Critical Psychopathology

Critical Psychopathology Abstract—I understand psychopathology as being mutually constituted in its multiple contours—not just biological, but also historical, social, political and anthropological—which are produced culturally through ideological processes. From this perspective I propose a critical psychopathology which opposes the individualistic epistemology pervading traditional approaches in psychopathology, marked as they are by the individualistic ideology which characterizes the western world as a whole. The approach I propose transcends the etiological model in which the origin and responsibility for mental illness is attributed to an individual, and from an internal viewpoint. Only by understanding the complex ideological framework underlying psychopathology today in its multiple contours will it be possible to build paths toward a clinical practice which goes beyond, based on the ideal of a psychology which has a real commitment towards human beings. Starting with a historical overview of psychopathology, which originated at the start of the 20th century in France with Ribot’s psychological pathology, I present some foundations for a critical psychopathology which aims for a “de-ideologized” understanding of psychopathological manifestations. Keywords—psychopathology, critical, ideology, phenomenology Framework: The multiple contours of psychopathology In “La doute de Cézanne” Merleau-Ponty (1966) draws an analogy between his philosophy and Cézanne paintings, showing how Cézanne mixes the real with reality, thus distorting reality. For Merleau-Ponty (1966) , Cézanne’s art, thus distorted and with multiple contours/outlines, is far more real than a photograph, for example, which claims to capture the exact reality of a particular moment. A photograph loses the movement, and separates the real from the imaginary, which makes it something fictitious and unreal, since reality, as perceived, is always in movement and is always distorted, especially as there is no clear dividing-line between the real and the imaginary ( Moreira, 1998; 2001 ). In the words of Merleau-Ponty (1966) : “Not to indicate any shape would be to deprive objects of their identity. To trace just a single outline sacrifices depth, that is, the dimension in which the thing is presented not as spread out before us but as an inexhaustible reality full of reserves” (p. 25). The design thus results from the color, and not from a single line, and the world appears in its thickness as a dense mass, an organism composed of colors and lines. Color gives it texture and consistency through its multiple contours and not from a single, limiting line, in such a way that Cézanne art would thus depict Merleau-Ponty’s thought through the definitive destruction of dichotomies, through the recognition of the ambiguities inherent to human beings in the idea of multiple contours ( Moreira, 1998; 2001 ). In previous studies ( Moreira, 1998; 2001 ) I used this idea of multiple contours for a worldly phenomenological understanding of psychopathology, proposing a view of the psychotic as someone without contours, or boundaries. What is experienced in psychosis, making an analogy with Cézanne paintings, is pure color which is dispersed without boundaries, leading to much mental suffering. On the other hand, the contemporary neurotic (which would include the syndromes of the type which rigidify the personality, characterized by impulsive and anxious behavior) also do not experience a multiple contour or boundary with the world, but a rigid one, supposedly precise and defined, with little or no color, being just a pure line, with the same false precision which Merleau-Ponty ascribes to photography. In this view, the mentally sick would have a static existence, without movement, either because they find themselves without any contour with reality, or because they have rigid contours, living, in both cases, in a world devoid of color. I now get back to this comprehension of psychopathology through its multiples contours in order to develop a critical psychopathology understood in a “de-ideologizing” way: based on the mutual constitution of the endogenous, the culture and the situation. Historical perspective Psychopathology [from psycho + pathology] is defined as pathology of the mental illnesses or as the study of the causes and nature of mental illnesses. Psycho comes from the Greek — psyche — meaning breath, blast of life, soul. This term is already documented in Greek words as psicagogo and many others. The prefix patho comes to us from the Greek pathos which means ‘sickness, passion, feeling’. All words to which we add the prefix “patho” such as pathology, carry connotations of both pain and affection. Both words, psyche and pathos, were incorporated into the scientific language of international community in the XIXth century (Cunha, 1997) . The psychological understanding of mental illness was inaugurated at the moment when mental illness was taken as an entity through philosophical speculations. This was possible in a psychology not yet individualized, expressed in philosophy and medicine concerned in treating psychically sick people. The term psychopathology was first used in Germany, in 1878, by Emminghaus, but at that moment it was equivalent to clinical psychiatry. As a method and a discipline psychopathology was born in the beginning of the XXth century with the French philosopher Teodule Ribot. He created the psychopathological method as a pathological