Recently, an article was published online by The Psychiatric Times entitled “Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry,” written by Ronald Pies, MD, Sairah Thommi, and Nassir Ghaemi, MD, MPH. While the article is academic in nature and the language is opaque, some important points are raised for psychiatrists and mental health practitioners across the professional spectrum. Specifically, what are the criticisms levied against psychiatry (and, in a broader sense, all mental health professions) and when are those criticisms legitimate?
I wish to focus on what the article terms “antifoundational” criticisms of psychiatry because it is my intention to show that such criticisms are largely accurate. Rather than causing anyone to conclude that mental health professions have no value, such criticisms should be embraced and used to inform responsible practice. To begin, examine the description of “antifoundational” criticisms as interpreted by the authors of the article:
It is important to remember that this description of antifoundational viewpoints is offered by authors who generally disagree with the viewpoint. Thus, its accuracy should not be automatically assumed without critical investigation. Michel Foucault, for instance, articulated a very robust social critique of which psychiatry and its role within society in the mid-20th century was but one small part. His broader themes are important and difficult to dispute. Namely, he argues that institutions have a strong vested interest in protecting “social norms.” But what are social norms? Who has defined “normal” and “abnormal” actions, behaviors or activities and for what purpose have they so defined them?
The authors of the article further interpret Foucault’s positions as follows:
While this may be a difficult notion for psychiatrists and other mental health practitioners to embrace, we must be aware at some level that diagnosis and treatment of mental illness is not based on clearly empirical or objective data. We have as of yet not traced mental illnesses such as Schizophrenia to genetic defect, disease, virus or some other tangible cause. Our diagnosis of mental illness relies on subjective interpretations of diagnostic criteria which list a series of symptoms to be observed and interpreted by an authority. There are no medical tests for the “disease” of Bipolar, for example. The judgment of the authority figure or group of authority figures is foremost. When Foucault points out this truth, he should not be criticized for doing so.
There is possibly no greater example of a self-legitimizing text than the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV.) Without clear concrete basis on empirically measurable data, standards for classification and labeling of a litany of mental “disorders” were created by fiat. That is not to say that there was no process, or that there was no evidence base of any kind (subjective and open to interpretation though it may be) or that there were not many safeguards erected in the development and evolution of the DSM in order to make it as “legitimate” and useful as possible. But the fact remains, it rests not in objective science but in subjective judgments about what other people’s behaviors and experiences mean to us, and thus how they should be labeled. Thus, Foucault is certainly well within bounds to make reference to self-legitimizing texts and linguistic conventions, and we look foolish when we attempt to run away from that criticism. We could instead embrace it and allow it to better qualify and humanize our practice.
Foucault’s critique about institutions wielding power and functioning as a mechanism of social control should not seem particularly radical. Psychiatrists and other mental health professionals hold tremendous coercive power over the freedom of others. There is a significant inclination to make judgments about a client’s “best interests” based on our understanding of social norms, western-cultural roles, and the interests of privileged members of society in maintaining “order.” When we are at our best, we make our primary focus the expressed needs and desires of the particular individual we are working with. But it is impossible to separate that effort from the social constraints imposed by our institutions that emphasize conformity to a set definition of “normalcy” or “mental health.”
I believe that it is a mistake to trivialize the criticisms made from an antifoundational perspective. The authors of the article choose to identify that they call “fallacies” with antifoundational positions and then attempt to dismiss the claims as invalid:
Foucault’s analysis may shed light on how differing epistemes affect society’s management of mental illness, but it does not impugn the ontological reality of mental illness or the immense suffering it causes. Furthermore, following Foucault’s own postmodern logic, his claims regarding madness must be viewed as merely another episteme, wherein Foucault asserts his own self-legitimizing power and knowledge. Like most postmodern claims, Foucault’s argument effectively devours itself.
Finally, whereas Foucault saw himself as a kind of cultural archeologist, he is more accurately viewed as an old-fashioned moralist. Foucault’s argument with psychiatric praxis, like Szasz’s, is fundamentally hortatory: it implicitly prescribes and proscribes how people ought to behave toward their fellow citizens; eg, “We should not lock people away merely because they think or behave in ways we don’t like!” Foucault’s analysis is perfectly respectable and potentially salutary political advocacy, but it is in no sense a scientifically based critique of psychiatry. Indeed, as Ian Hacking observes, “Despite all the fireworks, Madness and Civilization follows the romantic convention that sees the exercise of power as repression, which is wicked.”
