Firmly
ensconced in the biopsychiatry age, wherein wonder drugs like Prozac have
revolutionized psychiatric care, and the advent of neuroscience has convinced
psychiatric researchers that mental illnesses are essentially diseases best
understood via the medical model, Bradley Lewis writes a book calling for the
urgent need of a new academic discipline of ‘Postpsychiatry.’  In Moving
Beyond Prozac, DSM, and the New Psychiatry, Lewis diagnoses how the field
of psychiatry has walled itself off from external or internal critiques of its
methodological practices, eclectic approaches to healing mental illness, and
cultural studies exposés of the political maneuvers of the pharmaceutical
industry responsible for the paradigm shift to biopsychiatry.  Without drawing
on the innovative theoretical perspectives of the humanities–specifically,
postmodernism and post-structuralism–which lay bare the origins of
disciplinary practices, examines ‘who’ are authorized to speak, and what
powerful interests conspire to create the boundaries of a discipline in such a
way to distinguish the experts from the mere amateurs, psychiatry deludes
itself into thinking that it is in sole possession of the ‘truth," it is
the arbiter of ‘good’ and ‘bad’ practices and, above all, that its knowledge is
unsullied by ideology or theoretical perspectives.  That is, psychiatrists
believe themselves to be ‘value-neutral’ scientists who are dutifully
describing ‘real’ diseases (read: objective) and held to accountability in
their findings by the scientific method.

Lewis’
goal is to make a case for devoting resources and energy toward erecting a
field of Postpsychiatry, which would move beyond the seemingly unbridgeable
science/humanities divide in academic research.  Towards this goal, Lewis clarifies
in the first two chapters–"Theorizing Psychiatry" and "Dodging
the Science Wars"–how psychiatry has come to see itself, wrongly, as a
value-free science and actively rejects the perspectives of humanists,
particularly those steeped in the very theories Lewis argues are crucial for
exposing the scientific pretense of psychiatry.  Psychiatry has become another
player, Lewis argues, in the "Science Wars," where the
"fashionable nonsense" of humanists is exposed as the worst kind of
relativism, unable to ferret out what is real from what is cultural
preference.  Lewis ends chapter two by calling for a détente between these
warring factions, and proposes that we might find a third way to the
realist/relativist debates by paying careful attention to the epistemological
and ontological presuppositions of the realists, pragmatists, and
post-structuralists.  Chapter two is a very accessible introduction to the
theoretical insights of these three camps and hence does a nice job of setting
up a possible compromise between the mutually exclusive stance of the hard-nose
scientists vs. the post-structuralist cultural studies professors, by
highlighting Lewis’ own "semiotic realism," which affirms that
knowledge is both rooted in a real world and affected by cultural representations
that influence how we make sense of the real.  Bolstering Lewis’
epistemological approach are the writings of Charles Sanders Pierce, William
James, and Michel Foucault, all of who acknowledged that there was a real world
that humans interact with, even though our representations of that world would
inevitably be affected by both our larger cultural values and assumptions as
well as our human desires to transform it. Hence, Lewis argues that the proper
metaphysical stance to take toward the "real world" is to acknowledge
that all of our inquiries are motivated by practical questions and that how we
make sense of the world will be inextricably shaded by those human desires.

In
chapter three, "The New Psychiatry as Discursive Practice," Lewis borrows
the analytical tools of Michel Foucault as laid out in the Archeology of
Knowledge  and The Order of Things to illustrate how psychiatry set itself up
as value-neutral science dedicated to unveiling the ‘truth’ of mental illness. 
Lewis brings Foucault’s tools to bear on the a textbook crucial to training new
psychiatrists, Introductory Textbook of Psychiatry, and reads this book
against the grain.  He illustrates the rhetorical moves within that help set up
biopsychiatry as the one and only true method of treating mental illness, that
identify descriptivism and neuroscience as the best scientific approaches, and
that set up the trusted. Lewis’ ultimate goal is to belie the myth that any
science, psychiatry in particular, is the only method for accurately grasping
the world as it really is, undistorted by human interests.  He persuasively
argues that the paradigm shift in psychiatry, away from eclectic and hybrid
approaches to mental illness toward neuroscience and the medical model, was
really a political coup, orchestrated by various powerful interests invested in
making psychiatry fit mainstream medicine.

