Vincenzo Di Nicola, Drozdstoj Stoyanov: Psychiatry in Crisis. At the Crossroads of Social Sciences, the Humanities and Neuroscience (Cham, Switzerland: Springer; 2021)
The title of this remarkable volume, slightly misleading perhaps for marketing reasons, ought not to be taken ad litteram, and neither should it be interpreted in a cum grano salis key.
Let us then admit that the 1990’s “Decade of the Brain” is a prerequisite of several further developments, and accept that those who aren’t with us are not necessarily against us. If so, one could take this statement as a starting point and safely build up cross-disciplinary sub-branches, epistemologically- and ontologically-wise. The “wake-poise” might be an adequate term under the circumstances, to account for this special state of things that is required when one approaches psychiatry.
The Introduction and Part III are written jointly, but Part I is written by Dr. Stoyanov, whereas Part II is written by Dr. Di Nicola; barely any difference in approach and style, however, between the respective parts, only that Stoyanov deals with the “crisis” in epistemological terms as a crisis of knowledge, while Di Nicola deals with this “crisis” in ontological terms as a crisis of being. Apart from this self-assumed dual point of view, the differences of whatever nature are as minimal as could be.
The main statement in Part I is that psychiatry is in “a crisis of knowledge,” with taxonomy and methodology as its leading actors; projected as it is onto “a crisis of identity,” the former gets involved in a theoretical mind-brain debate – e.g., projected as it is into “a crisis of confidence,” the latter falls on flaw-ridden instrumental quantifications, on nomothetic and ideographic dichotomies that are in need of manuals to translate data across “transdisciplinary matrices” and thus make “bridges” or rather “law-like connections” between them. As for the mind-brain debate, this is part of the medical project of psychiatry, with Griesinger’s assumption that “mental disorders are disorders of the brain”, Kraepelin’s “non-etiological approach to nosological classifications”, Jaspers’ phenomenological psychopathology, Freud’s psychoanalytical assumption that mental and physical worlds, although “separate ontological entities”, interact in more than one way, in a sophisticated manner.
In the meantime, psychiatry went hand in hand with “its neighbouring disciplines”: psychology (with various other humanities) and neurology (with neurosciences and various other medical sciences). There was a certain level of consensus neurology-wise, but as far as psychology (and, implicitly so, psychiatry) is concerned, this “straightforward consensual structure” was missing from the start, with the experimentalists dividing human psyche into entities like perception, memory, thinking, and so on; the gestaltists defining human consciousness as a whole to be explained in terms like figure (object) and background (context); the phenomenologists denying experimental explorations and scientific explanations and relying on empathy; the personologists like Hans Eysenck validating nomothetic methods and assessment models, or like Robert Cloninger joining together disparate models in a psychobiological theory of personality (p. 18-19).
The desired level of consensus, on the other hand, seems to have been reached in the 1930s narrative-based clinical assessments, derived from professional (observed-based interviews) and self-evaluating (patient) reports – such diagnostic interviews and self-assessment tests (MMPI, BDI, Zung) being taken in a psychodynamic manner and following a scale-into-scale pattern over the next 40 years or so.
A mention is made at this point that behaviours and experiences should not be considered “abnormal because of genetic or neuroimaging scan”, they should be based on intersubjective backgrounds as “located in the domain of social, ethical, cultural, religious, educational, and other values”, the biological data in that regard being taken as “adjacent and supplementary”, rather than diagnosis-wise. The central problem, then, is “to formulate a methodological tool to translate from neuroscience to psychology, and vice-versa” – any model of translation considering “the possibility to embrace the entire psychosocial system of mental illness”. But this claim appears to be “vacuous, counterproductive and ineffective”, one of the reasons being the adherence of the biopsychosocial approach to “a positivist stance” in the tradition of “the general empiricism of the Enlightenment”. Nevertheless, the construct must incorporate “data from neuroscience” in what might be assumed as “diagnostic reification”.