I argue that the “ontological reality of mental illness” is a nonsensical statement. While it is an ontological reality that human beings have a wide range of experiences, that some of them are distressing either for themselves or others or both, “mental illness” is a label and mechanism of classification by which persons in authority decide which experiences meet the criteria for “illness” and which do not. Despite all desire to be as consistent as possible in these determinations, there is currently no way to avoid subjectivity in classification.
With regard to the suffering mental illness causes, the appropriate question to ask in response is, “causes for who?” It is certainly true that human beings can have experiences that cause deep pain and distress for themselves. When does distress become “insanity,” who makes that determination, on what basis and for what purpose? I would suggest within mental health professions there is a notable preoccupation with the distress someones experiences causes for society, their cost (financial or otherwise) to social institutions, as well as personal judgements about what should and should not be acceptable ways to live. All this points to the clear interest (conscious or unconscious) psychiatry, psychology, social work, etc. as institutions have in protecting social norms.
With regard to the characterization of Foucault as an “old-fashioned moralist” I am puzzled as to why this is considered to be a negative criticism at all. Ian Hacking may feel that a deep commitment to the values of non-exploitation and empowerment is mere “romantic convention” or old-fashioned. I argue that mental health professions lose their claim to any sort of legitimacy when they reject a sense of moral responsibility to the principle of empowerment in therapeutic relationships, the breakdown of traditional coercive power dynamics, promotion of empathetic and compassionate collaborative partnerships and resistance of abstract authority, heirarchy and unquestioned assumptions about social “norms.”
Notice that in objecting to Foucault’s criticisms, a separation is made between “political advocacy” and the work of psychiatry and mental health. Why is this this case? Seemingly without conscious thought, psychiatry commits itself to functioning as a defender of social norms and identifies its role as helping people whose lives exists outside those boundaries learn ways to integrate and conform to those standards. How often is it that we find psychiatrists questioning the usefulness, justice or legitimacy of the “standards” themselves? It is not just psychiatry that has adopted a largely conservative stance in practice but all mental health professions from social workers to crisis counselors.
Dennis Saleebey, writing specifically to social workers gives a statement broadly relevant to mental health professionals. He writes:
Malcolm Payne (2005) adds to this criticism by describing objections to the professionalisation of social work. In this context, the criticism is as important for psychiatrists, clinical psychologists, and crisis counselors as it is to social workers. He writes:
Bob Pease and Jan Fook (2001) argue that social workers should be actively skeptical of all theories that suggest a unified objective reality. And again, this exhortation is broadly applicable to all mental health professionals. They write:
What then, is the value of “antifoundational” (most of us would just call it postmodern) thinking in psychotherapy and across the mental health professions? As mental health practitioners, we can summarize the over-arching concept of post-modernism as a rejection of the notion that clients fit neatly into boxes. Thinking in this way can help practitioners avoid depersonalizing clients by an overdependence on classification. It can also assist practitioners in understanding important contextual realities for each client, such as the way environmental, ethnic, cultural, and historical factors color the client’s interpretations and experiences.
Postmodernist reflexivity can serve as a reminder to practitioners that a consistent feature of most quantitative generalizations is that there will most likely be persons to which such generalizations do not apply. While those cases may be a minority, mental heath practitioners are charged with the task of affirming and supporting difference rather than marginalizing it for the sake of convenient categories.
To this end, mental health practitioners must be critical of those who advocate certain practice approaches as “best” without careful consideration of difference and variability. What if there are actually few universal “best practices” but many practices that may be “best” for a specific client in a specific context? Postmodernist arguments even embolden social workers to challenge the dominant belief in quantifiable “evidence-based practice.”
We can deconstruct the hidden potentials for dogmatic thinking intrinsic to the term and reconstruct a concept of an “evidence-base” as heuristic and provisional - with the ultimate authority resting not on a body of evidence, but with the individual practitioner who must interpret – and in some cases reject – that evidence in a specific situation with a particular client. If we as practitioners fail to do this, then we may be in danger of confirming the charge that mental health professions from psychiatry to social work are conservative professions that blindly reinforce dominant social norms without questioning their validity.
