An increasing number of psychiatric patients with disorders ranging from
mild depression or anxiety to full-blown psychosis are being treated with
medication these days. Prozac is only the most well known of the many drugs
that are currently being used to alter mood, calm distress, defeat delusional
states, or relieve psychiatric symptoms of many kinds. This tendency is
specially strong in the context of the US’s system of managed care, in which
the speed with which a ‘cure’ can be effected affects the level of payment
received by the physician or the institution concerned. Elio’s Frattaroli’s
book mounts a broad, sustained, and well-argued critique of this tendency.

The argument draws most of its inspiration from Frattaroli’s own cases.
Frattaroli is a practicing psychoanalyst whose thesis is that the psychiatric
symptoms shown by patients are an expression of unresolved conflicts and need
to be worked through during the psychotherapeutic process by way of
transference and countertransference with the psychoanalyst. The book is
especially strong in describing and theorizing these processes and also in
explaining Freud’s various models of the mind. While professionals will be
familiar with most of these matters, they are explained with admirable clarity
for the layperson and will also serve to remind psychiatrists and psychotherapists
of what they are ignoring if they think that effective cures can be produced by
the administration of psychotropic drugs.

Frattaroli deepens his case when he suggests that those who prefer the
quick psychotropic fix to the lengthy and expensive processes of psychoanalytic
therapy are giving expression to a mentality that seeks to avoid psychological
disturbance and to restore equilibrium before all else. Using the analogy of
learning to ride a bicycle Frattaroli suggests that a learner must be prepared
to fall off and suffer a little hurt in order to grow in skill and strength. If
one thinks of life as a quest one will accept the occasional fall as a step
towards growth. It is the attitude that any fall is a bad thing and needs to be
avoided that prevents growth and which drives the psychiatric profession
towards an overuse of drugs. It is suggested further that Freud himself became
aware of the two antithetical tendencies towards equilibrium on the one hand
and towards life as a quest on the other, with his concepts of Thanatos and
Eros: a drive towards homeostasis and rest, and a drive towards loving life
with all its challenges and dangers. Rather than give priority to the
first, a healthy psychological state would be one of harmony between the two.

While many of these ideas will be familiar to those who align themselves
with the humanistic tradition in psychotherapy, Frattaroli invests his thesis
with a degree of originality when he argues that an even more fundamental
philosophical orientation underlies the tendency towards the quick psychotropic
fix: namely, physicalism. While Frattaroli, does not use this term it is clear
that what he has in mind is that those psychiatrists and physicians who
prescribe drugs in order to relieve psychiatric symptoms are committed to a
philosophical doctrine which equates the mind with the brain and which assumes
that altering the chemistry of the brain will alter consciousness for the
better. Frattaroli sees this as a form of reductionist materialism and as a deliberate
form of blindness to the depth and complexity of the human mind: a complexity
much more ably described by Freud in his various iterations of psychoanalytic
theory. In order to counter this reductionism Frattaroli espouses the use of
the word, ‘soul’ and urges psychiatrists and psychotherapists to ‘listen to the
soul’ (by which he means respecting the symptoms and seeking to interpret them
hermeneutically rather than seeking to suppress them with drugs).

But the problem with this approach is that it reinstates a form of
mind/body dualism which most people who think deeply about such issues would be
unable to accept. To use the word ‘soul’ as if it were the name of a
metaphysical entity carries with it the same problems as using the word ‘mind’
as if it were the name of a metaphysical entity: problems that have led most
philosophers to reject such dualisms in favour of a monistic view of
consciousness and mental functioning. But am I being fair in attributing
metaphysical dualism to Frattaroli?

There is no doubt that Frattaroli’s thinking is deeply dualistic in many
ways. These are but some of the distinctions that he aligns with the body/mind
distinction.

Body	Mind
Superego/it/repetition compulsion	The ‘I that stand above’ (superego)
Emotion	Reason
Passive	Active
Brain action	Mind action
Ego (self image)	Higher self attained by meditation
Thanatos	Eros
Flesh	Spirit
Lust	Love
Seeking equilibrium	Quest
Homeostasis	Harmony of drives and motivations
Passions of the soul	Actions of the soul (Descartes)
Being driven	Self-direction
Medical model	Psychotherapeutic model

But do distinctions of this nature imply a metaphysical dualism? The
classic case of such a dualism is Descartes’ positing of a ‘thinking substance’
as distinct from the ‘extended substance’ of the body. While Frattaroli
frequently alludes to this distinction he also shows how Descartes himself
modified it. Moreover, Frattaroli suggests that the ‘I’ or the soul has the
function of integrating the dualities listed above. But while this suggests a
monistic view, it also posits the soul as an agency over and above the
dualities and so, once again, removed from the wholeness of a person’s being.