As for data translation and diagnosis reification, the issue is quite “complex” and has “various meta-empirical, linguistic, and methodological dimensions”, that constitute the meta-structure of an interdisciplinary nomothetic network or matrix to be summarized as: “meta-linguistic compatibility (i.e., terminology and methods), axiomatic stability (i.e., uniform laws and validity criteria), integrative taxonomy (i.e., universal classification and nomenclature)”. When it comes to dissecting the psychiatry-wise status of translation and diagnosis reification as “an atypical case of a medical discipline”, myocardial infarction on the one hand, and depression on the other hand are good cases in point – if reification and translation to drug choice are considered (p. 20-22).
If so, if compared to “the progress in other fields of medicine”, pharmacological therapy in psychiatry appears to be governed by the “instinct” of the clinician, whereas the drug choice seems to be influenced by “subjective factors such as the professional experience of the doctor and/or marketing interventions from industry” – which comes “at a high cost both for the patients and the healthcare system.” All these, while neuroscience and the different types of chemical tools (interviews and inventories) seldom triangulate so as to converge on the aforementioned construct of “depression” as a diagnosis, the different kinds of measures representing “mere statistical correlations with no reference to the mechanism of disorder”, unable to “effectively translate,” and thus provide “diagnostic standards and procedures”– with a most important issue arising: “What is the subject of reification the procedures of translation may address?” and further: “Which method/dataset is the object and which is the subject of reification?” The assumption, on the other hand, is that “the narrative method, comprised of more or less subjective item reports, is the subject of reification, and its object is the biological method”, which gets psychiatry into a “rather reductionist stance”, the way out being the “mind-brain dualism”, promoting the view that “either both methods reify each other,” or that there is “no reason left for any reification at all” as long as “the very object of psychiatry” turns out to be “subjective human experience,” hardly liable to “any kind of reification and/or validation outside the domain of narrative” (p. 27-28).
At the crossroads of psychology and medicine, psychiatric nosology (regarding diseases or rather nosographic entities) gets qualifications (like pathology or abnormality), taxonomies (in ascending order: symptom, syndrome, nosological entity, and disease), nomenclatures (specific terms coining a disciplinary language), classifications (taxonomic nomenclatures) composed of nosological entities and implying validity (convergent or divergent in terms of the exact phenomenon it is intended to cover), specificity (differentiating between morbid conditions), reliability (repeatability under controlled conditions), sensitivity (differentiating norm from disease). As it is, psychiatric diagnosis has “a relatively high level of reliability” (approximately equal clinical assessments from different clinicians) while it seems to have “a disastrous validity” (hardly any biological markers to reify the diagnosis) – this last assumption on page 32, quite debatable, needs to be developed at the proper time…
Suffice to say, for now, that the category-guided approach (considering psychiatry to be a branch of neurology, with sharp boundaries), the antinosological approach (unitary psychosis, mental health, phenomenology) and the dimensional approach (quantitative measurements) are ultimately attempts to take psychiatry straight into or away from the umbrella of a sound medical speciality, with everything that this sound territory means.
In this respect, “a sound and complex inter- and multidisciplinary framework for medicine and psychiatry” is the biopsychosocial model which makes “a comprehensive assessment of mental disorder” if only four systems were taken into account: biology (anatomy, physiology, and biochemistry included), personality (motivation, habits and cognition included), society (characteristics of large groups related to the dynamics of disease and different forms of behaviour), culture (customs and norms of a particular ethnic, religious, or cultural group, with their impact on disorders) – each person being made of intrinsic systems while being part of larger external systems, all of the systems (biological, psychological and social) interacting with other levels of the system, and with the individual.