psychology, a branch of scientific psychology which was different from experimental or genetic psychology. During this period at the Sorbonne there was a cathedra and a laboratory of pathological psychology. This denomination was slowly changed in France due to the ambiguity of the term (psychology of the pathological or pathology of the psychological). Latter, in 1913, Karl Jaspers in Germany gave birth to psychopathology itself, publishing General Psychopathology, which represents a different stream from Ribot’s (Bauchesne, 1992) . Since that time many approaches to psychopathology were born. However, a quick historical view of psychopathology shows that in any moment a critical approach to the psychopathological phenomenon was taken in any of its main branches, e.g. general psychopathology, phenomenological psychopathology, fundamental psychopathology, ethno-psychopathology and social psychopathology. Foundations for a critical psychopathology 1. A critical psychopathology is understood in a non-dichotomized way. It is known that psychology in general and the traditional psychopathology as they developed within western thought are embedded in a Cartesian dualistic tradition: man/woman has an inside and an outside, a social and an individual dimension, an external and internal world and so on. Phenomenological studies on clinical psychology and psychiatry point out how psychopathology chooses the inner, the individual, as object of study ( Moreira, 2001 ; Tatossian, 1997 ; Tellenbach 1967 ). Theoretical analysts of phenomenological psychopathology as well as humanistic psychologists have made an effort to understand mental illness in a wide way that goes beyond traditional dualism. Unfortunately, these efforts were not enough, maybe because of the deep positivist formation of these professionals. Carl Rogers, the author of the Person Centered Approach, is a good example of this. At the same time that he understands mental pathology as a way of expression of the ill in his own world (Rogers & Stevens, 1976) , he is mostly concerned about working internal aspects, centered in the person of the ill, instead of “external” aspects. This belongs to a dualistic perspective, as I have analyzed in previous research (Moreira, 2001) . Apart from Rogers, it is not uncommon to find ‘psy’ (Rose, 1998) professionals who develop their clinic practice anchored in phenomenological and humanistic principles but use the DSM-IV when approaching psychopathology or diagnosing. Of course this choice is often related to institutional demands and the acceptance of the market of work. However, the result is that even those ‘psy’ professionals whom are closer to a non-dichotomized approach of the human being in their clinical practice nevertheless remain prisoners of an extremely dichotomized view of psychopathology. Based on the Merleau-Pontyan concept of worldly, I propose here to transcend this dualistic and dichotomized view. I have used this concept in previous studies to think of a clinical psychological practice beyond the person, embedded in the society where it is constituted (Moreira, 2001) . The concept of worldly in Merleau-Ponty definitively tears apart the dichotomies man/woman/world, subject-object, individual-society and, above all, real-imaginary. This is essential for the reading of pathological processes of hallucination and delusions understood as forms of relationship in between the mental ill and the world. The human life is involved in the sensible world, in history, in culture. To the French philosopher the sensible world would be the extension of the human being or everything that continues it. It exists in mutual constitution with it. The human being — ill or healthy — is implied in the world and his or her openness to this historical world is not a priority or an illusion, but a characteristic of human being. I think that the philosophical understanding of psychopathology, based on the overcoming of a dualistic thought, is crucial. A worldly approach for psychopathology is fundamental to the following principles, mostly related to a perspective developed by critical psychology ( Fox and Prilleltensky, 1996 ; Sloan, 2000 ). 2. A critical psychopathology is necessarily not individualistic; rather it gives priority to a cultural and historical comprehension of the psychopathological phenomenon, without losing its also biological comprehension. As Hare-Mustin and Marecek (1997) point out referring to a critical psychology of abnormality and of clinical psychology, the objective of a critical psychopathology is clearly to re-direct attentions to the social context, without losing contact with the biological. It takes into account how the inegalitarian welfare and social power distributions contribute to the suffering of the psyche. So, it is necessary to use a cultural lens in order to understand the psychopathological experience within its historical complexity. This means, for instance, identifying situations of injustice and social inequalities as part of the etiology. Analysis made by Kleinman, Das and Lock (1997) and Lira (2000) could probably highlight this proposal. They point out the mistake of diagnosing as post traumatic stress the lived experiences of patients of violent political situations. This does not mean that those persons are not sick; they are and they suffer a lot. But the mental pathology here belongs also to the oppressive and violent social field, not only to the psychological one. This is true not only for diagnosing