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Making Minds and MadnessReview - Making Minds and Madness
From Hysteria to Depression
by Mikkel Borch-Jacobsen
Cambridge University Press, 2009
Review by George Tudorie
Jan 25th 2011 (Volume 15, Issue 4)

Writing in 2005, in a chapter of the notorious Livre Noir de la Psychanalyse aimed at nullifying the Freudian claim that suggestion has nothing to do with analytic therapy, Mikkel Borch-Jacobsen presents the reader with the following dilemma: '[...] is there such a creature as an objective "psychological reality" [réalité psychique]? Or rather the reality one encounters in psychology and in psychotherapy is always constructed, produced, fabricated by [...] "expectations" [...]?' (pp. 386-7, my translation). In his new book, Making Minds and Madness, as in his previous writings, Borch-Jacobsen argues for the latter. Things psychological are not passive bits of nature, like rocks or livers, but entities that emerge from -- often tacit -- negotiations, choices and complicities. Social contracts rule not only the realm of politics, but all human affairs, including the design of the lenses through which we come to see our minds. The epistemologically inclined will be interested to learn that psycho(patho)logical entities, from hysteria to depression, as the subtitle has it, are not discovered, but 'made', i.e. decided upon. Such is the organizing idea of Making Minds and Madness. What the idea organizes is not new material (with the exception of one chapter, #12) though some of the chapters have not been published in English before. Readers of Le Débat or the London Review of Books will be familiar with more than a few of them, and such an educated but not expert audience remains the intended readership of the book.

In terms of structure, a methodological Introduction opens into four asymmetrical sections. The Introduction is representative of the book, in sharing both its qualities and its weaknesses. Borch-Jacobsen proposes to overcome 'the old theoretical complicity between the historian and the psychiatrist ' (p. 4) and to write a history of the field that is less 'iatrocentric' (dependent on the doctors' point of view). This recommendation is supported by the author's conception of the nature of mental illness. To his merit, Borch-Jacobsen, though relentlessly constructivist, steers clear of antipsychiatric clichés. He distinguishes between diseases that have a clear biological cause and which, as a consequence, are 'ahistorical' (i.e. Alzheimer), and claims that most psychiatric disorders do not fall under such a model. Rather, they are historical phenomena influenced by how both doctors and patients think and speak of them. The task of the historian then is to describe the life cycles of these performative 'idioms'.

This view of mental illness merits close attention. In saying that mental illness is constructed, Borch-Jacobsen does not deny that it is real. The 'inference' from saying that an illness is socially constructed to claiming that it is therefore fictional remains safely in the possession of antipsychiatrists. Moreover, according to Borch-Jacobsen, the 'language' of suffering that a disease provides is not simply a vehicle for expressing already existing, well-defined ills. The presence of such an 'idiom' in a culture has a contribution to fabricating the ills in the first place. The past epidemic of sophisticated sexual complexes might have been in fact an epidemic of psychoanalysis. The present epidemic of depression might be a partly commercial epidemic of antidepressants. This is an important idea, and in emphasizing the active role of those suffering, Borch-Jacobsen manages to illuminate it from a fresh angle.

As for the weaknesses, leaving aside the fact that many might justifiably disagree with Borch-Jacobsen's labeling most psychiatric disorders 'historical' (he contradicts himself at times, e.g. when he talks about the remarkably consistent descriptions of melancholy over time), there is one serious issue with his view of mental illness, and this doubt extends over the whole book. Speaking any language presupposes rationality, so the 'idiom' of mental illnesses will presuppose it too. Symptoms will collapse into the category of speech acts, and madness, as a consequence, will have at best an ambiguous relation with rationality. This amounts to a near refutation and is certainly an irony: it makes less sense to accuse psychoanalysts of interpretative adventurism when one insists that 'However aberrant or incomprehensible they might appear at first glance, the patient's symptoms are always distress signals, calls for help' (p. 7). Perhaps Borch-Jacobsen is too eager to argue that 'madness is always a folie à deux' (p. 8), i.e. that is collaborative work, and he forgets that one still deals with a 'folie', with unreason.

The first three sections of the book consist, mostly, of a multifaceted attack on psychoanalysis. Out of the nine chapters included in these sections, five have psychoanalysis as their main target, while the others indirectly contribute to caging Borch-Jacobsen's bête noire. This is not at all surprising from an author who is an important participant in the 'Freud wars', indeed one of the vehement public critics of 'psychodynamic' theories. Even if unnecessarily loud at points, Mikkel Borch-Jacobsen's acid reconstruction of the origins of psychoanalysis is meticulous and convincingly knowledgeable. It forms, by far, I think, the best part of the book.

The offensive begins with a chapter dedicated to the prehistory of psychoanalysis. The idea that neuroses have a traumatic origin and that shock is followed by amnesia has its roots in Charcot's work. Borch-Jacobsen shows that there was very little initial support for this claim, and that Charcot and his team at the Salpêtrière went on to create, by 'coaching' patients, 'a true psychiatric myth, fated to a grand future: the patient is entirely ignorant of the trauma that caused his symptoms.' (p. 30).

