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Supposedly a scene of intimacy, not dissimilar to those belonging in the confessional or the boudoir, the encounter of Everyman with the professionals of mental health has become something of a pop culture fetish. On screen and in print, on the stage and in the gallery, avatars of a pensive doctor Freud watch over the unwell and hear, as they must, their stories. The abundance of these images comes, perhaps, from a twist of public taste, or it may be yet another fingerprint of twisted times. Whichever the genealogy, there is hardly an educated person who could fail to imagine at least the outer skeleton of going through a therapy session or a psychiatric interview. It is fairly easy, for example, to picture oneself describing to one's caregiver feelings of devastating sadness. Borrowing the words of Chekhov's character Ivanov, one might lament thus: "I carry my sadness with me wherever I go; a cold weariness, a discontent, a horror of life." But if it is easy to imagine the professional sitting at one's side listening to this bleak tale, it is harder to discern what the therapist or the psychiatrist makes of one's words. Indeed, this may be a case of induced failure of the imagination. Therapists and clinical psychologists dominate the public retina, and therefore model our expectations in the direction of being listened to. The psychiatrist, on the other hand, remains a more obscure, and darker, figure. She, too, will hear you; but will she listen?
The question touches on a number of sour points in the conceptual and methodological foundations, but also in the ethics, of psychiatric practice. Current psychiatry works within a biological framework which has little use for what people mean when they describe their circumstances. What is said is data to be mined in order to identify symptoms and select the plausible diagnostic checklist. It is not the psychiatrist's job to understand what the patient is trying to convey, to the extent that, in the more serious cases, there even is such a thing. In a sense, then, the psychiatrist must listen, and attentively, if she is to find what her profession considers relevant – signs and symptoms. But there is also a sense in which the psychiatrist is not required to listen at all: she is free to treat what she hears as closer in status to borborygmus, the noises made by bowel movement, than to meaningful speech.
For many critics of biological psychiatry, this latter view represents itself a failure of the imagination, and one which is far more serious than the naiveté of the commoner who imagines that his story actually matters. Bradley Lewis's Narrative Psychiatry belongs in this camp. Not only that it denounces psychiatry's biological monomania, but it suggests an alternative built on the concept of story or narrative. The fundamental idea of the book is that psychiatry should embrace the multitude of perspectives which can be had on mental illness, including the perspectives of those who suffer themselves. Highbrow causal-biological explanation is just one of the narratives that can be constructed about mental illness and, while it must not be excluded from the matrix, as antipsychiatry has demanded, it possesses no priority. Redefined, the psychiatrist's mission is to understand intimately the array of stories which constitute a case ("the task of curiosity", as Lewis calls it – p.146), and to discriminate those elements which can help restructure the patient's own distorted narrative. Medication remains one among the tools that the narrative psychiatrist will use, but for the most part she will act as a pragmatic and enlightened editor.
This is not a technical book, and many in its audience – the general educated public – will find its driving ideals admirable. But most of these readers will also recognize, I fear, that the book fails to make a convincing case for its thesis. At critical points, Lewis remains vague and allusive, too often his claims are made with little or no support, and his anticipatory response to criticism exposes rather than consolidates his stance. As for the merits of the book, it will remind the reader that a degree of skepticism is in order when it comes to the verdicts of psychiatry; it will also act as a basic review of various approaches to mental illness, from expeditive medication to spiritual meditation and feminist criticism; and it will repeat the truism that literature is often a wiser teacher of things human than the various sciences of man.
Lewis states his aims in a Preface, and then develops them in the ten chapters of the book, which concludes with a beautiful short story by Chitra Divakaruni, included as an Appendix. Transcending the rusty cold war which opposes what Lewis calls, somewhat misleadingly, "probiopsychiatry" and "antibiopsychiatry" (e.g. p.2) is the book's general goal. Its specific objective is to use narrative theory with its tools of making sense of stories as an instrument of reconceptualizing psychiatry. Much as the narrative theorist would treat a text, say, a piece of fiction, the psychiatrist should be able not only to understand her patient's tale, but to present to the patient the vast horizon of alternative stories which can woven on the frame of the patient's suffering.
