Editor’s note: This is the first of a two-part series on Evental Psychiatry. The second part can be found here.
By Vincenzo Di Nicola
Philosophy is either reckless or it is nothing.
—Alain Badiou, Second Manifesto for Philosophy (2011, p. 71)
Instead of being reckless, as Badiou demands of philosophy, by which he means a bold and fearless program of innovation and change, psychiatry has become feckless, lacking courage, retreating into scientism and methodolatry, with no clear program or way forward.
In this atmosphere, already a full professor of psychiatry with classical training in psychology, psychiatry and psychoanalysis, I decided that psychiatry could not resolve its issues through more empirical research and sterile debates, so I turned to my first love, philosophy, inspired by psychiatrist-philosopher Karl Jaspers’ admonition in his re-visioning of psychiatry based on Edmund Husserl’s phenomenology (1970). At the end of his magisterial General Psychopathology that defined modern clinical psychiatry a century ago, Jaspers (1997) warned:
If anyone thinks he can exclude philosophy and leave it aside as useless he will be eventually defeated by it in some obscure form or other (p. 770).
Let’s look at this malaise from both sides—psychiatry and philosophy. Psychiatrists are living the curse of the best of times and the worst of times! We have never had so much diversity of clinical approaches, so many promising research projects along different lines, and yet there is malaise within the profession and mixed reactions from colleagues in the humanities. This malaise is captured in the resonant title of a volume on health care in the US—“doing better and feeling worse” (Knowles, 1977).
Why? Besides the debate about funding health care, which is at a boiling point in the USA and simmers elsewhere as well, there is within the profession of psychiatry a schism as to how to conceive of “psychopathology,” or how we conceive of mental illness. One way that Western academic psychiatrists are casting this debate is whether to persist in refining clinical criteria for defining “psychiatric disorders” with the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, now in its fifth iteration, or the Research Domain Criteria (RDoC) of the National Institute of Mental Health, until recently led by Thomas Insel, based not on clinical descriptions but on putative genetic and neuroscientific factors (Insel & Landis, 2013).
Among philosophers, there is a great divide as to questions about psychiatry, the mind, and related matters. Theorists in the “Continental” or critical theory tradition have largely addressed psychiatry through psychoanalysis, notably Lacanian psychoanalysis (e.g., Alain Badiou and Slavoj Žižek), or phenomenology, including Michel Foucault who trained first as a psychologist and translated Ludwig Binswanger’s Dream and Existence (1993) from German into French, adding a lengthy introduction. Much of Foucault’s later project, investigating aspects of the history of psychiatry and the deployment of “psychiatric power” is already on evidence there.
Theorists in the Anglo-American “analytic” or linguistic tradition, on the contrary, basically declared psychoanalysis a pseudo-science, including Karl Popper and Roger Scruton, and the attention to psychiatry, psychology and related disciplines including psychoanalysis has been via philosophy of science and is now focused on cognitive neuroscience by such stalwarts as Jerry Fodor, Daniel Dennett, and Patricia Churchland. This approach often combines with a narrow and highly selective view of the “progress of science.” This positivistic notion, reflecting Auguste Comte’s famous dictum, “Order and progress,” has been at the heart of trenchant critiques in the philosophy of science (Paul Feyerabend, 2010, 2011), the humanities (Christopher Lasch, 1991), and even within the paradigm of the life sciences (Stephen Jay Gould, 1996). The Continental tradition sees this paradigm at best as mere empiricism (or observation) and at worst as scientific positivism.
There are, of course, many crossovers between and among these schools of thought, including one of my professors, Catherine Malabou (2012) who was a student of Derrida and now focuses her philosophical work on plasticity in experimental and clinical neuroscience.
I decided to examine nothing less than the history of modern psychiatry and its relationship to philosophy by investigating trauma. During my seminars with Alain Badiou (2005, 2009a), I was struck by the symmetry between his description of the event as an opening and my emerging understanding of trauma as a rupture. When I consulted him, Badiou immediately recognized trauma/event as a fresh and innovative pairing and contrast.