The model that Frattaroli himself uses in an attempt to resolve these
difficulties is drawn from the writings of Niels Bohr. Starting from the
observation that light presents itself as particles when viewed in one way and
presents itself as waves when viewed in another (where ‘viewed’ is short for a
set of complex experimental procedures), Bohr developed a kind of ‘double
aspect’ theory in which the same thing could be seen under one aspect or under
another depending on the conditions of the observation. This allows one to say
that there is but one metaphysical entity in question but that it cannot but
present itself to observation in two differing ways. If Frattaroli were
consistent in applying this model then he too could say that a person is but
one thing but one which presents itself to observation in two differing ways: a
physicalist/body/brain presentation and a mental/soul presentation. And this is
often what Frattaroli seems to say.

However, this will not solve his problem because it would still follow
from this model that drug treatment is a valid alternative to the
psychotherapeutic approach. Both treatments address the same diseased entity,
albeit under the two guises that it presents to the world: malfunctioning brain
or disturbed mind. What Frattaroli insists on is that drug treatment, while it
may have short-term uses, does not touch on the real seat of the problem. In
affecting only the brain it does not reach the soul. Insofar as this is what he
wants to argue he cannot, and does not, avoid metaphysical dualism. His use of
Bohr’s ‘principle of complementarity’ merely distracts from this theoretical
commitment.

Frattaroli’s account of Freud suggests that the latter was caught in the
same theoretical dilemma. Wanting to be scientific led him to posit a
physicalist libido discharge theory of psychopathology, but wanting to ‘listen
to the symptoms’ led him to a positing of conflicting psychological
intentionalities constituting a structure in the mind/soul. His mantra, ‘Where It
was, there shall I become’, is dualistic in form even as it suggests a
monistic emergence of the soul from the merely causal processes of the body.

Frattaroli is impressed by the theory of one of Freud’s pupils, Robert
Waelder, for whom ‘every human experience must be viewed from two complementary
perspectives: both as driven by the It and as directed by the I,
both as a passion and as an action.” (325) This is a sophisticated double
aspect theory and is consistent with metaphysical monism. It shows that being a
monist does not entail that one must also be a reductionist or a physicalist in
the way that Frattaroli accuses the medical model of being. But it will not do
the job that Frattaroli wants it to do. It is still open for the medical model
to say that, just as there are two perspectives upon the self, so there can be
two equally effective treatment approaches: namely, drugging the It or
allowing the conflicts of the I to be resolved through the transferences
inherent in the psychoanalytic process. And if both approaches are valid, why
not opt for the briefer and cheaper one?

Frattaroli needs to do more than attack reductionist physicalism and
posit a somewhat obscure form of dualism. For all of his espousal of the soul
and vacillation as to its metaphysical status, he is still adopting the
observational point of view of science and therapy. The paradigmatic example of
an observational point of view is certainly that of the medical model with its
treatment of the brain as the objective locus of disease and the symptoms of
the patient as mere observational indicators of that disease. But it is no less
an observational points of view to ‘listen to the symptoms’ and to theorise
their etiology in the conflicts and repressions to which the I has been
subject. In either case the therapist is forming diagnostic hypotheses about
the patient and adopting an observational stance. Even when that perspective
includes what Dennett called ‘the intentional stance’: that is, a recognition
that the object of observation is active in the full sense of that word, such a
perspective is still confined to a third person, observational point of view.
The therapist is still essentially asking, ‘What is going on in this
case and how can I fix it?’ just as the medical model does.

What is needed is a different form of question: namely, ‘Who is
struggling in this case and how can I help them in their struggle?’ This
question acknowledges another ‘perspective’ or ‘aspect’ of the patient: namely,
that he or she is one who addresses the therapist and whom the therapist
addresses. They are not an entity observed, no matter under what humanistic or psychoanalytic
aspect. They are a person in interaction with the therapist: a self with a
conception of their own life and an intention to fulfill it. However confused
or pathological this conception might be, it is their subjectivity or their I
that owns this conception and approaches the world through it.

If there are two aspects to a person they are not two schemas for
observation: a physicalist and a ‘soulish’ one. They are the view from the
outside and the view from the inside. Observation, not matter what categories
it uses, can only give one the view from the outside. The view from the inside
cannot be observed. It can only be lived by the subject and communicated to
others by that subject. The therapist’s approach to this subjectivity is to
address it and be addressed by it rather than to observe it. The third person
point of view must be replaced by a second person point of view.

The irony is that, in his practice if not in his theory, Frattaroli
gives himself every opportunity to see this. While he struggles to articulate a
theoretically acceptable form of dualism he also recounts in honest detail the
processes of transference in his psychoanalytic encounters and his own
reactions and self-scrutiny in response to the interpersonal exchanges that
comprise his practice. It is this personal engagement that opens him to the
subjectivity of the other and that could provide the foundation for a monist
theory of the self: one based on the interpersonal complementarity which
discloses the patient, not as a soul/object to be cured, but as an I who
addresses one with a plea for help.

 

© 2002 Stan van Hooft

Stan van Hooft, Ph.D., Associate
Professor, School of Social Inquiry – Philosophical Studies, Faculty of Arts, Deakin
University, Australia

Categories: Philosophical, Medications, Psychoanalysis