Finally, I recommend two books as examples of how postmodern criticisms can be integrated into practice. Reading Foucault for Social Work, edited by Adrienne S. Chambon, Allan Irving and Laura Epstein is quite relevant given its opposite reaction to Foucault’s ideas. This collection of essays from mental health practitioners demonstrates the urgent need to embrace postmodern criticisms in order to connect more fully to meaningful context-driven practice. Understanding Exerpience: Psychotherapy and Postmodernism edited by Roger A. Frie focuses on the impact of postmodern philosophy on contemporary psychotherapy. Far from viewing the interaction as antogonistic, Frie sees the potential for postmodern criticism to enrich the potential of psychotherapy in a modern age.
Frie, R. (2003). Understanding exerpience: psychotherapy and postmodernism. London: Routledge.
Payne, M. (2005). Modern social work theory. Chicago: Lyceum Books, Inc.
Pease, B. & Fook, J. (Eds.). (1999). Transforming social work practice: post-modern critical perspectives. London: Routledge.
Pies, R., Thommi, S. & Ghaemi, N. (2011). “Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry.” Psychiatric Times (Online: http://www.psychiatrictimes.com/display/article/10168/1895157)
Saleebey, D. (2001). Human behavior and social environments: a biopsychosocial approach. New York: Columbia University Press.
I wish to focus on what the article terms “antifoundational” criticisms of psychiatry because it is my intention to show that such criticisms are largely accurate. Rather than causing anyone to conclude that mental health professions have no value, such criticisms should be embraced and used to inform responsible practice. To begin, examine the description of “antifoundational” criticisms as interpreted by the authors of the article:
Antifoundational philosophies and philosophers assert that there are no objectively demonstrable truths; rather, there are only various perspectives or narratives that cannot be privileged as uniquely or objectively true . . . Thus, the postmodern theorist Francois Lyotard denies the legitimacy of “grand narratives”—essentially, cultural myths that merely serve “. . . to mask the contradictions and instabilities that are inherent in any social organization or practice.”4Western science, in the postmodern view, tends to be associated with coercive power and oppression.
Michel Foucault’s analysis of psychiatry is perhaps the archetypal antifoundational critique. Foucault holds that psychiatric medicine has merely fabricated a set of pseudo-objective technical terms—“delusions,” “paranoid,” “acute schizophrenia,” etc—and imposed this linguistic framework on a largely powerless group of social misfits. According to Foucault,5 these unfortunates—labeled “insane” or “mentally ill” by psychiatrists—have been denied their own “discourse” and made to conform to the collective discourse (the episteme [systems of understanding]) of psychiatric medicine. There is some degree of convergence between Foucault’s claims and those of Szasz, in so far as both castigate institutional psychiatry for its supposed coercive or authoritarian practices . . .
It is important to remember that this description of antifoundational viewpoints is offered by authors who generally disagree with the viewpoint. Thus, its accuracy should not be automatically assumed without critical investigation. Michel Foucault, for instance, articulated a very robust social critique of which psychiatry and its role within society in the mid-20th century was but one small part. His broader themes are important and difficult to dispute. Namely, he argues that institutions have a strong vested interest in protecting “social norms.” But what are social norms? Who has defined “normal” and “abnormal” actions, behaviors or activities and for what purpose have they so defined them?
The authors of the article further interpret Foucault’s positions as follows:
Foucault argues that all disciplines—whether scientific, legal, political, or social—operate through a system of self-legitimizing texts and linguistic conventions. Truth, therefore, cannot be absolute and claims of objectivity are impossible. More specifically, Foucault maintained that the definition and treatment of insanity constitutes a form of social control. In his classic Madness and Civilization, Foucault held that involuntary confinement of those deemed insane is really a coercive attempt to confine and marginalize madness.
While this may be a difficult notion for psychiatrists and other mental health practitioners to embrace, we must be aware at some level that diagnosis and treatment of mental illness is not based on clearly empirical or objective data. We have as of yet not traced mental illnesses such as Schizophrenia to genetic defect, disease, virus or some other tangible cause. Our diagnosis of mental illness relies on subjective interpretations of diagnostic criteria which list a series of symptoms to be observed and interpreted by an authority. There are no medical tests for the “disease” of Bipolar, for example. The judgment of the authority figure or group of authority figures is foremost. When Foucault points out this truth, he should not be criticized for doing so.
There is possibly no greater example of a self-legitimizing text than the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV.) Without clear concrete basis on empirically measurable data, standards for classification and labeling of a litany of mental “disorders” were created by fiat. That is not to say that there was no process, or that there was no evidence base of any kind (subjective and open to interpretation though it may be) or that there were not many safeguards erected in the development and evolution of the DSM in order to make it as “legitimate” and useful as possible. But the fact remains, it rests not in objective science but in subjective judgments about what other people’s behaviors and experiences mean to us, and thus how they should be labeled. Thus, Foucault is certainly well within bounds to make reference to self-legitimizing texts and linguistic conventions, and we look foolish when we attempt to run away from that criticism. We could instead embrace it and allow it to better qualify and humanize our practice.