Freud thought that once he had eliminated (Charcotian) hypnosis from his therapeutic arsenal, he had thereby escaped the dangers of molding his patients' behavior, by suggestion, according to his own expectations. Chapters 2, and 5 to 9 give reasons to think Freud was not only wrong, but hypocritical. Chapter 2 documents the trajectory of seduction theory in the 1890s. The theory had it that hysteria was caused by sexual abuse, the memories of which Freud was able to recover in many of his patients at the time. Borch-Jacobsen offers conclusive evidence that this hypothesis was not motivated by clinical material, but preceded it (p. 48), and it was exported to patients by mechanisms of suggestion other than hypnosis (e.g. authoritative questioning). Symmetrically, under this umbrella of 'imaginary positivism' (p. 167), the theory did not die out because it lacked clinical data (the supply of memories of seduction seemed inexhaustible), but because the shaky nature of the patients' stories became obvious. It is here that Borch-Jacobsen parts ways with other critics of Freud, arguing that the 'scenes' of seduction were not simply Freud's inventions, but, at least in some cases, the way 'his patients actively responded to his suggestions, "reproducing" all the scenes that he expected of them.' (p. 51)

This story of seduction and suggestion becomes clearer in chapters 5 and 6. Discussing the work of Bernheim and Delbœuf, Borch-Jacobsen shows that, while extensively working with hypnosis, they arrived at the correct categorization of it as a species of suggestion among others. Their lucidity on the matter exceeded that of Freud, who based his postulation of the unconscious on the above mentioned move: no hypnosis, no suggestion. There are unconscious ideas, very roughly, because, since the patient has not been hypnotized, they could not have been suggested to her. An obviously fallacious argument, and a recipe for 'hypnosis without hypnosis' (p. 133) and for 'interprefaction' (p. 165) -- the production by contagious interpretation of the facts that were supposed to be observed.

This criticism is recurrent and takes center stage in the third part of the book (chapters 7 to 9), together with more serious accusations of endemic forgery. Borch-Jacobsen's use of the historical record is impressive. Chapter 7, for example, illustrates the founding bluffs of psychoanalysis, an enterprise similar to the summary of Freud's dismal therapeutic record in the second section of the Livre Noir (Borch-Jacobsen has also written a book-length account of the case of 'Anna O.'). We learn not only that the case histories which played 'an exorbitant epistemological role in psychoanalysis' (p. 144) were doctored, but that often enough they ignored the vocal opposition of the patients to the interpretations proposed by Freud. Whether such breaches of contract fit the suggestion model is a good question. Borch-Jacobsen emphasizes constantly the cooperative construction of psychopathologies, but the fact that patients 'are inevitable interested in the theories of which they are the object' (p. 165) does not translate into a invariable willingness to confirm the expectations of their doctors. Very likely, this signals both a degree a vagueness and a limit of the model of suggestion / interprefaction.

The interprefaction metaphor which informs chapter 8 captures the illegitimate transition between speculative interpretation and observation in yet stronger terms. On the one hand, we have the already discussed story of suggestion, the manufacturing of 'idioms of distress' by the duet doctor-patient, but there is also a stronger emphasis on the epistemological apparatus of psychoanalysis, on the selling of airy speculation as hard fact to the general intellectual market. There are epidemics which infect not only the ill, but whole cultures. Such epidemics are aggravated, as chapter 9 shows, by packing psychoanalysis, an empty theory, into an illusion of progress given by the fact that it easily branched into variants. There is no progress in this case because there is no metric of progress; it is not as if previous versions, including Freud's founding one, have been falsified and replaced by more resilient theories. This does not mean, however, that Borch-Jacobsen believes that there could be an objective psychological reality against which to unmask Freud's misconduct or the impossibility of progress in a 'zero theory' (Livre Noir) like psychoanalysis. He parts ways again, in this case, with 'realist' critics, by extending his constructivism to psychology and human sciences in general. Freud was a liar, but what he concealed was his production of artifacts, not an independent psycho(patho)logical) reality. There isn't any.

This generalized anti-realist stance about human sciences serves well to introduce the remaining chapters of the book and to formulate a number of conclusions. Given that we deal with a collection of previously published materials, it is perhaps not surprising that the book is not consistent in the ways it departs from its core (the criticism of psychoanalysis). But, overall, it is in these sections of the book that Borch-Jacobsen tries to show how the model extracted from his detective work on the origins of psychoanalysis can be applied to other areas of the study and treatment of the mind. The horizon of this effort is the idea that his model holds generally.

Chapters 3 and 4 add to the case of constructivism. The former deconstructs the disturbing history of the impact of one book, Flora Rheta Schreiber's 1973 bestseller Sybil, on the recent temporary inflation of multiple personality disorder (MPD), particularly in the US. Marketed as a solid case history, the book has turned out to be a dubious assembly of fact, fiction and wishful thinking. That such a forgery could lead to an escalation of diagnosis with all its accompanying effects is not only a reminder of the most dubious 'successes' of psychoanalysis, but evidence that the manufacturing of exotic varieties of madness did not stop with Freud. However, it is less clear what one can deduce from the MPD craze. Borch-Jacobsen wants to see in it a confirmation of his collaborative constructivism: 'Humans, even when afflicted with psychiatric disorders, are fully qualified actors [...]. They cooperate with doctors, theories, and institutions to keep the syndrome they suffer from alive.'(p. 71). While this might be the case with MPD, some psychiatric illnesses are, to return to the Introduction, 'ahistorical'. In what sense a psychotic person undergoing an acute delusional episode is a 'fully qualified actor' one can only wonder.

