How to Study Incommensurability

Andrew Lakoff, Pharmaceutical Reason: Knowledge and Value in Global Psychiatry. New York: Cambridge University Press, January 2006, 206 pp.

Andrew Lakoff begins his fascinating and readable book with a diagnostic event. In the late 1990s, a French biotechnology firm paid $100,000 to a hospital in Buenos Aires for permission to gather DNA samples from patients diagnosed with bipolar disorder. The company hoped to discover and patent the genes linked to this illness, but problems with the scheme soon multiplied. Doctors couldn't find enough bipolar patients to sample. The very diagnosis was suspect, and Argentinian psychoanalysts judged neuroscience itself as a brand of North American imperialism. Chapter by chapter, Lakoff skillfully unravels this clash of epistemes, politics, and practices. He shows the high stakes implicit in a single research project. How do genomics and biological psychiatry—universalizing techniques to reorder life—colonize new national spaces and unwelcoming professional territories? How will the contact between biological psychiatry and psychoanalysis affect the public imaginary as well as the restricted world of medical practice? In the edge between these incommensurate systems of thought, much hangs in balance: the clinical treatment of patients, the ethics and prestige of psychiatry, broad conceptions of the normal and pathological, techniques to care for the self, the remaking of society into a market, and the braiding of political history and expertise.

Lakoff connects such topics to the rise of "pharmaceutical reason," which he defines as the central dogma of modern biopsychiatry: that behavioral disorder has organic correlates; that drug treatment will restore normal cognition, affect, and volition; and that each drug targets a specific illness entity. He draws the following grand lesson from his Argentine case study. Pharmaceutical reason becomes convincing only at particular historical moments and milieux of practice. Therefore, we cannot account for its dominance (or, for that matter, the resistance against it), through a singular logic, such as the confident advance of scientific rationality, the operation of markets, the politics of professionalism, the pragmatic instincts of clinicians, or the struggle between reductionism and psychoanalytic humanism. Lakoff's book succeeds precisely because it keeps all these logics in the air at once. He does not assign analytic primacy to any one of them. The reader follows how they coalesce at one moment, and then separate again at the next, and thereby confound the totalizing dreams of biotech entrepreneurs and psychoanalytic purists alike.

This book contributes to three scholarly conversations: the anthropology of psychiatry, the exchanges between anthropology and science and technology studies (STS), and the social analysis of incommensurability. Lakoff bases his argument, in part, on the paradigmatic opposition between biopsychiatry and psychoanalysis. The opposition plays out on several levels: neuroscience vs. hermeneutics, pharmacology vs. healing through relationships, the organism vs. the deep biographical person, genes and neurotransmitters vs. psychic meanings, the diagnostic category vs. the idiosyncratic case. For Luhrmann (2000), the conflict is driven by scientific developments, the new financial climate of medicine, and psychiatry's struggle for legitimacy along side other specialties. Lakoff shows how the same conflict gets articulated in overtly political terms. Argentinian psychiatrists regard the dominance of biopsychiatry as a sign of US hegemony and the abandonment of their own country's welfare policies. They read the DSM through the lends of Argentina's economic crisis and the rise in social exclusion. Biopsychiatry—which ignores the social causes of illness and the patient's own voice—both produces and reinforces the neoliberal program of free markets and a shrinking state. To defend psychoanalysis, in this national context, is to struggle against global capitalism.

But Lakoff maintains his critical distance in this debate. He does not lionize the left-wing Lacanians of Buenos Aires or endorse their humanist critique. He does not predict a dystopia of soul-crushing reductionism caused by biopsychiatry. To the contrary, he sees new techniques of self-care emerging, through which people work on themselves of attain happiness while fully accepting the neurochemical cause of their illness. This book is...