In
chapter four, "Psychiatry and Postmodern Theory," Lewis begins to
unfold his positive program of creating Postpsychiatry as either a replacement
to biopsychiatry or as an important critical voice.  What is interesting about
this and subsequent chapters is that Lewis sets himself up to be criticized in
the same vein that he criticized the biopsychiatrists. Namely, he is setting up
an exclusive domain of inquiry "best" suited to help us grapple with
mental illness and its consequences.  He lays out a methodology–semiotic
realism–a metaphysical approach–pluridimensional consequences, acceptable
jargon that separates insiders from outsiders, and, sets up the trusted
authorities.  By adopting a postmodern frame, psychiatrists would have to
abandon the belief that any form of human knowledge is an unobstructed view of
the real world.  He explains: "If psychiatrists practiced from within the
worldview of a postmodern ‘crisis in representation,’ they would be much less
obsessed with ‘getting it right.’  Psychiatry would understand its knowledges
not as universal truths but as useful heuristics, necessarily formulated
through the constraints of a nontransparent language . . ."(70). Chapter
five–"Postdisciplinary Coalitions and Alignments"–focuses
particularly on what Lewis takes to be the foundational texts to the field of
Postpsychiatry.

In
chapter six and seven–"Decoding DSM" and "Prozac and the Posthuman
Politics of Cyborgs," Lewis demonstrates what Postpsychiatric analyses
look like.  In his critique of the DSM, Lewis argues that earlier attempts to
discredit this foundational text for biopsychiatry have made the mistake of
arguing that the DSM fails because it is "bad science."  By arguing
that the DSM is bad science, the pretensions toward setting psychiatry
exclusively on a scientific basis are unquestioned, and hence such critiques do
nothing to expose the political interests invested in moving psychiatry toward
neuroscience.  Lewis pleads for a rhetorical analysis of the DSM. For Lewis,
the fact vs. value distinction is a rhetorical move, designed to elevate
scientific thinking as objective, value-neutral, and true.  In fact, Lewis
rejects that long hallowed distinction between rhetoric and logic, arguing
instead that logical analyses are another form of rhetoric. With such crucial
distinctions dislodged, it becomes far more difficult to ferret out true from
false accounts of reality; in fact, there are no criteria for determining true
and false, in Lewis’s metaphysical frame, outside of what is practical or not
practical. There is no reason to invest in any one scientific pursuit outside
of its ability to bring us closer to our own, all-too-human, ideals of
happiness or excellence.  Hence, we should look at the DSM as "bad
rhetoric," following Sandra Harding’s model of the "science as
usual" critiques, which

"open
up questions about the very assumptions of science.  They highlight the way
dominant scientific discourses do not develop neutral methodological models,
distinctions, and priorities outside of a field of power and only later hold to
these methodological styles with tenacity characteristic of a battle.  The
models, distinctions, and priorities themselves are part of the power struggle
between dominant and alternative approaches" (106).

Adopting
a frame that characterizes mainstream knowledge as the interests of the
dominant group, Lewis sets out to correct what he takes to be an ethical wrong
of power struggle knowledge production by insisting on greater inclusion.