Foucault’s critique about institutions wielding power and functioning as a mechanism of social control should not seem particularly radical. Psychiatrists and other mental health professionals hold tremendous coercive power over the freedom of others. There is a significant inclination to make judgments about a client’s “best interests” based on our understanding of social norms, western-cultural roles, and the interests of privileged members of society in maintaining “order.” When we are at our best, we make our primary focus the expressed needs and desires of the particular individual we are working with. But it is impossible to separate that effort from the social constraints imposed by our institutions that emphasize conformity to a set definition of “normalcy” or “mental health.”
I believe that it is a mistake to trivialize the criticisms made from an antifoundational perspective. The authors of the article choose to identify that they call “fallacies” with antifoundational positions and then attempt to dismiss the claims as invalid:
Foucault’s analysis may shed light on how differing epistemes affect society’s management of mental illness, but it does not impugn the ontological reality of mental illness or the immense suffering it causes. Furthermore, following Foucault’s own postmodern logic, his claims regarding madness must be viewed as merely another episteme, wherein Foucault asserts his own self-legitimizing power and knowledge. Like most postmodern claims, Foucault’s argument effectively devours itself.
Finally, whereas Foucault saw himself as a kind of cultural archeologist, he is more accurately viewed as an old-fashioned moralist. Foucault’s argument with psychiatric praxis, like Szasz’s, is fundamentally hortatory: it implicitly prescribes and proscribes how people ought to behave toward their fellow citizens; eg, “We should not lock people away merely because they think or behave in ways we don’t like!” Foucault’s analysis is perfectly respectable and potentially salutary political advocacy, but it is in no sense a scientifically based critique of psychiatry. Indeed, as Ian Hacking observes, “Despite all the fireworks, Madness and Civilization follows the romantic convention that sees the exercise of power as repression, which is wicked.”
I argue that the “ontological reality of mental illness” is a nonsensical statement. While it is an ontological reality that human beings have a wide range of experiences, that some of them are distressing either for themselves or others or both, “mental illness” is a label and mechanism of classification by which persons in authority decide which experiences meet the criteria for “illness” and which do not. Despite all desire to be as consistent as possible in these determinations, there is currently no way to avoid subjectivity in classification.
With regard to the suffering mental illness causes, the appropriate question to ask in response is, “causes for who?” It is certainly true that human beings can have experiences that cause deep pain and distress for themselves. When does distress become “insanity,” who makes that determination, on what basis and for what purpose? I would suggest within mental health professions there is a notable preoccupation with the distress someones experiences causes for society, their cost (financial or otherwise) to social institutions, as well as personal judgements about what should and should not be acceptable ways to live. All this points to the clear interest (conscious or unconscious) psychiatry, psychology, social work, etc. as institutions have in protecting social norms.
With regard to the characterization of Foucault as an “old-fashioned moralist” I am puzzled as to why this is considered to be a negative criticism at all. Ian Hacking may feel that a deep commitment to the values of non-exploitation and empowerment is mere “romantic convention” or old-fashioned. I argue that mental health professions lose their claim to any sort of legitimacy when they reject a sense of moral responsibility to the principle of empowerment in therapeutic relationships, the breakdown of traditional coercive power dynamics, promotion of empathetic and compassionate collaborative partnerships and resistance of abstract authority, heirarchy and unquestioned assumptions about social “norms.”
Notice that in objecting to Foucault’s criticisms, a separation is made between “political advocacy” and the work of psychiatry and mental health. Why is this this case? Seemingly without conscious thought, psychiatry commits itself to functioning as a defender of social norms and identifies its role as helping people whose lives exists outside those boundaries learn ways to integrate and conform to those standards. How often is it that we find psychiatrists questioning the usefulness, justice or legitimacy of the “standards” themselves? It is not just psychiatry that has adopted a largely conservative stance in practice but all mental health professions from social workers to crisis counselors.