but also for treatment (all “neutral” psychotherapy models are inadequate to this pathology). There is already a quite long tradition of cross-cultural research showing that psychopathology has universal characteristics referring to its biological aspects as well as singular characteristics that refer to its cultural and historical aspects ( Kleinman and Good, 1985 ; Marsella and White, 1982 ; Marsella and Yamada, 2000 ; Moreira, 2000 ; Morris, 1998 ; Sartorius, 1983 ; Schumaker, 1996, 2001 ; Tatossian, 1997 ; Tellenbach, 1969 ). This has also been observed by psychiatrists and clinical psychologists working with multicultural patients (Cuéllar and Paniagua, 2000; Leanza and Klein, 2000 ; Nathan, 1999 ). However, these results are often kept as part of a marginal literature in the field of psychopathology. Studies on cultural psychology and ethnological psychiatry have begun to insert the concept of culture into the discussion of psychopathology, questioning the pure individualistic approach of psychopathology ( Kleinman and Good, 1985 ; Nathan, 1999 ; Sartorius, 1983 ; Schumaker and Ward, 2001 ). However, as Sloan (2001) points out, the concept of culture is frequently reduced to a mere synonym of the place where occurs the phenomenon to be compared to some another place. Besides impoverishing the concept of culture, this maintains the individualistic approach tradition. The proposal of a critical psychopathology includes giving priority to a cultural lens which can make possible a historical and ideological analysis of mental illness, breaking apart with the most well known models of psychopathology which attribute the responsibility for the mental illness to the individual. Traditionally, even if the patient complaints refer to questions of injustice, to social oppression in work, to prejudgments, to stress, to political persecution, to violence, to injustice or to social exploitation, the suffering of the psyche originated from that will be attributed to the ill person who will be then referred to a treatment also within an individualist model. Truly, the huge arsenal of ‘psy’ treatments (psychotherapies, psycho-pharmaco-therapies, etc.) is directed to the treatment of the individual, having in mind the individualistic understanding of the mental illness. A critical psychopathology aims to overcome this. 3. A critical psychopathology doesn’t aim for scientific neutrality; rather, it differs from what is taught as dogma in mainstream clinical psychology and psychiatry. Professional scientific neutrality favours an individualistic approach to psychopathology and vice-versa. In other words, only having in mind that the suffering of the psyche is an individual process makes possible a neutral or aseptic clinical approach. At the same time, a restricted individualistic look is imposed in the horizon of a scientist who thinks her or himself as neutral. Scientific neutrality in psychology and psychiatry is anchored on the biological model, which, as Marsella and Yamada (2000) point out, is predominant in the contemporary world as part of an ideological game of medical power. Having this model in mind, clinical psychologists, psychiatrists and other mental health care professionals should deal with the illness from basically a biological perspective. This is related to the huge progress of psychopharmacology during the last decades. A critical approach to psychopathology intends exactly the opposite, that is, instead of aiming for scientific neutrality it proposes a scientific commitment to human well-being. This means giving priority to an ethical and moral way of being scientific, where the reading of the psychopathological frame is also social, cultural and ideological, going beyond the mere biological without forgetting it. In other words, a critical psychopathology, besides evaluating the context of the pathological experience, takes position in front of its intrinsic questions aiming for human well-being. That does not mean only prescribing an anti-anxiolytic or developing a psychotherapy that gives the individual the possibility to survive feeling anxious. It also means the understanding of the causes of anxiety and the psychic suffering in the field of the community life in order to be treated. 4. A critical psychopathology searches for the etiology of mental illness, not restricting itself to the presenting symptomatology. That does not mean that the symptoms are not important, but that they are understood only as a language, as Rogers and Stevens (1976) have pointed out years ago. An understanding of the psychopathological phenomenon therefore goes beyond its symptomatology (Minkowski, 1999/1966) . This signifies that they do need to be listened to as they are the expression of pathos, of suffering and of passions (Berlinck, 2000) . Their listening to should be a multiple listening (Moreira, 2001). This way a critical psychopathology rescues the clinical place, in its wide sense. The contrary perspective is commonly found in our society which is in a huge hurry to eliminate the symptoms, as if the elimination of symptoms would mean the cure. Psychopharmacology is valued because of its immediate effects. Seeking the instant and efficient answers is exactly one of the characteristics of post-modern societies. (Morris, 1998 ). As Fédida (2001) points out, however, it is not that the patient who suffers from depression does not get cured when he takes the medicines; what happens is that the pathology takes the place of the patient who