Badiou’s Four Conditions
One of Badiou’s (2008) seminal contributions is to delineate the four conditions of philosophy—art (aesthetics), love (which includes psychoanalysis, or in my view, all that is relational and contextual, what Badiou calls the multiple), science (mathematics, physics), and politics (broadly conceived as ways of communal living).
Philosophy itself doesn’t generate truth but serves as the rubric under which the conditions present the truth through their truth procedures. A key consequence is that philosophy cannot be “sutured” to its conditions. Philosophy cannot be simply reduced to one or another truth procedure. Philosophy is not merely political philosophy or aesthetics or ethics or logic, say. So, for example, Badiou would not agree with Emmanuel Levinas’ stance that “ethics precedes ontology” or ethics as a “first philosophy,” suturing philosophy to ethics.
Psychiatry has its own conditions or, to communicate with colleagues in my community of practice, I would refer to psychiatry as a discipline with sub-disciplines. Psychiatry has many sub-disciplines, whose salience and impact change over time, depending on the contemporary problems that the discipline addresses, and they range from the social determinants of health and epidemiology to genetics and neuroscience. Along the way, psychiatry has benefitted from sub-disciplines as diverse as psychoanalysis and social and transcultural psychiatry.
My argument is that like philosophy, psychiatry cannot resolve its truth claims on its own. It can only use its sub-disciplines to generate truth claims. But psychiatry’s current crisis is that it is precisely sutured to one approach to truth, represented today by genetics and neuroscience using its chosen “gold standard” of evidence-based medicine (EBM). Yet, while neuroscience is a potentially valuable sub-discipline (notwithstanding it’s inflated claims and oversold promise—as one leading psychiatrist told me, it’s “aspirational”), EBM is hollow. It’s just a rhetorical restatement of the positivistic paradigm, elevating the notion of objective data as the “gold standard” for truth.
My two fundamental critiques of EBM address the scientism and methodolatry of psychiatry and the social sciences today by posing the questions: How can we evaluate the salient evidence in psychiatry? More critically, just what evidence is salient?
Evaluating the evidence. In the first critique, EBM isn’t so much scientific as scientistic, mimicking the practices of sciences rather than its spirit of inquiry. For example, the Society for the Study of Psychiatry and Culture, which straddles psychiatry as a medical discipline and the study of culture as a social science, demands that submissions be organized by the experimental model of hypothesis, methods, results; this is clearly not an adequate model for qualitative studies in psychiatry, not to mention the narrative and participatory approach of cultural studies.
Now, even if we grant EBM its premises, my mathematical metaphor is that EBM places us at an asymptote. EBM simply puts some selected studies on the table for consideration and while this is valuable and useful in a limited way, it does not get us all the way there. In the best case, even if we accept its truth procedures to arrive at the evidence, EBM takes us closer to the crucial point, but never breaches the chasm from observation to truth.
Clarifying the available information in a critical way, the clinician can then confront the clinical dilemma: How to diagnose the problem and what interventions are indicated based on a critical review of the available evidence? Here is where we reach an asymptote—at a certain point, no matter how close EBM gets us, we still have to make a subjective judgement using all the complex processes involved in human judgments. And that is the corollary of how to evaluate the evidence: the psychology of human judgments.
The notion that these can be reduced, explained, or revealed somehow is ephemeral. While EBM offers a procedural method, genetics and neuroscience offer seductive sub-disciplines (even though they only indirectly address psychiatry’s core concerns), and cognitive psychology pretends to offer the gold standard for how humans think (Pinker, 1997) and solve problems [or are bedeviled by such problems, as both Ludwig Wittgenstein (1953) and Daniel Kahneman (2011) would have it], we cannot breach the gap. Even if we grant EBM all that it claims (and to be clear, I do not), it only highlights the crucial point that clinical judgements are inescapably human, that is to say, subjective. “Subjective” here not only means subject to error but, even more importantly, that it is a human construction. What cognitive science has done, at its best, is to outline the parameters of that construction, notably in the brilliant work of Nobelist Daniel Kahneman (2011) and his associate Amos Tversky.