The chapters of the book form two clusters, with the exception of the final chapter which is dedicated to answering objections. The first grouping comprises chapters 1 to 5. The first chapter introduces Lewis's mix of literary theory and psychiatry using Chekhov's Ivanov as a vehicle, a choice one can but applaud. The second and the third chapters argue that medicine and psychotherapy respectively are already undergoing narrative turns, the point being that psychiatry would be well advised to follow suit. At least the claim that "the most insightful voices in medicine are calling for a narrative turn" (p.28) is, however, dubious. The fourth chapter acts as the centerpiece of the book, since it sketches the portrait of narrative psychiatry. The last chapter in this cluster, the fifth, imports the method of chapter 1 and uses fiction, this time Divakaruni's 'Mrs. Dutta Writes a Letter' (the short story provided in the Appendix), to argue that fictional characters are often better models for understanding the complexities of psychiatric conditions than the typical sparse case histories doctors currently use. This again is a problematic assertion.
The second cluster runs the case of Divakaruni's character through the mills of various schools of psychiatric thought, from the mainstream of biological psychiatry or psychoanalysis (chapter 6), to the softer person-centered therapies (chapter 7), and to the somewhat new agey expressive and political therapies (chapter 8). These chapters are best seen as rather simplistic histories of the schools and movements thereby discussed. They feed into chapter 9, which is the applicative counterpart to the abstract description of narrative psychiatry given in chapter 4. Here, Lewis tries to explain what a narrative psychiatrist would actually do when presented with a case as Mrs. Dutta's.
In this context, it is best to focus on what Lewis has to say about narrative psychiatry proper. This is because his criticism of biological psychiatry is unoriginal, referring, as one often does, to the medicalization, overmedication, and mechanization of illness, to the fragility of DSM-based diagnostic practice, and to the marginalization of the patients' views on their own suffering. The reader can turn to the more substantive literature on the subject, for example to the inflammatory books of David Healy or Richard Bentall, or to cerebral volumes such as The Loss of Sadness by Allan Horwitz and Jerome Wakefield.
The brief incursions into the methods of the various therapeutic schools are also only marginally helpful. It is hard to understand why the author decided to allocate, to give just one example, five pages to psychoanalysis and four to Zen meditation. The utterly naive will learn a little about these areas, but even this kind of reader will be misled, since the historical relevance, the theoretical significance, or the effectiveness of these approaches, not to mention the subtleties of the more serious schools, are indiscernible in Lewis's rendering. Simply dividing schools intro mainstream I, mainstream II, and alternative stories will not do. What Lewis calls "alternative stories" is not on a par with Off-Off-Broadway theaters, which are certainly not mainstream, but which can certainly be very good.
