- about “disease”; Foucault is episte- a disease process. ercised equally with your head.” mologically skeptical, in the post- Thus, in The Divided Self, Laing modern tradition. describes a patient of Kraepelin, and Reply to Michael A. Cerullo, M.D. Laing is a more complex case, notes, "...there is no question that this perhaps, than either Szasz or Fou- patient is showing the 'signs" of cata- We thank Dr. Cerullo for his kind cault . On the one hand, Laing is of- tonic excitement. The construction we remarks on our paper. At the same ten thought of as both “post-modern” put on this behavior will, however, time, we acknowledge that Dr. Cerullo and “existential-phenomenological” depend on the relationship we establish is justified in pointing out our omission in his approach to psychiatry and with the patient...it seems clear that this of an in-depth discussion of RD Laing “mental illness.” Indeed, psychiatrist patient's behavior can be seen in at least (“While [Pies et al] focus on the writ- Tony Benning, in an essay entitled, two ways...one may see his behavior as ings of Michael Foucault and Thomas “Was R. D. Laing a Postmodern Psy- 'signs' of a 'disease'; one may see his Szasz, one other writer of the period chiatrist?” concludes that, yes, Laing behavior as expressive of his exis- also needs to be included; R.D. was in the post-modern tradition; for tence." Laing….these three writers laid the example, he noted Laing’s “… repu- Indeed, in the following passage intellectual foundation for the antipsy- diation of the privileged status of by Laing, it is difficult to discern what chiatry movement…”). Dr. Cerullo ‘objective’ over ‘subjective’ knowl- Dr. Cerullo calls a “denial of the objec- finds a common “core” to Szasz, Fou- edge including his challenge of the tive existence of mental illness.” Laing cault and Laing; i.e., “an extreme form claims of ‘neutrality’ of science, par- states, of ontological skepticism…[that denies ticularly… the role played by the "The schizophrenic is desperate, is the]…. objective existence of mental observer’s presence or intention and simply without hope. I have never illness. “ Before replying directly, we his emphasis on intersubjectiv- known a schizophrenic who could say will simply take note of Szasz’s scath- ity…” [accessed at: http:// he was loved...We have to recognize all ing critique of Laing, which suggests www.soteria.freeuk.com/ the time his distinctiveness and differ- (from Szasz’s perspective) anything but Laingpostmodern.htm]. entness, his separateness and loneliness a common philosophical position; see, On the other hand, one section of and despair." (p. 38). e.g., see: Szasz, T. (2008). Debunking Laing’s classic, The Divided Self”, is Laing’s use of the phrase “ a antipsychiatry: Laing, law, and largac- entitled, “ The existential- schizophrenic’’—analogous to “a dia- til. Existential Analysis, 19(2), 316- phenomenological foundations for a betic” or “an epileptic”—suggests that 343, accessed at: http:// science of persons.” Now, we be- for Laing, there is a “reality” of some findarticles.com/p/articles/mi_6881/ lieve the two key words in this phrase kind that underlies mental illness. But is_2_19/ai_n31874753/; and the riposte are “foundations” and “science”. for Laing, the reality is to be under- offered by Brent Robbins, PhD, ac- Laing, in our view, did not truly de- stood in phenomenological-existential cessed at: http://www.szasz.com/ fend the post-modern position that terms. In sum: Laing is “anti- critics.htm]. “there is no truth” or that (a la Fou- foundational” in some crucial respects, We would generally agree with Dr. cault) all claims of genuine knowl- as Benning suggests; but in other ways, Cerullo that the views of Szasz, Fou- edge are merely pretexts for the im- Laing remains within the Western para- cault and Laing all had the effect of position of control . Indeed, he writes digm of foundational science—albeit undermining any notion of the that within the “science of persons”. “objective existence of mental illness”, "A genuine science of personal and that—for this reason—the three are existence must attempt to be as unbi- often discussed (appropriately or not) ased as possible. Physics and the

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Reply to Bradley Lewis MD, PhD seriously” and “not to categorize our metaphor” does not stem from an anti- critics and dismiss them.” Indeed, foundational or post-modern view that We thank Dr. Lewis for expressing our goal was to analyze these critics there are no “truths”, that all narratives so clearly the primary rationale for our critically—recognizing that their are merely assertions of power, etc. paper; i.e., the assumption that it is “… views may contain both errors and Rather, we believe Szasz wants to as- worthwhile for psychiatry to under- insights. For example, though we similate the term “mental illness” into stand its critics and to bring that under- disagree with the post-modern, cul- the class of statements or expressions standing inside the knowledge base of tural reductionism represented in he views as metaphors ; e.g., “The