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Healing PsychiatryReview - Healing Psychiatry
Bridging the Science/Humanism Divide
by David H. Brendel
MIT Press, 2006
Review by Jessica Wahman, Ph.D.
Jul 25th 2006 (Volume 10, Issue 30)

The purpose of Healing Psychiatry: Bridging the Science/Humanism Divide is--as the subtitle indicates--to repair the schism between competing explanations and treatments of psychological illness by offering a broader and more inclusive theoretical framework. In place of the "medication versus talk therapy" debates, David Brendel advocates a dialectical interaction between methodologies, and he finds both the justification and the means for this process in philosophical pragmatism. Brendel, an Associate Professor of Psychiatry at Harvard Medical School, draws on a variety of sources to make his claims: from the classical pragmatists William James, C.S. Peirce, and John Dewey, to contemporary pragmatic bioethicists, neopragmatists like Hilary Putnam and Richard Rorty, and self-styled American cultural critic Louis Menand. The results of his investigations are four "p" principles, which he identifies with the pragmatic approach and applies, in turn, to psychiatry. Pragmatism, in this context, addresses the practical benefits of therapy and argues for a plurality of methodologies, participation of the client in his or her own healing, and the provisional nature of any diagnosis, explanation, or treatment plan.

Brendel's audience is, from what I can tell, primarily philosophically-minded psychiatrists and similar members of the healing professions. This intuition may stem from the fact that the strongest moments in the book are the case studies, where Brendel provides evidence for the failure of unitary models of explanation and argues well for the greater benefit of his pragmatic approach. These parts of the book indicate not only that a psychiatrist needs to have access to multiple methodologies and to be flexible in their implementation, but, more importantly, that the patient's own interpretation of the method being employed alters the effectiveness of the therapy in question. As such, this book is successful at challenging the absolutisms that prevail in both biologically reductionistic and strictly psychoanalytic methodologies.

However, even though Brendel is careful and thorough in his investigation, a philosopher reading this book will be somewhat frustrated by the more theoretical aspects of the text. Philosophers of mind will readily detect the inconsistencies between a naturalist account of mind in Chapter Four, "Pragmatism and the Mind-Body Problem," in which Brendel asserts that there is only one mind-brain event in question, and his support of an interactionist dualism between mental and physical events in the next chapter when he interprets Sigmund Freud's "psychophysical parallelism" (95) as evidence that Freud was a pragmatist. Furthermore, the choice of Freud as an exemplar of pragmatic psychology is puzzling, for it begs more questions than it answers and therefore does not well serve the book's overall argument. For example, why does the author not draw on William James's own associationist approach, or on Carl Rogers's humanistic psychology, which was influenced by John Dewey? There are many easy challenges to the claim that Freudian therapy observes Brendel's four principles (to say nothing of whether Freud was a pragmatist), not the least of which is the controversial concept of denial in response to challenges by the patient to the therapist's diagnoses. At face value, the reader wonders how this can be reconciled with the imperative of participation on the part of the client in determining the source of suffering (a principle that Carl Rogers's client-centered therapy took pains to observe). In short, the reader may find the chapter on Freud to be a weakness in Brendel's argument rather than a clarification of pragmatism's strengths.

The contentious claim that Freud was a pragmatist illuminates a more significant problem with the philosophical aspect of Brendel's work, namely his misunderstanding of pragmatism's theory and method, though he is accurate about its pluralistic, participatory, and provisional implications. While pragmatic philosophy does focus on consequences and while it does view concepts as tools in some sense, it is not the instrumentalism that Brendel's principle of practical utility would indicate. The idea that pragmatism focuses primarily on practical benefit leads to the misapprehension that truths are simply aggregates of handy implements to be used to our advantage. This is why Brendel claims Freud is a pragmatist, because he utilized both neurological and psychoanalytic explanations. This confusion of pragmatism as instrumentalist (a common one, unfortunately) leads the author to propose a sort of grab bag of methodologies--a psychiatrist should have a toolkit of many methods because different ones may be required at different times. What this seems to imply is that the truth of the client's suffering is determined by whichever method happens to be helping. This kind of an explanation is not going to satisfy an empirically minded scientist nor even our common sense instincts that there must be something objectively going on, and so we need a stronger sense of pragmatism's power to overcome psychiatry's methodological divide.

In discovering his four principles of pragmatism, Brendel seems to have overlooked one deriving from the most obvious "p": pragma. While "practical outcome" is certainly one connotation of the Greek word, the primary meaning in the context of classical pragmatism is "action." While Peirce, James, and Dewey differed in many respects, each philosopher explained truth as the product of an active engagement with one's environment. In opposition to a purely abstract form of philosophical argumentation, the pragmatist argues that truth emerges only as a result of experimentation (more or less strictly construed). The truth of any given matter is what the facts present themselves to be when we test our hypotheses empirically.