If considered to be “too eclectic and instrumental,” thus lacking “the conceptual foundations for an integrative and holistic understanding of human nature”, the person-centered medicine is being called for assistance: it relies on “the quantitative assessment of the patients’ psychological experiences via structured clinical tools, and social dimensions via questionnaires”; it endorses a category-ordered model of diagnosis, a dimensional diagnosis drawing “borderline transitions between health and disease”, disease being regarded as a component of the person, and not vice versa; it is influenced by values-based medicine, with a critical role of the patient’s narrative in the respective social, cultural, and spiritual context; it is focused on both patient and clinician, as persons; it integrates the quality of life with its quantitative and dimensional aspects on the one hand, with its qualitative and experiential characteristics on the other hand. Indeed, “neither an evidence-based (biological, quantitative) nor a values-based (qualitative) approach” can constitute “the sole foundation of medical knowledge and practice”; they are simply supposed to “inform” clinical judgements, in the sense that they complement each other in the shared decision-making process (p. 39-40).
The issue to overcome the emerging crisis of confidence is now about incorporating scientific data from neuroscience “without turning psychiatry into an applied branch of neurology” (p. 43-44).
In line with the former assumptions, the reductive stance is dismissed in corpore as it reproduces reality in “a more or less deterministic, paradigmatic and ontologically fragile (if not vacuous) manner.” A moderate form of physicalism, based on the argument of multiple realizability, is proposed instead, the supervenience theory stipulating that “any difference in physical properties (neural events or mechanisms) is expected to cause differences in the mental world (states- or traits-dependent), but not vice versa” (p. 47-50).
Part III is written in an ontological key, is about “the crisis of being,” has phenomenology as the main target, and revolves around consciousness or rather the experiential chasms in order to find the right angle for diagnostic criteria by and large (“whether based on Kraepelinian aetiopathology or Jaspersian phenomenology of signs and symptoms”) or for ways to understand alienating experiences that are rather out of line. In passim, mention is made that the polysemic question “What is the subject?” is never “resolved/resolvable”, as a general definition of the field, as an object of study, as an understanding of persons – the aporias of the trauma experience have consequently no precise address, as if psychology needs to reinvent itself (and the world) for each new subject of study. All the same, Jaspers provides an important stop-over with his phenomenology or rather descriptive nosography, while “staying very close to clinical observations and patients’ subjective experience”; and so does Mayer-Gross with his existentially-phenomenological attempt to solve the problems of psychopathology by way of philosophical shortcuts rather than by slow developments of natural science – straight to man (der Mensch) rather than taking long turns into “cerebral anatomy or physiology, biology, psychology, characterology and typology, the science of the person” (p. 55-58).
Back to Jaspers, his phenomenology sets out several tasks: to give a concrete description of the psychic states which patients actually experience and present them for observation, to review their interrelations, to delineate them as sharply as possible, to differentiate between them and to create a suitable terminology. As one cannot get access to the others’ psychic experiences, one must make “representations of them,” for which “an act of empathy, of understanding” is needed – the chief help in all of this process coming from the patients themselves, from their self-descriptions. Again, Jaspers’ twofold experiential chasm is assumed to describe the divide between patient and psychiatrist into which meaning and empathetic understanding fall as if in a void; it is a separation of this dual approach of phenomenological psychiatry from psychoanalysis and “other hermeneutic approaches that persist with the attempt to understand, notwithstanding the difficulties and limits of the task.” If Kraepelin was rather more concerned with causal connections and explanations, Jaspers was looking for meaning and understanding – both of them introducing order to a mass of information (p. 59-60).
Alongside such milestones, several subdisciplines have made a try to help redefine psychiatry: child psychiatry with its focus on development and attachment, family therapy with its constant reference to systems theory, then community psychiatry, epidemiology, public health, social and transcultural psychiatry – last but not least, psychodynamic psychiatry based on Freudian psychoanalysis, evidence-based medicine and “a scientific soup of neurobiology and cognitive neuroscience” (p. 62).
As for the mission of psychiatry, the answer is manifold if one takes the case of Ellen West as reference.