What evidence? My second critique is more trenchant. Since it is purely procedural and cannot account for how proper research questions are generated or how they become dominant (the domains of Karl Mannheim’s “sociology of knowledge,” 1936), I do not grant that EBM can answer the question about what is to be construed and accepted as evidence. And, as Wittgenstein (1953) observed about psychology, the truth claims of psychology and psychiatry are not easily resolved by experimental methods:
The existence of the experimental method makes us think we have the means of resolving the problems that trouble us; though problem and method pass one another other by (p. 232).
Believing that the questions of the definition and tasks of psychiatry can be resolved by the experimental or any other method or procedure is methodolatry. Even before we consider methods, we must define in a philosophical sense what psychiatry is, what its concerns are, independent of the current tools at hand. That is what refusing to suture psychiatry to its sub-disciplines really means. And today’s temptation for suturing psychiatry to one of its sub-disciplines isn’t science, it’s scientism and methodolatry. As Jaspers (1997) concluded in his textbook of psychiatry, the effort to avoid philosophy will only result in its coming back to haunt us in some way or other.
All of this brings us to clarify psychiatry’s central task which requires three things:
- a general psychology as a science of human being;
- a coherent theory of psychiatry as a discipline; and
- because it proposes to help people, it needs a theory of change.
To state this more broadly, any helping profession, any approach to human problems, needs to explain three things:
- How people function [normal psychology—cognitive scientist Steven Pinker (1997) calls it “how the mind works,” but I would not limit it to “mind,” I would minimally address mind, brain, behavior and relations—these four domains are not reducible one to the other; philosophically we can ask what is a person or what is a subject? One of Pinker’s critics, philosopher Jerry Fodor (2000), wrote a rejoinder called, The Mind Doesn’t Work That Way].
- How problems arise (a theory of psychiatry beyond clinical descriptions or “phenomenology,” as it has come to be known in psychiatry).
- What the conditions of change are (including what is change and how does novelty arise in human experience?).
So, Badiou offers three profound things to psychiatry:
- first, he offers a theory of the subject (Badiou, 2009c), essential in any human psychology;
- second, his theory of how philosophy works (Badiou and Tarby, 2013), with its conditions and truth procedures (Badiou, 2008), offers a way to clarify what is proper to the discipline of psychiatry and what are its sub-disciplines;
- third, he offers a theory of change based on the event (Badiou, 2005, 2009a), which is sorely lacking in psychiatry.
In Badiou’s work, these issues are connected. In my reading of Badiou, the three conditions for an event are: To encounter an event (which is a purely contingent encounter), to give it a name, and to be faithful to it. The subject emerges through the event. By naming it and maintaining fidelity to the event, the subject emerges as a subject to its truth. It is not mere change: what was contingent becomes a necessity (Žižek, 2104). “Being there,” as subjective phenomenology would have it, is not enough.
Phenomenology and Psychiatry
Badiou offers a new, objective phenomenology to replace the phenomenological epoché that is at the heart of Husserl’s subjective phenomenology. Now this is a rather far-reaching project. To understand how far, let’s examine how some major streams of European philosophy and psychiatry flowed into each other.
In every generation since Edmund Husserl (whose own teacher Franz Brentano was also Freud’s teacher), there has been a rich dialogue between philosophers and psychiatrists:
- Edmund Husserl (2012) influenced/was influenced by Karl Jaspers’ General Psychopathology (1997).
- Martin Heidegger’s Being and Time (2008) influenced/was influenced by Ludwig Binswanger’s “The Case of Ellen West” (1958) and Dream and Existence (1993).
- J.-P. Sartre’s Being and Nothingness (1956) influenced/was influenced by R.D. Laing’s The Divided Self (1960), The Self and Others (1961), and Reason and Violence (1964); as well as Frantz Fanon’s Black Skins, White Masks (1967) and The Wretched of the Earth (1963).
- Alain Badiou’s Being and Event, I &II (2005, 2009a), influenced/was influenced by Di Nicola’s A Stranger in the Family (1997), Letters to a Young Therapist (2011), and Trauma & Event (2012).
While he didn’t outline a psychology let alone a psychiatry, Heidegger closely followed the work of his psychiatric interlocutor, Ludwig Binswanger, with whom he maintained a lengthy and detailed correspondence.