The upshot of the focus on truth as a consequence of interaction with the world is no mere technical matter. It is significant to Brendel's aim at overcoming the divide between science and humanism in psychiatry, and so should be investigated more closely than he does here. For the pragmatist, there is no hard and fast dichotomy between objective science and subjective humanism: science is a humanistic practice, for it is performed by humans in the service of human life; and humane beliefs about what is valuable must always be subject to empirical challenges. Pragmatism challenges the assumption of an objective/subjective divide by recognizing the human element in all inquiry as well as the objective nature of the situation under scrutiny. In other words, when properly construed, pragmatism can actually provide Brendel with the more inclusive dialectical concept he needs to overcome the reductionism of competing camps in psychiatry.

Despite my philosophical criticisms, I think Brendel's project is very important, and he makes an excellent case for a more integrated approach to the problem of human suffering. His case studies already provide prima facie evidence for the problems inherent in trying to make the client fit the theory, and he correctly identifies the pragmatic principles of pluralism, participation, and provisional knowledge that can aid in its solution. The contribution of a more thoroughgoing understanding of pragmatic truth than is here expressed will take him in the theoretical direction he needs to travel. I have great respect for Brendel's philosophical diagnosis of the disordered state of psychiatry, and I hope he continues to engage with pragmatism, for he will find in it an even stronger ally than I believe he has yet discovered.

 

2006 Jessica Wahman

 

Jessica Wahman, Ph.D., is an Assistant Professor in the Philosophy Department at Dickinson College in Carlisle, Pennsylvania. She specializes in American philosophy, especially the work of George Santayana, and in topics connected to philosophy and psychology, including the philosophy of mind.


David Brendel responds to Jessica Wahman's review [published 8/23/06]:

 

Healing Psychiatry aims to show how psychiatrists and patients can benefit from a philosophical approach rooted in classical American pragmatism and contemporary pragmatic bioethics. Many thinkers have attempted to apply philosophical pragmatism to their areas of study or practice -- such as medicine, law, and political science -- but, before the publication of Healing Psychiatry, there had been no systematic attempt to do so in psychiatry. Jessica Wahman and I agree that the "four p's" of pragmatism which I delineate -- the practical, pluralistic, participatory, and provisional aspects of scientific and psychiatric understanding -- provide a basis for a more nuanced and patient-centered psychiatry.

My book endeavors to show (rather than to provide an abstract argument for) the role of action in the pragmatic model. Indeed, chapter 3 of the book, which presents clinical vignettes that depict the application of my notion of pragmatism, is entitled "Pragmatism in Action: Clinical Cases." Since depicting the application of pragmatism in clinical practice is a central aim of Healing Psychiatry, I was pleased to learn that Wahman found this aspect of the book to be strong and convincing. I agree with her that my work with these patients, who suffered with complex biomedical and psychosocial problems, provides prima facie evidence for the inadequacy of reductive explanatory models. Therefore, Wahman's suggestion that I should have focused more of the discussion in Healing Psychiatry on the core pragmatist value of action is puzzling. I do not share Wahman's preoccupation with a de-contextualized theory of action, which strikes me as antithetical to the central principle of pragmatism. Clinical pragmatism, as I see it, is less concerned with abstract theory than with how its basic tenets can help real patients who are suffering in the real world.

Wahman suggests that my pragmatic approach allows a clinician to use a "grab bag" of diagnostic and therapeutic methods and that it conceptualizes a patient's suffering only in terms of what treatment appears to be helping. "This kind of an explanation," she writes, "is not going to satisfy an empirically minded scientist nor even our common sense instincts that there must be something objectively going on." Reading this criticism, I was first amused, then intrigued, to recall that at a recent "Author Meets Critics" event for my book in New York City, one of the discussants had suggested exactly the opposite -- i.e., that my book argues too strongly in favor of a realist model of science (the discussant stated that he would like me to adopt the relativistic pragmatism of someone like Rorty, instead of the "four p's). What's going on here? My definition of clinical pragmatism, it would seem, can be attacked from the "left" as too conservatively wedded to traditional scientific realism, or it can be attacked from the "right" ( la Wahman) as too relativistic, too liberally trading what is "true" for what happens to work. So it would be worth taking a few moments to define where I stand on this issue.

I am a scientific realist who believes it is important to study mental disorders empirically. On pages 33-34 of the book, for example, I specifically address the concern that Wahman has raised regarding objective science. There, after mentioning William James's related concern that a counterfeit banknote successfully passed off on an unknowing merchant should not be considered valid currency, I explain that pragmatism should not lead a psychiatrist to conclude that a treatment that works for some patients eliminates the need for empirical research into the underlying pathophysiology of the condition. A pragmatist who rejects scientific realism could conclude, for example, that there is no reason to understand what really happens in a patient's brain when an antidepressant medication takes effect, because a good clinical outcome has been assured. In my opinion, such a conclusion is not only intellectually dissatisfying, but also would stymie research into more effective ways to treat depression that are based on what is actually going on in the brain.