Such ecumenism can only damage a text of about 170 pages, but it finds a putative motivation in Lewis's constructive project, i.e. in what narrative psychiatry proposes to be. While it never is completely clear what the project amounts to, a tentative reconstruction might be the following. Psychiatry is fractured along a number of historical and conceptual fault lines. There is, for example, the separation between talk cures and biological intervention, or the institutional tension between clinical psychologists and psychiatrists, or that brutal front of the culture wars which has seen the clashes between antipsychiatry and the scientific-minded establishment, or the frictions between patients and doctors. If one may note that these divisions are in fact external to the biological consensus which rules over institutional and academic psychiatry, there is one fissure which extends to the very core of the field. This is the problem of defining an explanatory language for mental illness, a problem which, as Lewis himself writes, has been given its classical formulation by Karl Jaspers almost a century ago. Either explanation works as it does in the natural sciences, which implies that notions like meaning, intention, belief, or desire must go, or, alternatively, mental phenomena can be understood by educated empathy; they are illuminated as having meaningful content, as making, in certain conditions, sense. As Derek Bolton and Jonathan Hill write, Jaspers
attempted to construct a psychiatry that could embrace both causal explanation in terms of material events and empathic understanding of non-causal meanings. The tension between the two methodologies, however, was covered over rather than resolved. Jaspers' problem was psychiatry's problem. He anticipated what was to become a split within psychiatry between explanation of disorder in terms of brain pathology and 'explanation' in terms of (extraordinary) meanings. (Mind, Meaning, and Mental Disorder. The Nature of Causal Explanation in Psychology and Psychiatry, Second Edition, Oxford University Press, 2003, p.xvii)
Lewis thinks that an approach which uses the tools of narrative theory and its focus on different kinds of stories and their structure can "heal" this divide and liberate psychiatrists from the "uncomfortable conceptual zone" (p.68) in which they find themselves. For example, if one considered the notion of plot – the feature of stories which "allows intelligible connection to be made between the elements of the story" (p.45) – then one might see that stories can be built which integrate biological explanation and its language of disease, and empathetic understanding and its language of illness. This is because, in Lewis's words:
Whether we are talking about disease or illness, the common ground between the two is that they are both forms of meaning making. Disease makes meaning one way, illness another way. But they are both meanings, and they both rely on the tools of language to shape their meaning. (p.69)
Unfortunately, this begs the question. If the language of disease were already a language of "meaning making", there would be no problem to solve. The bet on biological explanation, after all, is motivated by its promise to by-pass intentional stuff, i.e. anything that can be evaluated semantically or in terms of meaning. Such 'naturalized' explanation is, for some, the sought-after mark of proper science. "Plotted stories" – to use Lewis's terminology – may combine elements of both explanatory orders; but a plotted story, intelligible as it may be, will not amount to a unification of the orders, the story will not constitute one explanation. No healing has taken place, and Jaspers's problem remains the problem of psychiatry.
To be fair, Lewis may not care too much about theoretical unification, even if that is Jaspers's problem. A more charitable interpretation, consonant with the line of the book, is that the narrative turn in psychiatry should mean, first, that both the reports of the patients, and the technical narratives of doctors qualify as attempts to make sense of clinical conditions, and that both should be taken into consideration. Second, the healing of the psychiatric divides via narrative means that psychiatrists should be open to alternative manners of conceiving mental illness, e.g. those of person-centered or even alternative therapies, in the sense of presenting these options to the patient and letting her choose. Third, the role of stories in identity construction and in organizing one's life, well exemplified and analyzed in the case of fiction, should be exploited by psychiatrists in the attempt to support or restart the broken self-narratives of their patients.
A few things are to note about the project thus restated. Given current conventions, it is unlikely that narrative psychiatry could qualify as psychiatry to begin with. Yes, there will be medication, but the narrative psychiatrist still seems a very laissez-faire clinical psychologist entitled, as for example Richard Bentall has demanded, to prescribe psychiatric drugs. Some may be skeptical about an abrupt abandonment of psychiatry's admittedly dicey commitment to being an unexceptional, i.e. scientific, branch of medicine; and rightly so.
Connected to the previous point, there is Lewis's obvious inclination for pragmatism, strange in psychiatry, but unexceptional among therapists. Early in the book, we are told that "From a perspective of multiple and ambiguous interpretations, the question to ask is not simply, which story is true? But, instead, what are the consequences of each story?" (p.14) This is a recurrent theme, but its recurrence does not make it more convincing. Treatment implies choice. Lewis denies repeatedly that his ideas lead to relativism, since "actions have consequences" and "[w]hich truth we choose matters deeply" (p.12) . Leaving aside the nonsense about choosing what is true, Lewis provides no feasible way for making choices in the clinical context. What if the patient is so deluded, or muted by raging depression that she cannot partake in any kind of decision making? Of course actions have consequences, but one cannot wait for those consequences to decide which course of action to take. The narrative psychiatrists can be "as comfortable talking about Yoga, creativity, and politics as they are neurotransmitters, cognitive distortions, and psychodynamics." (p.156), but will the patient be in a similarly comfortable position? Surely, the psychiatrist need not be "cocksure" to exert her epistemic authority; if she is wise, she knows that the guidance she can offer is limited, but she also knows that guidance she must offer.