na- psychiatry.” And, we fully agree with Foucault’s thought, we agree with the tion has a sick economy” or “Bigotry is Dr. Lewis that our profession needs “… need for attention to the cultural con- a plague that has spread across the psychiatrists who have thought through text of mental illnesses. Unfortu- country.” So Szasz wants to claim that in advance some of the key reasons nately, our current postmodernist the statement, “Joe has a mental ill- people are unhappy with psychiatry and spirit leads to too much imitation, and ness” is in the same class of state- why many believe psychiatry can be too little thoughtful criticism, of ments—and thus, has the same limited harmful.” That said, we would respect- thinkers like Foucault. We hope that ontological “standing”--as the state- fully dissent from Dr. Lewis’s view our paper may begin to change that ment, “The U.S. has a sick economy.” that our paper presents a “a sharp foun- trend, if only among our more phi- We, of course, do not accept this dationalist/antifoudationalist dichot- losophically-minded colleagues. Szaszian conflation of categories. In omy” that inadvertently “…slides into ordinary language, when someone problematic stereotyping.” Nor do we Reply to Elliott B. Martin, Jr., says, “Joe has a mental illness,” there is agree that our argument encourages M.D. no intention at all of speaking meta- psychiatrists to “…ignore the many phorically, nor is the locution ordinar- subtleties of the philosophers and the While we appreciate Dr. Mar- ily understood as a metaphor by most many complaints of the critic”, and to tin’s diligent philological scrutiny of people. The statement is usually in- “go back to business as usual in psy- our paper, we wonder if he really tended to mean, “Joe has a real illness chiatry.” intended to use the linguistic frag- that is affecting his ability to think or Alas, “business as usual” for many ment, Che sará , with its incorrect behave rationally.” To be sure, we find psychiatrists these days already ignores accent marking; or if that was simply the term “mental illness” problematic philosophical subtleties—both those an oversight? Perhaps Dr. Martin had on other grounds (e.g., it raises various that undergird the basis of psychiatric in mind the expression, che sarà, metaphysical problems concerning practice, and those marshaled by critics sarà , which is actually ungrammati- “mental” vs. physical conditions—a of psychiatry. It was precisely our in- cal in modern standard Italian; the topic well beyond the scope of our dis- tention to give such philosophical is- idea should be rendered " Quel che cussion). But we stand by our position sues a forum for debate and discussion. sarà sarà " or “ sarà quel che sarà . that Szasz’s views are squarely within Neither do we wish to create (to use a But then, to paraphrase Churchill, the logical positivist and “Virchovian” popular post-modern term) an alien grammatical corrections are some- tradition (though Szasz may have mis- “Other,” in the form of psychiatry’s thing up with which one should not understood Virchow’s views on what critics. On the contrary, as we state in put! And so, having had a little fun constitutes “disease”--see footnote on our paper –citing the work of psychia- with Dr. Martin, we now address Virchow**, and Pies, 1979, op cit). trist Laurence Kirmayer, “…not all some of the substantive points in his We confess some perplexity at our critiques aimed at demonstrating the remarks. ex-philologist colleague’s complaint role of cultural values in psychiatric Dr. Martin writes, “Szasz, by that we “fail to engage in any meaning- diagnosis are “anti-psychiatry”; nor do virtue of his defining mental illness in ful dialectic between the past and the they necessarily originate from sources terms of its negation, implies that now”; and that by creating “novelty anyone would reasonably consider since mental illness is not a patho- terms”, we vitiate “any meaningful “anti-psychiatry” in his or her views.” logical phenomenon, then it must be dialogue with the past.” We attempted Moreover, we point out that while ‘something else’. In good old- to place modern critiques of psychiatry “...we have categorized antipsychiatry fashioned postmodern terms, it must (Szasz, Foucault et al) in a historical critiques as broadly divided into be an ‘Other’….this plants Szasz context precisely in order to engage in “foundational” and “antifoundational,” firmly among the supposed ‘Anti- a “dialectic” between past and present it should not be surprising that “hybrid” Foundationalists’, not the philosophical thinking—hence, our arguments also abound.” We offered ‘Foundationalists’. This then reduces discussion, albeit brief, of philosophers our classification not with any implica- the ‘meta’-categories of anti- from Augustine to Ayer. Moreover, we tion that the foundational/anti- psychiatry proponents to one.” would not regard our use of the key foundational categories represent We would not agree that Szasz terms “foundational” and “essences” of any sort; but rather, that belongs among the anti- “foundationalism” as constituting they might serve as a “heuristic model” foundationalists, or that he believes “novelty terms” or neologisms. Specifi- that furthers understanding. “mental illness” must be “something cally, our definition of “foundational” We agree with Dr. Lewis’s admo- else” in any ontological sense. is compatible with (though not identical nition “…to take psychiatry’s critics Szasz’s claim that “mental illness is a to) the long-standing definition of 34 Volume 18, Number 2 2011

