By Vincenzo Di Nicola
The first piece in this two-part series is here.
What will philosophy say to us? It will say: “We must think the event.” We must think the exception. We must know what we have to say about that which is not ordinary. We must think change in life.
—Alain Badiou, Polemics (2006, p. 8)
Just as Badiou rejected what he calls subjective phenomenology, following his work, I criticized what I call “trauma psychiatry.” While Badiou holds that philosophy must be reckless, psychiatry as both Nietzsche and Jaspers brilliantly pointed out must be prudent and balanced, in the spirit of the Greeks’ sophrosyne. The psychiatrist needs to be methodologically up-to-date, a good communicator, attentive and empathic, and a role model, Nietzsche recommended. This is not enough, he must acquire the skills of “every other profession” (Nietzsche, cited by Jaspers, 1997). Clearly, something stands apart from the requirements (conditions) and skills and that is the core of psychiatry. For Jaspers (1997, p. 808), a psychiatrist who turned to philosophy, that was a combination of “scientific attitudes of the sceptic with a powerful personality and a profound existential faith.” Another physician-philosopher, William James (1890), referred to a similar duality of tough-minded empiricism and tender-minded rationalism.
Integrating the balance that psychiatrists need in practice with the boldness that Badiou calls for in philosophy, I called for an evental psychiatry in my doctoral dissertation (Di Nicola, 2012). The first fruits of this project are on a broader canvas, a course on psychiatry and the humanities which we pioneered at the University of Montreal (see my previous APA blog), and in more detailed form, presentations in various fora and two chapters: “Two trauma communities” which discerns a critical tension between clinical and cultural views of trauma (Di Nicola, in press, b) and “Pedagogy of the Event,” analyzing medical and psychiatric education in light of Badiou’s theory of the event (Di Nicola, in press, a). A more complete statement of my evolving project is available online: “Slow Thought: A Manifesto for a Psychiatry of the Event” (Di Nicola, 2014).
An Evental Psychiatry of the Threshold
Evental psychiatry describes a psychiatry that would be singular, radically contingent, inherently unstable and unpredictable. A psychiatry that is irreducible to categories and essences, open to what Badiou calls in French novation. Evental psychiatry works at the site where singularity can exist, novelty comes into being, and change may occur (developed in my doctoral dissertation with Badiou, Di Nicola, 2012).
I anticipated the event in psychiatry by describing the predicament (Di Nicola, 1997) as an alternative to categorical diagnosis. The predicament is unstable, unpredictable, pregnant, and morally charged. The predicament is not the event, but it is akin to Badiou’s notion of the evental site. The predicament occurs in a moment of rupture—it could open possibilities and thus become an event which the faithful subject maintains. While a predicament is not trauma or traumatizing per se, mishandling a predicament could trigger trauma.
An evental psychiatry would deal with threshold people in liminal situations—crossing over, arriving and departing, émigrés, immigrants, refugees of all sorts, people “betwixt and between,” in transitional states (Di Nicola, 1997), what philosopher Thomas Nail describes in his seminal work on the migrant and the border (2015, 2016). Not trauma psychiatry, that has categorized stress and trauma with the notion of Post-Traumatic Stress Disorder (PTSD), but a psychiatry concerned with “orphan cases” that addresses the liminality arising from predicaments and the threshold people it creates. People caught between subjectivation (the theme of Foucault’s work) and desubjectivation (the thread through Agamben’s work that connects him to Foucault). Albert Camus’ étranger was such a person as was Robert Musil’s “man without qualities.” Samuel Beckett’s characters are such people: “We can’t go on, we must go on.” Walter Benjamin was himself such a person and I sense a kind of wistful self-recognition in his portrait of “porosity” in Naples (Benjamin and Lacis, 2007). What is porosity in a city is reflected in the liminality of its denizens. And it is possible to imagine this more positively than Agamben’s (2005) “state of exception.” Like Simone Weil, who was rapturous about being displaced and counseled that one should uproot the tree of one’s life to make a cross of it, there is no “here” for such people, torn between affiliation and uprooting. The Canadian sensibility—dispersed among the Native Peoples, “the founding races,” and the rest of us—was framed by Northrop Frye (1995, p. 220) not as who we are but, “Where is here?”