Lastly, a few words about the use of fiction in this book. Lewis is right to deplore a certain vain ignorance of literature and the humanities in some quarters of medicine, but given the amount of information a doctor must handle these days, it is absurd to write that doctors must undergo training "in narrative reading and writing" (p.29). This is not to deny the obvious. Many have recognized the merits of literature in illuminating the mysteries of the mind. Here is Chomsky:
[W]e learn much more of human interest about how people think and feel and act by reading novels or studying history or the activities of ordinary life than from all of naturalistic psychology, and perhaps always will [...]. (New Horizons in the Study of Language and Mind, Cambridge University Press, 2000, p.77)
And here Irvin Yalom:
The truth of fictional characters moves us because it is our own truth. Furthermore, great works of literature teach us about ourselves because they are scorchingly honest, as honest as any clinical data [...]. (Existential Psychotherapy, Basic Books, 1980, p.21)
Lewis, however, treats fictional characters and their stories as patients and case histories, and claims that fiction is a better test ground for his conception of psychiatry than documented case studies. This, I think, is the path to not learning from literature, and an abuse thereof. Yalom's honesty is not the issue here. Worse than diagnosing retrospectively the melancholic writers of yesteryear as suffering from our corporate-megalopolitan depression is to throw whatever psychiatry one favors at their characters. Not even the most psychological of novels is psychiatry in disguise, as honest and true as it may be. Simply insisting that metaphors and scientific models are the same kind of thing proves nothing, because it is false.
The best part of this book, leaving aside Divakaruni's story, is the final chapter. Lewis is manifestly aware of the problems of his proposal, including those that I have raised here. Unfortunately, none are answered adequately, and there is no reason to think that most can be answered. Indeed, the marriage of narrative and psychiatry, as described in this book, seems either obscure, or imitative. It provides no instrument of making responsible clinical decisions. It promises to the ill participation, but it is likely to give birth to more confusion and pain. And it glosses over obvious and decisive difficulties, a fault which cannot be balanced by whatever synthetic information the book manages to provide.
© 2011 George Tudorie
George Tudorie is a PhD student in philosophy, Central European University, Budapest; and teaching assistant, College of Communication and PR, Bucharest.
Response by Bradley Lewis. Received Saturday, December 10, 2011. Published January 4, 2012.
What a strange review. At times, the reviewer seems to be sensitively reading the book. For example, he does a very thoughtful summary at the beginning, and he uses the material of the book to bring up subtle and complicated questions—like what happens to the old conundrum in psychiatry between explanation and understanding once you introduce narrative theory? But at other times the reviewer moves into a dismissive and derogative rhetoric which suggests little or no value in the book. In this mode, he says my claims are "dubious," "problematic," "unoriginal," "unhelpful," "nonsense," and "false." Plus, he says my "ecumenism" (by which he means my openness to alternative points of view) damages the text. For the most part, these charges are stated without reasons, so I'm not really sure why he uses such strong rhetoric. And I don't understand the sharp contrast between his seeming appreciation and his denigration. Maybe the summary is just parody, but it doesn't really seem like it.