Contrary to what Wahman suggests, I do not endorse a relativistic brand of pragmatism. Psychiatrists, I believe, must engage in empirical science to identify what happens in the brain when mental illness strikes. Notwithstanding this commitment to scientific realism, however, psychiatrists must act on their patients' behalf in the present, when scientific knowledge is rudimentary. Scientific realism does not get a clinical psychiatrist very far when the relevant science is not available (and even if it were available, patients may reject "evidence-based" recommendations in favor of an individually tailored approach that they participate in co-constructing). This is why I argue that psychiatrists can find a firm grounding for clinical action in the "four p's" that I delineate in Healing Psychiatry. I do not espouse a "grab bag" of clinical tools, but rather a well-reasoned treatment plan that is rooted in the available scientific evidence and in an open-minded, pluralistic, and collaborative assessment.

My final points relate to what I see as Wahman's misreading of the material on Freud (chapter 5). Nowhere do I state or imply that I support what she calls "the controversial concept of denial in response to challenges by the patient to the therapist's diagnoses." Such an approach would run counter to clinical pragmatism's principles of participatory care and provisional explanation, and it is not an aspect of Freud's work I emphasized in chapter 5. In fact, I would argue that the unseemly use of denial as a weapon against patients was not part of Freud's work at all, but instead a bastardization of his work by narrow-minded psychoanalysts who succeeded him and misapplied his ideas. I am aware that some of Freud's corpus, such as his ideas on female sexuality, has turned out to be questionable -- and I state this clearly on page 91. Rather than appreciating the strength of Freud's other contributions to clinical practice, however, Wahman would have us throw out the baby with the bathwater. I, on the other hand, stand by my claim that Freud's most important clinical and theoretical work is consistent with clinical pragmatism's focus on constructing action-oriented treatment approaches that incorporate a broad range of concepts in the service of relieving emotional suffering.

Overall, Healing Psychiatry's practical framework for clinical work draws on concepts from a diversity of disciplines, including neuroscience, psychology, and philosophy. My book provides evidence that philosophical pragmatism, a conceptual model that Wahman and I both embrace, provides a sound basis for a 21st-century psychiatry in which patient and clinician together construct a therapeutic action plan that draws on emerging science and enduring human values. By bringing philosophical pragmatism to the clinic, I hope that Healing Psychiatry will strengthen the therapeutic possibilities for people suffering from mental illness.

 

2006 David Brendel

 


 

Jessica Wahman replies [published 8/23/06]:

Where's that Confounded Bridge?

One of the many points of sympathy between David Brendel and myself is a shared interest in the participatory nature of pragmatic inquiry. In other words, we need to work together in our investigations. As it appears that my criticisms of some aspects of his book have been misinterpreted, I will happily attempt an explanation again in the hopes that we may better understand each other. I think there is a good deal that Brendel has already accomplished in his book, and the places where it falls short of its goals can be surmounted. I am highly sympathetic to his project and am primarily interested in offering suggestions that will help him accomplish it even more solidly than he has here.

In regard to his concern that I am focusing on technicalities of theory to the detriment of the actions he has grounded in four basic tenets, let me reiterate that my concern is with one of his four basic tenets, namely the first. Reading pragmatism to be focusing on "practical effect or benefit" of a given theory is a common misunderstanding of pragmatism as an instrumentalism, one which leaves Brendel open to objections such as that which he received in New York, namely that he should give up on the objectivity of science and embrace a Rortyan sort of relativism. I am very pleased that Brendel wants to resist Rorty's version of pragmatism, and I do recognize those passages in which he supports the objectivity of scientific inquiry. But he has not yet shown how pragmatism can provide the dialectical (his word) concept that can truly bridge scientific and humanistic approaches. His project, as he has thus far explained it, leaves him open to objections from opposing sides, from Rorty Relativists as well as reductive scientistic types who claim that humanism will dissolve once science is sophisticated enough to solve the problem at the biological level. It is my wish to buttress his argument against both of these objections by inviting him to reinvestigate the classical pragmatists Peirce, James, and Dewey in order to see how their theories of truth as a product of interaction with one's environment overcomes the false dichotomy between object and subject that currently plagues psychiatry.

Finally, to the disagreement about Freud. Let me clarify that there is much that I like about his defense of the worth of Freud. I never argued that the "baby should be thrown out with the bathwater." In fact, I am a great supporter of Freud's general philosophy. However, I do not share the belief that Freud is a pragmatist and I remain unconvinced by Brendel's argument that he is one. My sense is that the Freud chapter undermines what Brendel wants to achieve in this book in much the same way as does his interpretation of pragmatism as practical utility. There is plenty about Freud that merits defense, in particular the biological grounding of his mythological constructs (id, ego, eros, thanatos, etc.). Perhaps this issue deserves its own book. But here, as a chapter in support of Brendel's attempt to heal the scientific/humanistic divide, it detracts from his project more than it supports his goals.

In short, pragmatism can do even more for Brendel than I believe he realizes. Ours is not an idle technical disagreement but a mutual concern with providing a theoretical justification for exactly the kind of therapeutic practice he supports. I would warmly embrace the opportunity to discuss pragmatism with him further, as I believe it would be to both of our benefits.

 

2006 Jessica Wahman


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