In
chapter seven, he proposes two concrete solutions for breaking up the
stronghold that pharmaceutical companies have over psychiatry, an influence
that has aided and abetted the turn toward neuroscience and biotechnology. 
First of all, we need to rethink the role of ethics in medicine.  Lewis
astutely observes that given the current fact vs. value distinction view of
knowledge, ethical analyses come too late.  Ethics committees are entrusted
with the task of determining whether an already existing practice is
"good" or "bad."  Ethics committees rarely consider the
political and social context in which a current biotechnological practice, such
as Prozac, comes into existence.  Prozac comes to be seen as a
"neutral" medicine that can be used well or badly, i.e. to treat
diseases or to enhance human capacities.  To bolster ethical analyses of
biotechnologies such as Prozac, Lewis argues that psychiatrists cannot ignore
the concrete conditions under which technologies are developed.  In the final
chapter, "Postempiricism," Lewis proposes that at every stage, we
should be asking the following questions:

"What
kinds of psychiatric knowledges are good to pursue, and for whom are they good
to pursue?  Which of the available methods of knowledge inquiry are best for
psychiatry?  And on what ethical or political grounds do we exclude possible
contributors to psychiatric knowledge?" (144).

When we
see values operating at every juncture of knowledge production (the phrase that
Lewis uses to describe what others might innocently call knowledge), rather
than judgments we need to make about how to use the knowledge we have, then we
will better align our scientific inquiries with human interests.

Human
interests are the basis of the second proposal Lewis makes.  Psychiatry, if it
were to be guided by Postpsychiatric aims, would strive for greater inclusion
in knowledge production.  Lewis is pessimistic about any radical reversals
springing out of the hegemonic biopsychiatry institution, yet finds some hope
in what he calls "posthuman activism" (140).  Models of such activism
are to be found in groups like La Leche League or ACT UP. What activist groups
do when they challenge mainstream medicine, according to Lewis, is reaffirm
that democracy should be the most important value undergirding human action,
particularly scientific and technological advances.

While I
appreciate the clarity and passion with which Lewis writes this book–and find
myself sympathetic with his project, I have real problems with many of the
arguments put forward.  For example, in the early chapter, where Lewis explains
the different "frames" of realists, relativists, and pragmatists, I
couldn’t help but find Lewis’ description of the camp he is most at odds
with–realism–to be a mere caricature.  Lewis’ description of what analytic
philosophers mean by the ‘sign,’ seems to be stuck in the early logical
positivist projects of Gottlob Frege or Bertrand Russell.  Certainly,
philosophers of language and logicians have developed far more subtle and
sophisticated theories of representation beyond the "correspondence theory
of truth."  I find the same sort of strawman arguments going on when he
suggests that bioethicists take complicated questions, wherein competing values
and political interests are intertwined, and then reduce these complex
questions into mere judgments of "good" or "bad." 
Bioethicists, in Lewis’ view, aren’t capable of making subtler, context-dependent
arguments.  If Lewis were to spend more time carefully reading many of the
folks that he characterizes with such broad brushes, he might find more allies
for his project than he realizes.

I am also
left wondering why we should value democracy and inclusion above all else,
given that Lewis’ Postpsychiatry metaphysical view has no clear way of
determining which values and goals our human projects should tend toward. There
is no normative force to his critique, other than descriptions of powerful
interests intertwining themselves with particular practices, which only suggest
something is wrong with these practices, rather than give us principled
arguments about why we should avoid them.  Lewis assumes democracy to be a
value to Postpsychiatry, but we are not given any reasons why. Furthermore, it
is not clear how he would cope with democratic decisions that dismissed his
postmodern project.

Lastly, I
am concerned about the inefficacy of this project to actually transform
problematic practices in psychiatry. Not only will many psychiatrists find this
theoretical approach a bit too esoteric, but they will wonder how this cultural
critique of psychiatry will help them better serve their patients. There is a
risk inherent in these types of studies that we will sacrifice the patient to
abstract and heady theories.  I wager that psychiatrists are far more practical
and eclectic in their approach to treating patients than Lewis gives them
credit for.  He has a tendency to conflate the views of psychiatric nosologists
and academic researchers with practicing psychiatrists.  I think so many of
Lewis’ criticisms, such as, the unhealthy relationship between big Pharma and
academic research or how advertisements create consumer preferences, are
important, urgent even.  But, we seem to part ways on how best to educate the
public about what is wrong.