“foundationalism” provided by the Ox- it clarifies many of his later philoso- “absolute,” nor do they discuss the ford Dictionary of Philosophy (edited phical positions. problem of relativism. They do indeed by S. Blackburn, 1994); i.e., as “the believe that ‘facts’ are ‘objective,’ cer- view in epistemology that knowledge Reply to Prof. Marilyn Nissim- tainly in the sense that they are based must be regarded as a structure raised Sabat on empirical observation allegedly un- upon secure, certain foundations.” clouded by ideology.” Indeed, the philosopher Richard Rorty We appreciate the thoughtful We would like to aver that we do used the terms “foundationalism” and comments from Prof. Nissim-Sabbat, not believe that psychiatry or any other “anti-foundationalism” more than two and we agree that “relativism” is an medical discipline is likely to arrive at decades ago, in his book, Philosophy important issue in this discussion, any “absolute” truths. Neither do we and Social Hope (1999). Though he albeit not one we dealt with in any assert that “objective” and “empirical” defined these terms somewhat differ- detail. We also agree that “…the observations are necessarily always ently than we do, we believe our usage nature and existence of facts is itself a “unclouded by ideology”—or by the- is roughly compatible with that of very charged and profound philoso- ory. As one of us (SNG) has written, Rorty. phical question, one that engages “…facts cannot be separated from theo- Of course, the specific terms in our ontology and epistemology, as well ries…[and] no facts are observed with- paper may or may not turn out to be as ethics.” However, in attempting a out a preceding hypothesis…it is in this helpful. Like Max Weber’s ideal types, sort of anatomy of anti-psychiatry, sense that philosophers say that facts such constructs can bring out certain we did not feel we could do justice to are “theory laden”; between fact and insights, at the cost of obscuring others. the complex issues of “relativism”, theory no sharp line can be No concepts are absolute, and our ontology and epistemology to which drawn.” (Ghaemi, SN: A Clinician’s “foundational/anti-foundational” termi- Prof. Nissim-Sabbat refers. More- Guide to Statistics and Epidemiology in nology was intended only as a heuristic over, we do not believe that the onto- Mental Health, Cambridge, 2009, p. 1). model—and all models have their limi- logical and epistemological status of If, following Amartya Sen [Sen A: Ob- tations. “facts”—controversial, to be sure-- is jectivity and position. Lindley Lecture; Finally, we would offer an obser- fundamentally different in psychiatry Kansas, University of Kansas, 1992], vation on Dr. Martin’s musing as to than in neurology, pain medicine, or we define “objective” endeavors as whether “…any of the steadfastly anti- several other medical disciplines. entailing (1) repeated, careful observa- psychiatry crowd, Dr. Szasz included, When, for example, a patient with tions; and (2) achievement of good has ever been face-to-face with a flo- migraine headaches tells a neurolo- inter-rater agreement, we can still ac- ridly psychotic or manic individual, gist, “I see bright, jagged lines and knowledge that “objective” investiga- with an acutely suicidal or homicidal feel nauseated each time I get pain in tions may sometimes partake of individual, with a catatonic individual.” the left side of my head,” the onto- “ideology”. For example, , one can In the book, Szasz Under Fire , edited logical and epistemological status of make careful measurements of skull by Dr. Jeffrey A. Schaler, Szasz pre- these linguistic and behavioral “facts” size that are technically accurate and sents a brief autobiography. He com- is not fundamentally different than replicable by other observers, but do so ments that, although he “…had seen when a patient tells a psychiatrist, “I under the influence of an “ideology” involuntary patients begging to be set hear threatening voices each time the that asserts such measurements are free” in medical school, he specifically aliens bombard my brain with micro- closely related to intelligence or racial chose psychiatric residency at the Uni- waves.” Nor is the currently-accepted superiority. An objective measurement versity of Chicago because “…it of- diagnosis of migraine headaches-- certainly strives to be free from bias, fered no opportunity for contact with based almost entirely on symptomatic but we don’t claim that this is always involuntary patients.” (op cit, p. 19). reports from the patient-- the case, or that all objective measures He notes that the Chairman of the de- fundamentally different than