The categorical system of psychiatry demands definitions for “caseness” with criteria for inclusion and exclusion—“brackets” in our jargon—which create boundaries, regardless of construct validity or even face validity, and the creation of “orphan cases” that do not easily fall within the boundaries. This creates the pseudo-problems of “comorbidity” and “complexity.” The complexity recognized by such a system is not the complexity of lived human experience or even the attempt to understand it but rather the complexity of shoehorning experience into categories. What falls in between or among defined categories is explained away by comorbidity (“fleas and lice”, as they say in internal medicine), leading to “complexity” and ultimately to “orphan cases.” The most common diagnosis within each diagnostic group is “NOS,” Not Otherwise Specified. That creates a lot of orphan cases for a system whose major goal is a coherent and reliable diagnostic system.
Hence the study of orphan cases is always a challenge for diagnostic systems, categorical thinking and typologies of all kinds. Orphan cases in medicine and psychiatry are what the state of exception is to political theory, and for analogous reasons, just as the exception becomes the norm, orphan cases force the creation of new categories or new ways of thinking. Orphan cases create a rupture in established systems of thought.
Categorical psychiatry becomes obsessed with measurement and with questions of reliability: inter-rater and intra-rater reliability (across raters and across time) and predictability. An evental psychiatry is more concerned with truth procedures and with questions of validity—not if it is measurable and repeatable but whether it is valid and true.
Rupture versus Continuity
Most definitions of mental health revolve around emotional stability and social functionality but these are at odds with the event. To be stable and functional by ordinary measures means to avoid ruptures, events, and the radical reorganization they engender. The entire subtext of DSM psychiatry is that health is continuity, translated as functionality and adaptation. “Life events” or stressors are ruptures that create, minimally, transitory “adjustment disorders” or more serious “mental disorders.” In evental psychiatry, rupture is the prerequisite for the possibility of event. So-called “life events”—the incidents and interruptions of normal life we call stressors—are necessary precursors to events.
One of the implications is that diagnosis as we currently understand and use this notion would not be a fundamental part of an evental psychiatry. None of the challenges to academic psychiatry concurs with its nosography. In fact, that is the first practical impact of every new theory. Pavlovian psychiatry had a radically different approach to psychiatric diagnosis, as did behaviorism based on learning theory and systemic family therapy. Except in the synthesis called psychodynamic psychiatry, psychoanalysis and academic psychiatry also have different and, since DSM-III, incompatible diagnostic schemas. A nosography based on neuroscience would also reconfigure what academic psychiatry considers the core phenomenology of psychopathology.
Evental psychiatry’s therapy would be a kind of “Ideology Therapy” as a form of discourse analysis. Any form of “talk therapy” deals directly with ideology. This is evident not only in the sense that it deploys ideology as part of its method or technique and not only because the non-intended effects work through expectations and other unintended or unannounced influences but because it directly addresses beliefs, perceptions, motivations, ways of perceiving and understanding experience.
In classical psychoanalysis, for example, interpretations shape the patient’s understanding (insight) of their experience by analyzing defense mechanisms (already an interpretation of human experience). In cognitive therapy, cognitive schemas are posited (already a theory of mind) about how the individual perceives the world and his own experience and schemas are confronted, shaped and changes to schemas are recommended. As a clinician, I often question this in practice, which is to say, theory aside, clinicians easily misunderstand their patients. As the old joke goes, even paranoids have real enemies. It is intriguing that Lacan saw “philosophical systematization as akin to paranoia” (Badiou, 2011, p. 64). The psychoanalytic notion that everything is analyzable, that all is grist for the mill and that there are no accidents, slips or lapsi, in short, that there is no contingency in the psychoanalytic world-view is hermetic and slightly paranoid. In practice, psychoanalytic interpretations have more than a little of the paranoid as a stance. Perhaps any form of systematization runs the risk of being a hermetic system that is suspicious of alterity and change. This has been a key charge against psychoanalysis from the beginning, expressed with cynical humor by Karl Kraus, (“Psychoanalysis is that disease which considers itself its own cure”) and with sustained and pertinent critiques from philosophers of science and scientists. The most notable of the sustained critiques was by philosopher Karl Popper who established different truth procedures, falsifiability and verifiability, as standards for science and this has been echoed by philosopher-scientists like Mario Bunge and scientists like Peter Medawar. My answer to this is uncomplicated: psychoanalysis is not a scientific procedure. It is, in Badiou’s schema, a different truth procedure; specifically, that of love. Psychoanalysis is neither science nor philosophy but something new. Just as it cannot suture philosophy, psychoanalysis cannot be sutured to science or psychiatry.