 

© 2006 Jennifer
Hansen

 

Jennifer
Hansen is an Associate Professor of Philosophy at Gettysburg College.  Her
research focuses on feminist theory and the intersection of psychiatry and
philosophy, with particular interest in affective disorders, such as depression. 

 

---

August 3: 2006: Bradley Lewis responds to Jennifer
Hansen’s review:

I found Hansen’s review of Moving
Beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry to
be a careful and smart reading of the book. She clearly understands the main
themes and motivations, and her summary sections are excellent.

Along the way, she also raises
several concerns about the book, so I will take a moment here to discuss these
concerns. In Hansen’s discussion of chapter four, she argues that I set myself "up
to be criticized in the same vein that [I] criticized biopsychiatry." She
says that I do this by making pospsychiatry "an exclusive domain of
inquiry" with a particular methodology and jargon available only to
initiates and experts of postpsychiatry. Hansen is right that there is a
similarity between postpsychiatry and biopsychiatry in that postpsychiatry is
just as much a discourse as biopsyhciatry. However, despite this similarity,
there is an important difference. Postpsychiatry does not insist on being the
truth or the only valid method of approaching mental suffering. Postpsychiatry
does not seek to expand by the force of truth, but rather by the force of
persuasion and coalition. If people find that postpsychiatry is helpful to
their goals, then they are invited to join. Postpsychiatry does not claim that
alternative approaches are wrong, or worse "irrational," only that
they are different.

To briefly address Hansen’s other
concerns; she argues that I set up straw man opponents in my discussion of the
science wars and bioethics. This concern seems to be a misunderstanding as much
as anything. This book is about helping people see the main thrust of the
discursive patterns surrounding psychiatry. Within each discursive field there
are writers that develop considerable nuance, but that does not mean that the
discursive field as a whole has this same nuance. Terms like "realist,"
"relativists," and "bioethicists" are useful terms, even if
anything anyone might say about them would always be incomplete and inaccurate,
and would always reduce them to straw men in important ways. This is a problem
of language–indeed, a problem that I spend a good deal of time discussing in
the book.

I admit to being baffled by Hansen’s
statement that there is "no normative force" to democracy and stakeholder
inclusion in psychiatric research and knowledge making. My reading of key texts
in disability studies (James Charlton’s Nothing About Us Without Us),
feminist philosophy of science (Sandra Harding’s Whose Science? Whose
Knowledge? Thinking from Women’s Lives), science studies (Bruno Latour’s Politics
of Nature: How to Bring the Sciences into Democracy), philosophy of science
(Philip Kitcher’s Science, Truth, and Democracy), technology studies
(Richard Sclove’s Democracy and Technology) and postmodern theory
(Ernesto Laclau and Chantal Mouffe Hegemony and Socialist Strategy: Towards
a Radical Democratic Politics) all point to democracy and stakeholder
inclusion as perhaps the most useful normative guide. This is particularly so
in a time when truth and ethics have shown themselves to be cultural products
rather than timeless universal necessities.

Perhaps Hansen’s skepticism about
democracy comes from the way that the contemporary political stage shows how
easily democracy can be manipulated. If so, I agree with this problem, and it
is why I turn to Benjamin Barber’s work to make the distinction between "weak
democracy" (voting for a U.S. president) and "strong democracy"
(contributing to a local town hall style government). See page 153 for further
discussion of this point.  

Hansen’s final concern regards her
sense that many, if not most, psychiatrists will find my theoretical approach
too difficult and abstract. That is probably true, but the problem here is the
assumption that psychiatry is the primary audience for the book. I don’t believe
it is. I believe the primary audience is critics of psychiatry, those who have
a deep sense that the contemporary field of psychiatry has run amok in its
relentless pursuit of science, drugs, and profits. Some of these people will be
psychiatrists, but many will be cultural scholars, philosophers, intelligent
readers, politicized consumers, and concerned relations. If these people
develop the tools sufficient to demand a different kind of psychiatry, I
believe that will be the most helpful route for changing psychiatry and
developing alternative forms of care. 