the diag- are veridical, “true”, universally valid, partment, Dr. Henry Brosin, felt the nosis of schizophrenia, in the present etc. Our claim is simply that objective Chicago program was “gravely defi- DSM system. Similar claims could be data are those derived from careful and cient” in that the young Dr. Szasz made regarding the epistemological repeated observation, and replicable by would not have “…any experience with and ontological status of the “facts” other competent observers—and that treating seriously ill patients” (in doctors evaluate in various pain con- this description applies to many Brosin’s words; op cit, p. 21). Szasz ditions, such as atypical facial pain. (though not all) clinical observations in declined Brosin’s recommendation to Of course, other medical specialties, psychiatry. take his third residency year at Cook such as orthopedics or infectious dis- Prof Nissim-Sabat writes, “…The County Hospital, and notes, “I was not ease, do present somewhat different question arises then, if psychiatric val- about to tell [Brosin] that the persons ontological and epistemological is- ues are based on judgment, are they not he called “seriously ill patients” I re- sues, vis-à-vis psychiatry. relative to, for example, culture or his- garded as persons deprived of liberty Prof. Nissim-Sabat writes that, torical period? And, if they are relative, by psychiatrists.” (op cit, p. 21). We “…nowhere in their article do the what motivates psychiatrists who are strongly recommend reading Dr. authors indicate that they believe that scientists to prefer one judgment to Szasz’s autobiographical statement, as psychiatry should seek a truth that is another, as to what, for example,

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constitutes health?” putatively “objective” indicators, are widely shared across time and ge- The question of what “motivates” such as adaptive advantage or repro- ography, it would be an exaggeration to psychiatrists to prefer some judgments ductive vigor; e.g., a body mass index call them “universal” or “absolute”. to others is certainly important from a of <25 is “better” than a higher BMI, With respect to psychiatry, we believe psychological and historical perspec- because we can correlate higher values pertaining to “health” and tive, just as Thomas Kuhn felt that sci- BMIs with higher mortality rates, and “disease” are generally as well-founded entists’ motivation has a great deal to hence, reduced reproductive poten- as are analogous values (e.g., with re- do with how “paradigms” come to tial. But this by itself can never prove spect to “normal” weight, normal pain change in science. However, we be- that the value in question is more tolerance, etc.) in several other medical lieve that psychiatrists are, in principle, “valuable” than alternative or con- disciplines. no more (and no less) influenced in flicting values; e.g., one might say, their “values” than are many physicians “But I value culinary pleasure more Reply to James Phillips, M.D. in other specialties who treat other than longevity and reproductive ca- types of illness, such as obesity, pacity, and consider it a perfectly We appreciate Dr. Phillips’ bal- chronic pain syndromes, or sexual dys- reasonable trade-off to lose a few anced and judicious assessment of our function. All of these conditions par- years of life and eat whatever I want paper, and we agree with many of his take of often implicit cultural values to eat!” Here, in our view, we are comments. He asks, “…would it be fair and value judgments that may shift faced with something akin to Hume’s to argue that the foundationalism de- over time and across ethno-cultural admonition that we must avoid jump- bate is an affair of the modern era, with borders; e.g., the ideal or “normal” ing from an “is” to an “ought”. its origin perhaps in late medieval body weight or physique is greatly af- Prof Nissim-Sabat writes: “… nominalism, its first dramatic expres- fected by time period and cultural bi- the authors discuss health as the fun- sion in Descartes, and its flowering in ases. Similarly, what is considered damental value of psychiatry, but reactions to 17 th rationalism and the “sexual dysfunction” also varies widely they do not ask whether or not the Enlightenment? Dr. Phillips raises an across time and culture. Indeed, as concept of health as such…can be interesting question in the history of Jaspers put it (In Part 6, chapter 4, "The relative… and therefore be devoid of philosophy. We suspect that some ele- Concept of Health and Illness" (779- universality.” We believe that values ments of the foundational/ 790) ] the only feature common to any regarding health are often stable and antifoundational debate go back as far understanding of illness is the value enduring , as well as transcultural — as ancient Greece, and may be seen in judgment inherent in it. but this does not mean the values are the arguments between Platonic ideal- As one of us (SNG) has noted, either “absolute” or “universal.” We ists and Aristotelian empiricists, as well “[Jaspers’] perspective automatically believe that the