My best guess is that the reviewer is coming from a disciplinary perspective which makes it hard to appreciate the particular interdisciplinary mix of clinical work, cultural studies, and medical humanities that I bring to the question of narrative and psychiatry. From what I can tell, the disciplinary point of view of the reviewer seems to be philosophy (or perhaps the reviewer is also interdisciplinary but a different mix than mine). This seems to bring out a cross-disciplinary (or cross-interdisciplinary) ethnocentrism which can create a sense of superiority and can scaffold dismissive comments of the other. This is not particularly surprising and is common phenomena in my experience when academics try to work across disciplines without doing considerable work to avoid disciplinocentrisms. I address a version of this problem in the book and call it the "philosophy light" critique. It goes like this:
A call for greater rigor can also create objectors [to narrative psychiatry] from literature and philosophy. These disciplinary humanities objectors argue that narrative psychiatry is theoretically and philosophically too thin. It rests on an insufficient awareness of fiction and too little interpretive philosophy. These objectors argue that if psychiatry is to take seriously the possibilities of fiction, it requires a much thicker engagement with the literature and philosophy. The difficulties of terms like metaphor, plot, character and point of view, plus the difficulties of epistemology and ontology have only been partially explored. And what about additional narrative elements like setting, dialogue, tone, style, etc? All these issues are highly relevant to the stories people tell about their troubles. Grounding narrative psychiatry in the work of Paul Ricoeur helps, but Ricoeur is only one philosopher and even the richness of Ricoeur's work has only been hinted at in narrative psychiatry. In short, for these humanities scholars much more work in literature and philosophy needs to be done to work through the conceptual issues in narrative psychiatry.
My response goes this way:
My first response to these concerns is to agree. Yes, more work from the humanities is definitely needed. Narrative psychiatry invites scholars in these domains to add their sophistication and insight to clinical work. That said, narrative psychiatry will never be a pure humanities discipline and must remain an interdisciplinary endeavor. Narrative psychiatry brings together insights from a variety of domains for the specific purpose of clinical work. As such, narrative psychiatry is an interdisciplinary scholarship that will always be too broad to completely satisfy disciplined critics from the humanities (or from the sciences). Disciplined critics must remember that disciplinary depth of knowledge is not necessarily superior to interdisciplinary breath of knowledge. Both depth and breath have their roles, and interdisciplinary work is as valuable as disciplinary work. The dangers of dilettantism in interdisciplinary work are real, but so are the dangers of overspecialization in disciplinary work.
© 2012 Bradley Lewis
George Tudorie sent the following reply to Bradley Lewis. Received Wednesday May 2, 2012. Published May 12, 2012
I would like to thank Professor Lewis for taking the time to respond to my review of his book, Narrative Psychiatry. There are two parts to this reply, one in which Professor Lewis expresses doubts about my rhetoric and intellectual pedigree, and one in which he answers what he takes to be the core of my criticism. This latter part (the last two paragraphs) is an excerpt from his book (pp. 160-1).
In what concerns the first part, I want to defend my review only in one respect. Professor Lewis writes that most of my "charges are stated without reasons". Now, perhaps I did not find the best of them, but I did provide reasons for my claims: I used examples from the book, I compared it with other books, and I put forward arguments. For instance, I said why the criticism of biological psychiatry presented in this book is un’original (it borrows the customary themes of antipsychiatry, e.g. the medicalization of sadness). I said why Jaspers's problem is not solved or made solvable given the narrative tools one is offered in this volume ("meaning-making" cannot suture the wound separating psychological and biological discourses, since in a sense it constitutes this fault line). I cannot see why mentioning such things counts as a suffering from a "sense of superiority" or as a symptom of "disciplinocentrism".
As for the excerpt, I think it is fortunate that the reader is offered yet another example from the actual text of the book. The response, I think it is reasonably clear, misses the point. This is because "too thin" is given a benign meaning, which is not the meaning intended by the critics, this one included. The criticism is not that the theoretical apparatus of Narrative Psychiatry is a set of sound general ideas which leave some work of detail to be done, which detail is, for the time being, missing. The criticism is that, at the general level, this conceptual machinery is ill designed. If, for example, the fundamental notion of mental illness is misconceived, and the very basics of narrative psychiatric practice look dubious, what reasons are there to think that once they are put together they constitute a solid foundation for psychiatry? "Breath of knowledge" is certainly welcome, but one needs to make sure it is knowledge to begin with.
© 2012 George Tudorie