Chapter 4, a discussion of Ian Hacking's concept of 'transient mental illnesses', provides an explanatory machinery for a life cycle of psychopathologies as that exemplified by MPD. Like organisms, these illnesses adapt to 'ecological niches', that is, to local social conditions. While Hacking is careful to distinguish between the transient and the 'real' mental diseases (e.g. schizophrenia), Borch-Jacobsen pushes constructivism to the limit (indeed, beyond it), and leaves behind his own more prudent phrasing, by expressing doubts about any such distinction. His attempt to patch this unconvincing generalization with a kind of Wittgensteinian refusal of depth is, to my mind, disappointing.

This risky tendency manifests itself fully in the fourth part of the book, which, as a consequence, is strikingly weaker than the rest of the text.  Borch-Jacobsen develops in these chapters (10 to 13) a taste for hasty generalizations and allows his prose to become repetitive and programmatic. This section begins with a loose criticism of the victory of the 'men in white' (biologically inclined psychiatrists) over the 'men in tweed' (psychodynamically oriented psychiatrists). One is offered the usual menu: the suggestion that Western biological psychiatry can be seen by the 'symmetrical anthropologist' as a belief system about madness as any other, including in terms of its capacity to treat mental illnesses; the attack on the DSM system; the doubts about the 'way in which therapeutic efficacy is measured and demonstrated in modern medicine.' (p. 192); the accusation that the hegemony of medication has led to a 'barbaric system' (p. 193) in which 'prisons [...] have, to a large extent, replaced asylums.'(p. 194); the unmasking of the dark role of the pharmaceutical industry in the marketing of profitable illnesses; and a description of the increasingly challenged (by patient groups) deficit of democracy in psychiatric practice.

Some of these ideas are worth discussing and, without exception, they have been and continue to be the subject of extensive debates (e.g. certainly the field can do better than mistake the DSM approach for scientific medicine). Leaving aside that Borch-Jacobsen's treatment of even these legitimate topics is often biased (even in the better parts of this section, in chapter 12), some of his claims lack any reasonable justification. His attack on the double-blind, placebo-controlled testing reads like a summary of Bentall's Doctoring the Mind, a recent revival of antipsychiatric dogma. This is not a compliment. Even worse is his insistence to extend the paradigm of multiparty constructivism to all 'sciences of the psyche' (p. 128) and their applications. It is one thing to criticize Big Pharma for acting like a 'depression cartel' (p. 199), and quite another to overuse the terminology of 'recruitment' to the point of emptying it of any meaning: 'Antidepressants [...] "recruit" depressives, and do so because they work.' (p. 201). Same goes for democratization. It is best not to confuse the patients' experience of their diseases with expertise (p. 216). But the most important mistake, I think, is the leveling of vital differences. Borch-Jacobsen speaks earlier in his book about 'the end of psychology' (p. 120) and the 'impossibility of psychology' (p. 128), and the idea that psycho(patho)logy is impossible as a science of passive, objective stuff is recurrent in the text. However, going from this interesting though controversial stance to putting psychopharmacology and psychotherapy (or psychoanalysis and experimental psychology) in the same boat is a blunder. Not because psychopharmacology or experimental psychology are epistemologically flawless, but because faced with the kind of criticisms that Borch-Jacobsen himself levels against psychodynamic theories they fare better. This difference of degree is all important.

Psycho(patho)logy was left by the waves of Freudianism in a mess. Borch-Jacobsen, as in other occasions, offers a convincing and erudite demonstration thereof. His account of the MPD epidemic is a condensation of scholarly and detective work at their finest. When he is not abusing the concept of transient mental illnesses and the illustrations of the power of psychiatric concepts to recruit willing adepts, he builds a credible argument for considering some mental illnesses interactive. But in generalizing this model of mental illness as contract and complicity he has a much weaker case. As Daniel Eisenstein observed in the London Review of Books about an earlier version of the present book's chapter 9, 'As for the fashionable idea that mental suffering mimics trends in psychoanalytic theory, tell that to an eight-year-old silently in the grip of acute obsessional anxiety.' The criticism Borch-Jacobsen draws from such unwarranted generalizations inherits their flaws. Biomedical psychiatry is not without sins, but is not 'a form of rhetoric' (p. 202) and psycho(patho)logy, more often than not, is not a category of politics. Madness can be 'made' and perhaps seeing it in such contexts as a 'life-form' (p. 228) is not without merit, but one has to wonder whether that is the rule, and whether it is not better to speak, in such cases, of 'madness'.

 

© 2011 George Tudorie

 

George Tudorie is a PhD student in philosophy, Central European University, Budapest; and teaching assistant, College of Communication and PR, Bucharest.


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