Foucault (1972) described discourses as systems of thought that systematically form the subjects and the worlds of which they speak. Unlike Wittgenstein’s ladder, you cannot throw away the discourse or apparatus after you have used it. There is no illusion here that we can bracket it out or rid ourselves somehow of ideology. To do philosophy or therapy à la Foucault or Agamben would mean precisely to keep all the ladders and other apparatuses around us in plain view so we know how we got to where we are. In other words, we should eschew illusions. It is like theatre without the fourth wall. There is no recourse to hidden discourses, no “magic bullet” and no philosopher’s stone.
Such a therapy would tend towards a flattening of the hierarchy of knowledge and power, as Foucault construed it. The face-to-face encounter that Levinas described can never be altogether symmetrical but we identify the asymmetry as much as possible and negotiate the differences. Psychoanalysis is being conceived more and more as a “bipersonal field” and so much work is going on in this field that Werner Bohleber (2010) refers to an intersubjective turn.
An analysis of subjectivation, desubjectivation and resubjectivation following the models of Foucault and Agamben would be valuable. And of course, an analysis of subjectizable bodies following Badiou’s (2011) schema. The kind of philosophical archaeology that Foucault and Agamben have conducted must be conducted for each person’s predicament. Discourse therapy would examine the nested hegemonies that lie side by side, one obscuring the other, one justifying the other sometimes. Often, they are buried, like landmines, and our task is to locate them, map them, and either avoid them or disarm them.
Evental analysis or discourse therapy would apply what I dubbed Badiou’s shears to clarify the task of therapy, unsuturing psychiatry from its conditions. Then, one would do an evental analysis of the person’s world: the evental site, the type of subjectizable body, what processes are in place. An evaluation of the person’s porosity, her capacity for novation would be valuable, along with the extent to which trauma interferes with that porosity.
Let me elaborate with one detailed example. The way psychoanalysis explains its own functioning can be enhanced using evental analysis. Insight, the goal of psychoanalysis, requires fidelity. A rupture occurs in the analysand’s understanding of herself, then a reorganization follows that insight. James Joyce, who was influenced by Freud through the first Italian psychoanalyst, Edoardo Weiss, called this an epiphany. Joyce’s epiphany is Freud’s insight and may be understood as something that occurs in the evental site, which I call a predicament. The epiphany or insight is a response to the predicament. We could go so far as to say that the predicament, the evental site, is a necessary condition for insight. Only a cut, a tear in the world can create the acute sense of a rupture that requires a response. Once the analysand has her epiphany, thoughts, actions and feelings are at first interpreted, and later experienced, differently. For this translation from interpretation to insight to new experience to occur, a deep fidelity must accompany the procedure.
As with Badiou’s theory of the event, real change cannot occur without fidelity. Fidelity is what binds the insight into a world. The psychoanalytic event is insight. But any analyst can relate anecdotes of pseudo-insights, passing insights (“truths-of-the-moment”), insights that merely mimic the analyst’s worldview (transference), without being understood, integrated and lived with fidelity. Genuine healing can only come with this more complete insight—embodied, enacted insight that emerges from the analytic relationship. Healing in this sense is not operational or instrumental change, nor is it merely symptomatic relief. This reflection addresses one of the most difficult questions in any kind of therapy: how to maintain the gains, however defined. We need Badiou’s theory of the event because psychiatry needs a theory of change: how novation comes into the world and how to live with that change.
Conclusion: A New Opening
After radically redefining clinical psychiatry by introducing the phenomenological method, Karl Jaspers promptly left clinical practice, leaving others to work out the implications for psychiatry. Turning to philosophy, Jaspers brought to philosophical puzzles the insights of psychiatry. For example, Hannah Arendt’s (2006) famous formulation of Eichmann as “the banality of evil,” was taken from Jaspers’ correspondence with her.
In a similar gesture, after writing his Tractatus, perhaps the most famous and provocative work of philosophy of the last century, Wittgenstein (1922) concluded that he had resolved the problems of philosophy and abruptly abandoned academic philosophy even before it was published. Proving once again the wisdom of Jaspers’ admonition about philosophical hubris, Wittgenstein was to revisit the Tractatus in his Philosophical Investigations (1953) and other reflections on psychology, offering philosophy as therapy.
Badiou challenged me to confront the puzzles of contemporary psychiatry by either abandoning it or boldly announcing a new vision based on the event. Accepting Badiou’s challenge, I chose to avoid Jaspers’ and Wittgenstein’s extreme gestures. As a late-career psychiatrist and an early-career philosopher, re-visioning psychiatry through the event is a philosophical prescription for both radical change in psychiatry and firm fidelity to track it through.
What could be more critically relevant to a 21st century science of the mind and of human relations than a return to metaphysics?
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.