To make a long story short, the case of Ellen West has been revisited more than once, and the question for philosophers rather than the psychiatrists who are tempted to see it as a closed case, is what makes it a “case”, what makes it canonical. Its openness to iteration/repetition might well come first, its katechon, its capacity for withholding comes second: What is withheld in the patient’s name, Ellen West? What is withheld in the name of the “foreign consultant” who was speaking about “a life unworthy of life”? Once again, Di Nicola puts it, we confront a “cut”: What is suppressed? What is edited? Where is the ellipsis? What is the lacuna? Where is the “cut”? And what is that “cut”? Is that “cut” a conscious suppression or is it an unconscious repression? In what follows, detailed answers are provided for such impending questions. They involve subtle philosophical debates, like that one whose starting point is based upon the double meaning of katechon: “the force that restrains” and “that which withholds”; or they involve an elaborate case for the “evental psychiatry” – they certainly deserve a future return to this canonical case that seems to have started it all (p. 70-74).
This celebrated case seems, in the first place, to have started our perception that we have just come upon an “evental state”, a place and time where an event is likely to come about. It is “radically contingent” so far, but “once it occurs, people change in important ways, name the experience, and live and work faithfully in the light of such an illuminating event” (p. 158).
The theme of the volume in general (and, to be sure, Part III in particular) – focusing on antipsychiatry or rather the movement to be abstracted as “psychiatry against itself” and key-worded as “tradition versus innovation” and “negation versus affirmation” – is threefold in the sense that the psychiatrists involved in this movement are united by a critical negation which changes them into “rebels, radicals, reformers or revolutionary psychiatrists” who rise against the extending compactness of psychiatry and as such separate a subdiscipline to provide a change of topos and approach (p. 83).
The psychiatrists to be singled out are Ronald David Laing (1927-1989), a “radical” who meant to return psychiatry to its clinical roots (with his criticism of Binswanger’s existential analysis and psychiatric practice generally), “calling for social phenomenology, negating the mystificafion of mental illness by placing the suffering of the self in social, family, and political context” (p. 95); Jacques Lacan (1901-1981), a “subversive psychoanalyst” who insisted on the psychoanalysis indebtedness to Freud while “rebelling against both the psychoanalytic and psychiatric establishment, negating the institutionalization of psychoanalytic practice, whether in the academy or in psychoanalytic institutes” (p. 97); Franco Basaglia (1924-1980), a “reformer” who instigated “psychiatric deinstitutionalization around the world” (p.100); Frantz Fanon (1925-1961) who negated “nothing less than the claim of European psychiatry to universalism” in his radical criticism of the psychology of “colonization and identity formation”, thus providing “a more humane psychology on which to found psychiatry in a revolutionary program for a new society” (p.107); Thomas S. Szasz (1920-2012), a “destructive reactionary psychiatrist” who trivialized mental and relational suffering as mere “problems in living,” arguing against “the majority of psychiatric disorders having biomedical origins, thus promoting the medical model in its most reductive form” (p. 105); Michel Foucault (1926-1984), who questioned “the very basis for imagining madness and reason/unreason” while informing and impelling psychiatrists “to reorder medical perceptions, psychiatric thought”, and the very “order of things”. (p. 108)
What the “crisis” in the title ultimately means is that psychiatry is a living entity whose openness is to be found, as mentioned in the explanatory subtitle, at the crossroads of social sciences, the humanities, and neuroscience. To put it differently, all frustration aside with the admission to full membership – ever since the publication of DSM-3 in 1980 – in the field of medical studies, psychiatry now claims a more liberal status, with an increased focus on its roots.
Professor Di Nicola (University of Montreal and The George Washington University) and Professor Stoyanov (Medical University of Plovdiv) started their dialogue at the regional congress of the World Psychiatric Association in Bucharest (in 2013) and the First Eastern European Conference of Mental Health in Galaţi (in 2017).