concepts of as in the radical skepticism of Sextus negates the positivistic/Szaszian view “madness”, “insanity”, and Empiricus ((c. 160-210 AD). (Sextus, that physical illness is a fact, while “psychosis”, for example, are rela- for example, raised doubts about induc- mental "illnesses" are cultural values. tively stable and cross-culturally ac- tive reasoning long before David Just as in contemporary philosophy, the knowledged constructs that reflect Hume). We agree with Dr. Phillips that distinction between fact and value has widespread and enduring ideas about the foundational/antifoundational dis- been increasingly questioned, and in “health” and mental health. tinction also has affinities with medie- philosophy of science even destroyed, Indeed, to our knowledge, virtu- val debates between “realists” and so in any rigorous understanding of ally every culture ever investigated “nominalists”. And, of course, there medical illness, it would seem that shares some variant of terms like were those in medieval times, like Pi- value must be allowed a role.” [Ghaem “crazy”, “ loco” “mishugah ”, etc., erre Abelard, who took somewhat am- SN: On the Nature of Mental Disease: though the particular expression of bivalent or intermediate positions in the The Psychiatric Humanism of Karl these states vary somewhat from cul- controversy (see, e.g., Sharon Kay, Jaspers; Existenz Volume 3, No 2, Fall ture to culture. That these conditions Medieval Philosophy , 2008). 2008] or states are “pathologized” trans- Similarly, we agree with Jim Phil- Prof. Prof Nissim-Sabat, “Why are culturally reflects equally general and lips that in modern times, philosophers my or anyone else’s judgments regard- pervasive transcultural values regard- and philosophies do not divide neatly ing what is good and bad with respect ing mental health; i.e., those who are into “foundational” and to health more worthy than anyone “crazy”, “mad”, “loco”, etc. depart “antifoundational” camps—a claim we else’s judgments? from a state of good mental health in do not make in our paper. Rather, we Indeed, arguably, they are not very characteristic and stereotypical suggest only that the foundational/ more “worthy”; at least, there are no ways. For example, the person who is antifoundational dichotomy is a useful “experiments” or investigations within “mad” is typically unable to realize “first cut” when considering the types the framework of science itself that can his personal goals, seek and achieve of criticism that are usually leveled demonstrate such a claim regarding her prudential interests (Dr. Robert against psychiatry. Some phenome- “worthiness.” Of course, one can try to Daly’s term), maintain physical nologists, including Merleau-Ponty, link “value judgments” about health to health, etc. But whereas these values may indeed incorporate both founda-

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tional and antifoundational elements in ernist/positivist position. From sev- power evinced by psychiatry is prop- their epistemology, as Dr. Phillips sug- eral AAPP Bulletin discussions, it has erly regarded as therapeutic as opposed gests. Similarly, we agree that many become clear that the leadership of to pathological.” Our rebuttal of some philosophers escape any simple “either/ DSM-IV, at least, is clearly antifoun- critics of psychiatry certainly does not or” dichotomy that entails either a “no- dationalist-postmodernist, and be- obviate the need to protect the rights holds-barred objective truth, or hope- lieves that “pragmatism” is more im- and civil liberties—and of course, the less relativism in which all perspectives portant than data from scientific re- basic human dignity—of those we enjoy equal status.” We are not experts search--pragmatism being explicitly treat. on Hans Georg Gadamer, but we agree defined as whatever the leaders of that Gadamer’s hermeneutics and DSM-IV felt are in the best interest of Reply to Prof. Tim Thornton “merging of horizons” does not lend the profession and/or patients and/or itself to a foundationalist/ others. Such purely utilitarian ap- We very much appreciate Prof. antifoundationalist dichotomy. As the proaches to defining DSM-IV catego- Thornton’s thoughtful and detailed Stanford Encyclopedia of Philosophy ries--peremptorily rejecting any ob- critique of our paper. He raises many notes, for Gadamer, “…understanding jections as “naïve” realism--is akin to important philosophical issues, only is an ongoing process, rather than gerrymandering in political elections. some of which we will address here. something that is ever completed, so he There is no natural geography that Prof. Thornton writes, “I think that also rejects the idea that there is any explains the political map; similarly it is a mistake to hope that a binary final determinacy to understanding. It there are no biological “natural opposition which locates forms of anti- is on this basis that Gadamer argues kinds” that could possibly match the psychiatry on both sides will, in itself, against there being any method or tech- purposefully (and this is is the impor- be very helpful. How could