Dennis Saleebey, writing specifically to social workers gives a statement broadly relevant to mental health professionals. He writes:
As a profession, Social Work is sometimes criticized as a “conservative” endeavor which seeks to adapt individuals to social norms without questioning whether such norms are in fact illegitimate or oppressive. In fact, Robert Lindner, author of the famous case study Rebel Without a Cause, stated precisely that. He accused social work of “being a tool for promoting mindless adjustment to both oppressive and inane social norms” (2001, p. 239).
Malcolm Payne (2005) adds to this criticism by describing objections to the professionalisation of social work. In this context, the criticism is as important for psychiatrists, clinical psychologists, and crisis counselors as it is to social workers. He writes:
[Critical] social work was concerned with how the professionalisation of social work disadvantages clients’ interests, and leads social workers to become part of the state and social interests which oppress clients, and seeks their profession’s development even where this is contrary to client’s interests. Moreover, professionalisation encourages an emphasis on the technical rather than the moral and political aspects of helping, separates social work from other related professions by emphasizing qualification and promotes professional hierarchies and so incorporates inequalities (p.234).
Bob Pease and Jan Fook (2001) argue that social workers should be actively skeptical of all theories that suggest a unified objective reality. And again, this exhortation is broadly applicable to all mental health professionals. They write:
As social workers, we should question how our cultural experience might cause us to privilege some aspects of reality and marginalize and disqualify others. We would encourage clients to collaborate in the construction of meaning associated with their experience. Meaning is constructed through conversation and dialogue. This requires social workers to allow their professional knowledge to be challenged . . .we must reconsider the notion that social work is a unitary activity based on a coherent body of knowledge and expertise (p. 11)
What then, is the value of “antifoundational” (most of us would just call it postmodern) thinking in psychotherapy and across the mental health professions? As mental health practitioners, we can summarize the over-arching concept of post-modernism as a rejection of the notion that clients fit neatly into boxes. Thinking in this way can help practitioners avoid depersonalizing clients by an overdependence on classification. It can also assist practitioners in understanding important contextual realities for each client, such as the way environmental, ethnic, cultural, and historical factors color the client’s interpretations and experiences.
Postmodernist reflexivity can serve as a reminder to practitioners that a consistent feature of most quantitative generalizations is that there will most likely be persons to which such generalizations do not apply. While those cases may be a minority, mental heath practitioners are charged with the task of affirming and supporting difference rather than marginalizing it for the sake of convenient categories.
To this end, mental health practitioners must be critical of those who advocate certain practice approaches as “best” without careful consideration of difference and variability. What if there are actually few universal “best practices” but many practices that may be “best” for a specific client in a specific context? Postmodernist arguments even embolden social workers to challenge the dominant belief in quantifiable “evidence-based practice.”
We can deconstruct the hidden potentials for dogmatic thinking intrinsic to the term and reconstruct a concept of an “evidence-base” as heuristic and provisional - with the ultimate authority resting not on a body of evidence, but with the individual practitioner who must interpret – and in some cases reject – that evidence in a specific situation with a particular client. If we as practitioners fail to do this, then we may be in danger of confirming the charge that mental health professions from psychiatry to social work are conservative professions that blindly reinforce dominant social norms without questioning their validity.
Finally, I recommend two books as examples of how postmodern criticisms can be integrated into practice. Reading Foucault for Social Work, edited by Adrienne S. Chambon, Allan Irving and Laura Epstein is quite relevant given its opposite reaction to Foucault’s ideas. This collection of essays from mental health practitioners demonstrates the urgent need to embrace postmodern criticisms in order to connect more fully to meaningful context-driven practice. Understanding Exerpience: Psychotherapy and Postmodernism edited by Roger A. Frie focuses on the impact of postmodern philosophy on contemporary psychotherapy. Far from viewing the interaction as antogonistic, Frie sees the potential for postmodern criticism to enrich the potential of psychotherapy in a modern age.
Works Cited
Chambon, A., Irving, A. & Epstein, L. (1999). Reading foucault for social work. Columbia University Press. Frie, R. (2003). Understanding exerpience: psychotherapy and postmodernism. London: Routledge.
Payne, M. (2005). Modern social work theory. Chicago: Lyceum Books, Inc.
Pease, B. & Fook, J. (Eds.). (1999). Transforming social work practice: post-modern critical perspectives. London: Routledge.
Pies, R., Thommi, S. & Ghaemi, N. (2011). “Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry.” Psychiatric Times (Online: http://www.psychiatrictimes.com/display/article/10168/1895157)
Saleebey, D. (2001). Human behavior and social environments: a biopsychosocial approach. New York: Columbia University Press.
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