takes anti-depressants. A critical psychopathology gives priority to the etiology [aitologia, from the Greek and aetilogia, from Latin], meaning the study of the origins of the psychopathological phenomenon. That means to comprehend what determines the psychopathological experience in order to be able to treat it having in mind its constitution. The treatment of the symptoms without the treatment of the origin of the illness is only palliative. That is why a critical psychopathology rescues its etiological vocation. What will be found in the study of the origins of psychopathological manifestations, understood in a non-individualistic way and with a cultural lens is, as I mentioned before, that mental ills are often consequences of ill societies. Processes of social inequality, poverty, human exploitation, besides many other ideological processes, install emptiness, disempowerment and lack of meaning in life. This is a frightening discovery because if we assume that this constitutes illness, the treatment for psychopathology should be a lot more complex than what have been traditionally used in clinical psychology and in psychiatry. It should give priority to political and community processes which help to make it possible and preserve mental health. 5. A critical psychopathology understands all psychopathological experience as a disempowerment experience. Suffering does not necessarily mean psychopathology. Independently from the clinical diagnosis it can be observed that disempowerment and incapacity of meaningful living characterize all kinds of psychopathologies (Sloan, 2001) . The sick individual feels without power, without the capacity to develop live projects. He or she lives an experience of oppression, often feeling as having no chances to go ahead in the person’s life and often feeling a lack of energy, of will, of hope. The person suffers from a nihilism which seems chronic sometimes. Contemporary occidental society contributes not only to create this personal feeling from the individualism and narcissism that perpetuates social injustice but also to maintain it: the sick individual is incapable of getting out of this situation by himself, without professional help. He needs to seek for a specialist who will take care of the illness (Prilleltensky, 1994) . This process of disempowerment is lived simultaneously with the incapacity to live meaningfully which generates the emptiness feeling characterized by contemporary anguish. Mental pathology is culturally determined through social and ideological processes of oppression. These obviously create psychic suffering. The danger is to treat this psychic suffering as a psychopathology. That is what often happens in the ‘culture of psychopathology’ which we now live in our society. Anti-depressants are prescribed to someone in mourning for having lost a loved one. Anxiolytics are prescribed to handle the competitive stress of the post-modern world. Yet the truth is that suffering is part of the mourning process and anxiety is more than a natural but a healthy reaction in competition. Even worse is when psychic suffering which refers to situations of oppression and social exploitation is treated as a ‘mere’ mental illness. Mental pathology will always include suffering, which is, by the way, a clinical criterion. However, the opposite is not true. Psychic suffering does not necessarily mean mental illness. What occurs is that on one hand we live in a hedonist society of cults of pleasure. Suffering is something to be eliminated; we live seeking an ideal of happiness. We are the narcissist center of the world, which, on the other hand, leads us to the “emptiness era” (Lypovetsky, 1996) . To make this worse, suffering must be eliminated very quickly. The post-modern subject cannot stand suffering, which explains the great arsenal of ‘psy’ treatments nowadays. Or are these many treatments the ones which would explain the current human incapacity to live psychic suffering? 6. Critical psychopathology is a de-ideologizing endeavor. This is probably the central principle of this approach of psychopathology. Keeping in mind that mental illness is understood with the lens pointed by the previous principles, its comprehension is essentially des-ideological, using this concept as defined by Martin-Barò (1985) . In other words, understanding the cultural production of mental illness also from ideological processes leads to the necessity of a de-ideologizing approach to psychopathology. Understanding ideology as ideas or images which sustain social injustice promoting particular interests (Sloan, 1997) , a critical psychopathology will look for an ideological comprehension of the existential situation of the individual who is mentally ill; in the social-historical structure where he or she lives, he or she relates to others, he or she works, he or she gets ill. That means interrogating the function of the illness in this context. A specific group in the society has interest in its existence. The most obvious example of this situation is the current epidemic of depression. This is viewed as illness is truth now, as it was in ancient Greece. However, if the narcissist way of living in the contemporary world motivates depression, it is difficult to identify to which point it is really depression which has been diagnosed or just psychic suffering instead. After all, the word ‘sad’ is almost disappearing from the post-modern subject’s vocabulary. 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