 

© 2006 Bradley
Lewis

 

---

August 3, 2006:  Jennifer Hansen replies:

I read Professor Lewis’s comments
with great interest.  While I would love to continue a debate on whether the "value-neutral"
approach of biopsychiatry is less honest that the post-psychiatry stance that
acknowledges the partiality and incompleteness of its discourse, I will focus
instead on the issue of inclusiveness.

Lewis once again defends the
importance of democratic processes in knowledge formation, which means that we
should be as inclusive as possible and acknowledge that no one method or
position can hope to speak the last word.  I wondered, in my review of the
book, how Lewis justifies democracy, that is, inclusiveness, as an important
ethical norm.  I have since concluded that his justification rests with his "semiotic
realist" metaphysics, which justifies practices and norms by virtue of
their usefulness. 

In abstract terms, promoting
inclusiveness seems right.  It appeals to the very best of our natures, and our
desire to always keep the conversation going in hopes that something we had not
yet considered might be crucial for solving a particular problem or helping us
articulate a inspiring vision of the future.  However, I must point out that I
live just down the street from Dover, PA, where committed opponents to
evolution set out to exploit the good natured intentions of inclusiveness in
order to force high school biology teachers to teach Intelligent Design. In
practice, inclusiveness to all ideas, without some method for sorting out
better or worse ones–something like a concept of truth–can turn out
disastrously.  If you embrace a kind of relativism that is, I believe, inherent
to Lewis’ project, then you have very few resources for warding off those who
use your relativism against you: "since there are no truths, since no
theory is the whole truth, then we should include as many perspectives as
possible, including creation science."  It is this concern with Lewis’
advocacy of activism (which the creationists certainly are) and his faith in
inclusiveness that makes me ill at ease.  Unless you have a way of sorting out
better ideas from worse ones–independently from political interests–then all
ideas are politicized. And, frankly, nothing worries me more than the
politicization of all knowledge.

 

© 2006 Jennifer
Hansen

---

[At the request of both Bradley Lewis and Jennifer Hansen, Metapsychology
is publishing one further exchange on the topics raised above.  Editor.]

 

Bradley Lewis (published 9/14/06):

Clearly, this debate could go on at some length.
I appreciate Hansen’s raising the issue of relations between secular world
views and religious world views (which the Intelligent Design controversy is
largely about). This is a critical topic–particularly in this time of
tremendous tension and war around the world. Obviously I can not do justice to
the topic here, but I would recommend Bruno Latour’s recent book, War of the
Worlds: What about Peace? (2002), for a fascinating discussion of
the topic.

The issue is important for psychiatry too
because so many people in the clinics live by very strong religious worldviews.
Psychiatry, being a secular profession, has had great difficulty working with,
taking seriously, and learning from religious perspectives. That too is one of
the many problems with its overly modernist frame. Postpsychiatry helps side
step either/or, truth/myth relationship to worldviews (including religious
worldviews) that can be immensely helpful in these kinds of cross-cultural
(cross-worldview) encounters.

And, finally, it seems that Hansen and I agree
on one thing: we are both worried about the "politicization of all
knowledge." The difference is that my experiences in psychiatry (watching
what passes for "truth" in the field over the last many years) and my
experiences reading postmodern literature have both led me to believe that
there is no way to avoid the politicization of knowledge. As such,
postpsychiatry does not advocate politicizing knowledge. Just the opposite,
postpsychiatry tries to cope with the inevitability of politicized knowledge.

And that of course is where democracy and
inclusion come in. As imperfect as democracy may be, it remains the political
system I find most appealing. Plus, it is a political system that would have
many advantages for the most important (and at present most disenfranchised)
stakeholders in psychiatry.   