it? If a bi- nique for achieving understanding or tant word) artificial definitions of nary distinction exhausts logical possi- arriving at truth.” This might be con- DSM-IV; in short, DSM IV was con- bilities – if everything is either in the strued as “anti-foundational” in our sciously designed so that it would one or the other category – then all the terms; however, it is not clear that have to fail any modernist/positivist positions we can take will be in one or Gadamer would endorse the post- test. DSM III and IV failed precisely the other.” modern view that “all perspectives en- because of the antifoundationalist But as we noted above in refer- joy equal status.” There is, as we think postmodernism that is behind them; ence to Dr. Phillips, we did not intend Dr. Phillips would agree, a difference these DSMs turned their back on and our foundational/anti-foundational di- between saying that there is no “final” betrayed the Enlightenment modern- chotomy to exhaust all logical possi- truth or understanding; and saying that ist view of science and knowledge. bilities –merely to explicate some of truth and understanding are themselves One can hardly use the failures of the more important possibilities. Other illusions , or that one proposition is “as such a postmodernist-relativist ap- typologies of “anti-psychiatry” cer- true as any other.” We are prepared to proach to psychiatric diagnosis -- tainly could have been discussed; e.g., accept a similarly complex view of about which failures we might all the Oxford Textbook of Philosophy and Thomas Kuhn, whose views continue agree - -as a rationale to deny the Psychiatry —of which Tim Thornton is to be source of considerable contro- modernist perspective. co-editor!--lists “five forms of antipsy- versy. Indeed, we would characterize chiatry”: the psychological model; the our own epistemology as neither logi- Reply to Douglas Porter M.D. labeling model; the hidden meaning cal positivism, nor post-modernism. models; the unconscious mind models; Rather, we endorse a version of We very much appreciate Dr. and the political control models (pp. “Enlightenment modernism” that sees Porter’s kind assessment of our pa- 16-17). (R.D. Laing is included within knowledge as attainable, but provi- per, and find ourselves in broad the “hidden meaning” models; i.e., “the sional; and “truth” as shaped by one’s agreement with nearly all of his apparently meaningless symptoms of frame of reference, but by no means points. We agree, for example, that someone with schizophrenia could be illusory or “hopelessly relative.” In our “Foucault can be interpreted as join- decoded, once their origins in the pa- view, the world has become so relativ- ing ranks with Szasz in implying that tient’s contradictory experiences of istic that we prefer old fashioned words evidence that psychiatric discourse is others were recognized.”). like “truth”, even if used in small let- value-laden is tantamount to evidence Prof. Thornton writes, “I think it a ters. Physicians, at least -- who kill of its illegitimacy.” Indeed, as we mistake to aim a taxonomy at anti- people as well as save lives--cannot have tried to show, the infusion of psychiatry rather than at views of men- avoid being responsible for the truth or values into one’s epistemology does tal health and illness (or disease or dis- falsity of their life-and-death decisions. not delegitimize one’s epistemic order) in general. It will probably, at One of us (SNG) also takes issue claims—it merely introduces a note least, not be particularly helpful.” We with Jim Phillips’s comments regarding of humility and perspective, and dis- agree with Tim Thornton that – in ad- the claim that “…DSM III/IV diagno- courages “reification” of one’s cate- dition to, not in place of, what we de- ses have failed the validity tests” and gories . At the same time, we share scribe – the effort to define and under- that this represents a failure of the mod- Dr. Porter’s concern that “…the stand the meaning of “health” and

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“illness” is of immense importance in scribed—though, of course, there are Yet it would be passing strange, in this discussion. But this expansive many individuals unhappy with psy- ordinary discourse, to say that a ca- topic simply goes beyond the intent and chiatry for highly personalized or daver is “ill” or “sick,” except perhaps purview of our paper. idiosyncratic reasons. Nor, once as a macabre joke! But if one would Prof. Thornton writes: “The com- again, do we claim that our founda- not seriously insist that a cadaver is ment that Szasz’ claim is ‘far from a tional/anti-foundational classification “ill”, how can a cadaver have “illness”, straightforward “analytic” claim; exhausts the universe of all com- as Szasz claims? Indeed, unlike rather, it appears to be a pseudo - plaints against, or critiques of, psy- Szasz,Virchow believed that disease analytic’ suggests that an analytic claim chiatry. In the end, we shall have to presupposes life ; thus, w ith the death of might be in perfectly good order. The see how our arguments “wear with the cell, the disease also terminates . problem is not so much that Szasz is time” and how useful those within This is a crucial point. For Virchow, appealing to the notion of an analytic and outside psychiatry find them. when the organism dies, the disease truth; rather, he is doing that badly. If terminates . Now, it is a rudimentary so, the problem with Szasz’ anti- **Endnote on Virchow and principle of pathology (as Szasz's view psychiatry is not that it is foundational- Szasz: makes clear) that lesions persist after ist but that it is bad foundationalism. The pathologist Rudolf Virchow, the death of the organism. But if le- But if that is the case, the taxonomy of of course, is best known for his sions persist and disease terminates, anti-psychiatry into foundationalism maxim, Es gibt keine allgemeine disease must be something over and and anti-foundationism does not seem Krankheiten, es gibt nur locale above the presence of lesions, even at to be carving the nature of anti- Krankheiten. “There is no general, the molecular level. Indeed, one of us psychiatry at the right – significant, only local, disease.” However, in (RP) would contend that in ordinary informative – joint.” 1854, Virchow commented that one discourse, disease usually entails an On the one hand, we agree that could localize " diseases ," but " not enduring and substantial state of suf- Szasz’s argument represents “bad foun- disease ." (See Disease, Life, and fering and incapacity in the living or- dationalism”, and that, in principle, one Man: Selected Essays by Rudolf Vir- ganism, and is recognized as such by might come up with a “good” founda- chow , ed. By LJ Rather, Stanford ordinary persons-- long before it is tionalist argument against psychiatry University Press, 1958, p. 16). classified as a particular type of disease (though we have not seen one). But it The distinction is between by pathologists or other medical would still be a foundationalist argu- Krankheiten [diseases] and die “experts.” [see Pies R, Archives of ment, which would probably fail for all Krankheit [disease in general]. Fur- General Psychiatry, Feb. 1979; and the reasons we adduce against founda- thermore, as L.J. Rather notes (in A Kendell in Szasz Under Fire , op cit.] tionalism in our paper. Furthermore, it Commentary on the Medical Writings seems to us that the category of founda- of Rudolf Virchow , p. 56), Virchow *** tionalism remains a useful “lens” "...rejects the claim that specific dis- through which we may examine both eases are necessarily associated with actual and potential arguments against specific anatomical lesions...and in (President, continued from page 1) psychiatry. addition, the claim that every disease Greta’s situation? Is Greta’s self- Prof. Thornton opines that at every stage of is development is assessment any more (or less) subjec- “There is little point in aiming to open to anatomical study: 'Every ana- tive than the input from her family, taxonomise arguments against psy- tomical change is a material one, but friends, or therapist? If I grant Greta’s chiatry, because whilst valid views is every material change anatomical evaluation of her own mental state, in support of psychiatry are all alike; as well? Can it not be molecular?’" substance use, or safety status primacy, every unhappy anti-psychiatric argu- Virchow hoped for the eventual am I appropriately weighting the most ment is unhappy in its own way.” We "localization of diseases ", but it is not important source of clinical informa- appreciate Prof. Thornton’s paraphrase clear that he believed disease per se tion; or is my judgment clouded by of Tolstoy (“Happy families are all was localizable. If this interpretation loyalty to my patient, and my desire for alike; every unhappy family is unhappy is correct, the “lesions” to which her to live independently as she in its own way”) but we are not con- Szasz typically appeals would consti- chooses? In psychiatry we seem to vinced that a taxonomy of anti- tute the basis of disease, but not nec- have the least and the most objective psychiatry is either pointless or fruit- essarily the sine qua non of disease. sources of information: from simple less. Here, an intriguing difference be- patient report to imaging and laboratory Perhaps Tim Thornton might at tween Szasz and Virchow emerges. studies. My problem is that none of the least grant that, in our role as psychia- Szasz argues that: "Every 'ordinary' information I have about Greta -- in- trists, we are exposed to a good many illness that persons have, cadavers cluding collateral from people who more of these anti-psychiatry argu- also have. A cadaver may thus be know her well and the advantage of a ments than is, say, the average philoso- said to “have” cancer, pneumonia, or longitudinal relationship with her – pher. In our experience, most of these myocardial infarction.'' (from Szasz help me to know her, what ails her, or arguments typically do fall into one of T, The Second Sin , Routledge, 1974, what she needs to maximize her health the two major categories we have de- p. 99). and safety. I can document extensively

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that I don’t know much, even with the reasonably consider ‘anti-psychiatry’ neutral fact and non-neutral value. most objective assessment a health care in his or her views.” Marilyn Nissim-Sabet questions this dollar can buy. Jeff Bedrick challenges the assumption in arguing that, whatever thorny assumption—received wisdom may be the value status of facts, they Claire Pouncey, M.D., Vice-President since DSM-III and endorsed by the are always theory-laden and thus not authors—that mental disorders are neutral. The authors agree and point out *** not different from other medical dis- that Nassir Ghaemi has in fact written orders. I am not sure the issue is set- of the theory-laden aspect of suppos- tled in this discussion, or anywhere edly objective facts. But they also try to (Editor, continued from page 1) else, but I welcome the discussion. nuance the discussion is arguing that way to analyze anti-psychiatry When the authors state in their argu- carefully observed data have some (Thornton), and whether it misses a ment that “‘disease’ is properly predi- claim on objectivity. more nuanced combination of these cated of persons (‘people’)—not of Finally we should note a bit of categories in much analysis and cri- minds, brains, bodies, tissues or or- levity in this appropriately sober sym- tique (Lewis, Phillips). The authors gans,” Bedrick questions, what about posium.. Our linguistically trained respond that their division is only one diseased plants, and the authors re- commentator, Elliott Martin, calls the possible way to map out the anti- tort, what about cadavers? I would authors out on their use of the verb psychiatry terrain, that they do not in- only add to this interesting exchange “entitle” when they mean “to title.” The tend it to be exclusive, definitive, or that I missed seeing Arthur Klein- authors politely return the grammatical final, and that it is simply a division man’s distinction between illness and favor, hoisting Martin on his own pe- they have found useful. They indeed disease, which deserves a place in the tard in noting that his Che sará flubs introduce some of the requested nuance discussion. both the Italian accent (Que sarà) as in the target paper with statements such One of the themes threading its well as the phrase ( Che sarà, sarà). As as: “Indeed, we should also be clear way through the target article and a self-avowed pedant, I enjoyed the that not all critiques aimed at demon- commentaries is the distinction be- exchange. strating the role of cultural values in tween fact and value, with an as- psychiatric diagnosis are “anti- sumption that psychiatric diagnoses JP psychiatry.”; nor do they necessarily represent some combination between originate from sources anyone would

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Membership in AAPP is open to all individuals interested in the subject of philosophy and psychiatry by election through the Membership Committee. The Association welcomes Student Members (enrollees in degree-granting programs in col- leges and universities and physicians enrolled in approved psychiatric training programs and post-graduates in post-doctoral programs). In order to join AAPP please detach this form and mail to: Ms. Alta Anthony, Journal Subscriptions/ Memberships, The Johns Hopkins University Press, P.O. Box 19966, Baltimore, Maryland 21211.

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39 Volume 18, Number 2 2011

The Association for the Advancement of EXECUTIVE COUNCIL Administrative Secretary Philosophy and Psychiatry was estab- Linda Muncy lished in 1989 to promote cross- Department of Psychiatry Robyn Bluhm, Ph.D. disciplinary research in the philosophical UT Southwestern Medical Center aspects of psychiatry, and to support edu- Louis Charland, Ph.D. 5323 Harry Hines Blvd. cational initiatives and graduate training K.W.M. Fulford, D.Phil., MRCPsych. Dallas, TX 75390-9070 programs. Phone (214) 648-4959 S. Nassir Ghaemi, M.D. Fax (214) 648-4967 OFFICERS Monica Gupta, M.D., Ph.D. E-mail [email protected]

President Jennifer Hansen, Ph.D. Bulletin Editor Nancy Nyquist Potter, Ph.D. Douglas Heinrichs, M.D. James Phillips, M.D. Vice-president Loretta M. Kopelman, Ph.D. 88 Noble Avenue Claire Pouncey, M.D., Ph.D. Milford, CT 06460 Robert Kruger, Ph.D. Founding President Phone (203) 877-0566 Michael A. Schwartz, M.D. Paul R. McHugh, M.D. Fax (203) 877-1404 E-mail [email protected] Marilyn Nissim-Sabat, Ph.D., M.S.W. Past Presidents George Agich, Ph.D. Christian Perring, Ph.D. Philosophy, Psychiatry, & Psychology Jennifer H. Radden, D. Phil. K.W.M. Fulford, D.Phil., MRCPsych. Jerome L. Kroll, M.D. Douglas Porter, M.D. Louis A. Sass, Ph.D. Founding Editor Secretary John Z. Sadler, M.D. Deborah Spitz, M.D. James Phillips, M.D. Co-Editor Treasurer G. Scott Waterman, M.D. John Z. Sadler, M.D. Osborne P. Wiggins, Ph.D. AAPP Web Site www3.utsouthwestern.edu/aapp J. Melvin Woody, Ph.D. Peter Zachar, Ph.D.

INTERNATIONAL ADVISORY BOARD Emilio Mordini, M.D. Gerrit Glas, M.D.

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