Sartre offered an explicit psychological theory (see his Sketch for a Theory of the Emotions, 2002) and influenced R.D. Laing’s call for a “social phenomenology” in his critiques of psychiatry (while his colleague David Cooper coined the term “anti-psychiatry,” Laing specifically refuted this term). Laing and Cooper (1964) produced a précis of Sartre’s work in English with a laudatory preface by Sartre welcoming the advent of a “truly human psychiatry.”
Until I worked with him, no one in my field had really paid attention to the import of Badiou’s event for psychiatry.
This line of investigation in philosophy with its applications to psychiatry has reached an asymptote, the point of diminishing returns (see Tom Sparrow, The End of Phenomenology, 2014). We may call it, from Husserl to Sartre and their epigones in both philosophy and psychiatry, “subjective phenomenology.” With his key philosophical works, the foundational texts for a new ontology—Theory of the Subject (2009c) and Being and Event, I and II (2005, 2009a)—Badiou sets out a new “objective phenomenology.”
Deep into my philosophical investigations, Badiou offered this crucial assessment and challenge: “You are at a crossroads, either you will abandon psychiatry as such or announce a new, perhaps, evental psychiatry.” It was an accurate philosophical diagnosis! This added another year and another hundred pages to my doctoral dissertation which I called with Badiou’s approval, “Trauma and Event” (Di Nicola, 2012).
My turn to philosophy was confirmed by Badiou’s assessment, echoed Jaspers admonition of a century earlier, and reflected the critical insight of the founder of the modern scientific approach to knowledge, Francis Bacon who in his Novum Organum (1620) distinguished “experiments of light” from “experiments of fruit” (or profit):
[W]e must first, by every kind of experiment, elicit the discovery of causes and true axioms, and seek for experiments which may afford light rather than profit. Axioms, when rightly investigated and established, prepare us not for a limited but abundant practice, and bring in their train whole troops of effects (Aphorism 70).
I tasked a triumviri of philosophers for my investigations: Foucault (1972), the philosopher of discourses and apparatuses; Agamben (2009), who adapted Foucault’s work on the apparatus and paradigm to forge a method of inquiry called “philosophical archaeology,” is our philosopher of the threshold; and Badiou (2005, 2009a), our contemporary Platonist, is the philosopher of the exception and of the event. By seizing on the profound symmetry between Badiou’s ontology based on the event and the rupture that precedes trauma, I was able to re-read the history of psychiatry, psychology and psychoanalysis through the apparatus of trauma to make it contemporary. This method is Agamben’s philosophical archaeology (2009).
Rupture is a breach that suspends the past and interrupts the world. Radically contingent, hence unpredictable and uncontrollable, it can lead to novation, an opening for new possibilities that leads to an event, or shut down into trauma, closing down possibilities. Ultimately, this allows us to see a psychiatry of trauma (that not only concerns itself with trauma but can also be traumatizing) and a psychiatry of the event (that not only studies the event but is radically open to recognizing radical change and being faithful to it in the construction of new forms of human relations).
And, as Freud observed, everywhere we go we find that a poet has been there before us. Amichai grasped this dichotomy of being in his poem inspired by the Babylonian Talmud:
Open closed open. Before we are born everything is open
in the universe without us. For as long as we live, everything is closed
within us. And when we die, everything is open again.
Open closed open. That’s all we are.
—Yehuda Amichai, Open Closed Open (2000, p. 6)
Vincenzo Di Nicola, MPhil, MD, PhD, FRCPC, DFAPA, is a tenured Full Professor of Psychiatry at the University of Montreal, where he works as a Child & Adolescent Psychiatrist. Trained in psychology, psychiatry and philosophy, Professor Di Nicola completed his doctorate in philosophy at the European Graduate School, where he worked with Giorgio Agamben, Alain Badiou and Slavoj Žižek. His 2012 dissertation, “Trauma and Event: A Philosophical Archaeology,” was granted Summa cum laude and inspired his call for an Evental Psychiatry. He is now working with fellow psychiatrist and philosopher Drozdstoj Stoyanov on a volume called, Psychiatry in Crisis: At the Crossroads of Social Science, the Humanities, and Neuroscience, to be published by Springer International.
You can find more about his work on these sites: