Binary Oppositions in Psychiatry: For or Against?

In their interesting and informative paper ‘From Szasz to Foucault: On the Role of Critical Psychiatry,’ Pat Bracken and Phil Thomas contrast, in a clear and helpful way, some central themes in the works of Thomas Szasz and Michel Foucault. They go on to endorse a form of critical psychiatry inspired by the latter. Szasz’s critique of psychiatry, they explain, is premised on binary oppositions, principally that between ‘mental’ and ‘bodily.’ Szasz begins by assuming the legitimacy of the distinction and proceeds to argue that the term ‘illness’ can only be legitimately applied to what is ‘bodily.’ According to Szasz, there are medical pathologies, which are to be understood in naturalistic, biological terms, and there are also ‘problems in living,’ which should not be conceived of in that way. Bracken and Thomas then show how Foucault’s work challenges this kind of view, by exposing the historical contingency of the discourses, practices and ideologies in which binary oppositions such as that between ‘mental’ and ‘bodily’ are embedded. Having contrasted the two approaches, they conclude that Foucault serves as the better role model for current critical psychiatry. Psychiatry, they propose, should strive to make explicit the contingency of its concepts and practices, opening up not just new positions within an already established arena of debate but also new possibilities for debate.

I sympathize with much of what Bracken and Thomas say. However, there is perhaps a tension in their critique of arguments that work by contrasting A with B and then rejecting B, given that their own argument proceeds by contrasting Foucault with Szasz and then rejecting Szasz. In what follows, I question the assumption that a Szaszian mental/bodily contrast and a Foucaultian critical project have to be incompatible. Of course, Szasz and Foucault part company in many ways. For instance, their political views are quite different. But thinking in terms of an opposition between ‘mental’ and ‘bodily’ does not require prior endorsement of a specific political position (although I do not rule out the possibility that it is symptomatic of deeper forms of social organization that are presupposed by superficially divergent political positions). One conciliatory strategy, I suggest, is to maintain that Szasz and Foucault are involved in different kinds of project and that the mental/ bodily opposition is legitimately assumed in the context of one project even if not the other.

Having raised this possibility, I go on to argue that a strict contrast between ‘bodily’ and ‘mental’ illnesses, or between ‘bodily’ illnesses and ‘mental’ problems in living, should indeed be rejected, regardless of which project one is involved in. Drawing on the work of the phenomenologist and psychiatrist J. H. van den Berg, I briefly indicate how both ‘bodily’ and ‘mental’ illnesses can involve profound shifts in the patient’s experience of the world and in her relations with other people. In fact, the ‘mental’ and ‘bodily’ symptoms of an illness are sometimes one and the same, and so a line between mental and non-mental kinds of illness cannot be clearly drawn. Nevertheless, I conclude by shying away from complete rejection of the distinction between mental and non-mental illnesses, suggesting instead that it can be retained in a pragmatic role.

Overcoming Binary Oppositions

Although Bracken and Thomas focus on the mental/bodily opposition, there are plenty of closely related distinctions at play in philosophy, psychology, psychiatry, and elsewhere, including internal/external, mental/physical, subjective/ objective, cognitive/affective, mind/body, and psychological/non-psychological. They all have slightly different connotations and so it is important not to use them interchangeably. In addition, it is frequently unclear what is meant by them. For instance, a mental/bodily contrast might be employed to characterize substance dualism, but it might also be used by a non-dualist to distinguish between psychological and non-psychological aspects of a person. Hence, in recommending that the contrast be rejected, there is a need to be clear about what exactly is to be rejected. Furthermore, there are different ways in which one could be said to oppose a binary...