 

© 2006 Bradley Lewis

---

Jennifer Hansen (published 9/14/06):

Let me underscore that I agree with
much of what Lewis has to say about the problems inherent to psychiatry–both
epistemological and practical.  However, his latest response to me highlights,
I think, where we part ways.  He writes: "my experiences in psychiatry
(watching what passes for ‘truth’ in the field over the last many years) and my
experiences reading postmodern literature have both led me to believe that
there is no way to avoid the politicization of knowledge" (my
emphasis).  This disagreement may hang on the ambiguity of what the phrase–the
politicization of knowledge–means.  Does this mean that all knowledge is
intertwined with political interests?  Is all scientific knowledge, for
example, driven by human interests and thereby our desire for certain
outcomes?  Do we only seek out the answers to questions that will directly
benefit either our pocketbook or our ideology?  If Lewis answers yes to all of
these questions, then my definition of the "politicization of knowledge"
differs.

I have too read a great deal of
postmodern texts and I always find myself unconvinced by the assertion that all
knowledge is tainted by coercion or unequal power relationships between those
who have resources and those who don’t.  The bottom line, for most
postmodernists, is that whatever passes as value-neutral facts are really just
the views of the elite, and as such, benefit them materially. 

When Lewis sets out to explain his reasoning
for why all knowledge, he says, in passing, "watching what passes for ‘truth’
in the field over the last many years."  Lewis, I take it, is angered by
positions that are not well supported by evidence or at least that is what I
take from his phrase "watching what passes for ‘truth.’  The implication here
is that some arguments are better than others and because they either exhibit
good reasoning, good evidence or both.  If, however, all knowledge is nothing
other than might made right, then it seems unlikely that anyone would be upset
with what passes as truth.  Frankly, they should be unsurprised.  Those with
the most access to resources will define agendas and those on the outside will
be dismissed as laughably irrelevant. 

For me, the politicization of
knowledge means that some arguments will be buried, misconstrued or attempts
will be made to not fund them.  Take the recent example of the FDA’s highly
political attempt to prevent making Plan B (emergency contraception)
over-the-counter.  All the evidence refuted the positions made by those who
oppose this medication, e.g. that it will increase promiscuity, it is an
abortion pill, or that it is unsafe.  And yet, the decision makers were still
able to block its OTC status.  Alas, politics again prevail, but this time on
the side of evidence, when Hilary Clinton and others pressure the FDA to
finally grant OTC status to Plan B or else suffer the consequences, i.e.
blocking the President’s nominee for the FDA. Certainly, politics was at work
at every level of this decision, but the evidence upon which to make an
informed decision about the status of Plan B did not, arguably, demonstrate
only what Barr Labs wanted it to say.  We are able to make strong inductive
arguments–open for revision based on new evidence of new techniques–that
enable us to get a better handle on the world.  I agree that politics buries
good evidence sometimes, but I disagree that knowledge is politics all the way
down.

Lastly, I am still dogged by Lewis’
defense of democracy as the method for knowledge production in
postpsychiatry.  Perhaps I just don’t see democracy as always leading to
greater inclusion.  There are all sorts of embarrassing laws and elections that
democratically took place, and none of these has much to do with the best
answer or best approach.  Democracy is, in its better moments, about the art of
compromise. And, while compromises are excellent tools for keeping together a
disparate body of citizens, they aren’t the best way to do science.  I wholly
support taking seriously the scientific method and thereby remaining a skeptic.
Scientists should not rest until they have exhausted all attempts to disprove
their hypotheses and towards that goal, it seems important for them to take
seriously radically different ideas and approaches.  Surely the way in which
psychiatric research is funded perverts the scientific method, regularly, but
then the solution seems to lie in preserving the scientific method by
regulating how studies get funded.  

 

© 2006 Jennifer Hansen

Categories: Philosophical