A Department of Psychiatry’s Embrace of Philosophy: From Amnesia at the Margins Toward Parrhesia at the Center

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COMMENTARY

Philosophy and Psychiatry: A Local History

Sixty-three years after The Myth of Mental Illness was published,¹ the work of Thomas Szasz, MD, and the controversy it invited are still vividly recalled by some of his colleagues at Upstate Medical University’s Department of Psychiatry and Behavioral Sciences, where I serve as an associate professor and Director of Psychology Training. But as time has dulled institutional memory and, sadly, taken some of those colleagues away, Szasz’s influence grows fainter. Younger faculty and trainees are often unaware of his work on the ethical and epistemological claims of psychiatry, and of its relevance to their own professional development.

Softer still are the echoes of cultural anthropologist Ernest Becker, PhD, (1924-1974), despite his Pulitzer Prize-winning, philosophically-informed The Denial of Death²—a global cultural touchstone and profound influence on clinical and social psychology. Becker was also a vocal supporter of Szasz’s academic freedom to pursue and teach his own ideas before his early departure from Upstate. Today, despite the popularity of terms like “existential therapy” and “death anxiety,” Becker has become a mostly a forgotten ancestor in his onetime academic home.

This history, especially as it fades, points to a question not just for our own department, but for the field in general: What is psychiatry to do with its philosophers?

Why, indeed, should it bother with them at all? After all, some will say, psychiatry’s interest is in scientific process, knowledge, and outcomes, and while philosophy might be interesting outside those boundaries, it is notscience, and therefore falls short of the gold standard of knowledge claims. Habermas (1972) pointed out, however, that this objection is itself an epistemological (that is, philosophical) claim, and not a properly scientific one.³ I would not be the first to suggest then that all psychiatrists are already involved with philosophy, whether or not they are aware of it. I would argue that everystep in psychiatric thinking, and its everyclinical act, relies for its sense-making on explicit or implicit commitments to philosophical positions. Some of psychiatry’s failures to make sense are the results of its lack of awareness of those commitments.

Similarly, psychiatry has lately been involved in vigorous criticism, from within and without, through the lens of social justice and critical theory. Think, for example, of Mad Pride, or calls to “decolonize” psychiatry.^4,5 These discourses emerge directlyfrom philosophy. Their path arguably originates with Kierkegaard in the 1840s and runs through Nietzsche, Dilthey, Husserl, Heidegger, Sartre, Levinas, Fanon, Foucault, Derrida, and yes, Thomas Szasz. It is no matter of indifference how we take up their contributions. On the contrary, significant and ubiquitous sociopolitical and scientific claims are being staked daily on interpretations of that philosophical tradition, and this obligates us to consider it seriously.

Whether or not psychiatry wants to bother with philosophy, philosophy has already bothered with it. While there is a history of engagement, especially in this publication,^6,7 psychiatry has traditionally been ambivalent about philosophy. At Upstate, for example, though Szasz was stripped of his teaching privileges because his critique offended his colleagues, he retained a place in our department, where he wrote, lectured, and otherwise joyfully provoked, into his 90s. The department itself thus took a crucially important, if not unambiguous, stance on the side of philosophy and its indispensable condition, parrhesia: the classical Athenian virtue of frank speech in pursuit of truth.

Creating CP3

In 2022, I sent a survey to our department, which showed that respondents generally felt “philosophical thinking has played an important role in the history of the department,” and that we should do more to “philosophically examine issues we face as mental health professionals.”

Concurrently, our Chair created a spending initiative meant to direct funds to employee-driven proposals for projects that reflect the department’s mission. A small amount of financial support was sought and granted from this fund, as well as from the Upstate Foundation, a charitable endowment managed by our university, to support the creation of the “Center for Philosophy, Psychology, and Psychiatry,” or “CP3” for short. In this way, we moved to reclaim a place for philosophy, and to renew our stance on the side of parrhesia.

Events as Public Philosophical Interventions

CP3’s main activity so far has been offering meetings organized around single presentations at the intersection of philosophy, psychology, and psychiatry. Presenters have come from within and beyond our group, and some guest presenters have subsequently become members.

As director of CP3, I take stock of the group’s interests via email and in-person discussion, solicit suggestions for presenters, and research the work of potential speakers, always with an eye to what seems important to our professional and social contexts. We ask presenters to speak to what is meaningful to them at this time, and in their encounter with this audience. We conceive of these talks as interventions on vital issues rather than as passively received content, and tend not to record them, asking instead for presence and active participation. They are offered to inspire, provoke, or enliven ongoing discussion, reflection, and change in our communities (See the Table for a list of 2023’s events).

Table. CP3 Presentations, 2023

This interventional ethos was on clear display in December’s half-day workshop by Kirk Schneider, PhD, on his Experiential Democracy Dialogue project. Schneider marshals existential philosophy, humanistic psychology, and Rankian psychoanalysis to frame the dynamics of polarization in our culture.⁷ His intervention focused on 2 volunteers who identified themselves as politically polarized against one another, and helped them move beyond what he conceives as a form of existential anxiety informing that polarization. Our group felt deeply edified and affected, and many individuals expressed a sense of encouragement that speech can be freer, and that such divides can be bridged.

Basic Philosophy of the Group, Feedback, and the Future

Rather than a curricular addition to a pre-existing training program,⁸ we sought to create a self-sustaining, intrinsically motivating, cross-disciplinary program. Under that model, CP3 has grown from 7 to over 60 members in 1 year, and now comprises staff, trainees, academics, and clinicians from our department, the medical center, and the local community.

An insular group for the already initiated would be contrary to our goal of expanding engagement with philosophy. Like advocates of the Public Philosophy movement, I believe philosophy must engage “with the community it finds itself in”⁹, and so we work to create a humble and welcoming place for both professional philosophers and those from other backgrounds to practice a “love of wisdom” (philo- "love," -sophos, "wisdom") regardless of fluency in its formal literature. While we engage the philosophical literature formally, we do so with humility. We try to resist the temptation to demonstrate mastery of material, leaving open questions of meaning and interpretation as an invitation to each member to engage in their own way.

Our hope is to resist the foreclosure brought by “the answer,” in favor of the cultivation of passion for the infinite nature of the question, as Kierkegaard might have it.¹⁰ This allows participants to share their own resonances with the material in ways that are sometimes startlingly illuminating and movingly personal. A story of a member’s physical suffering, for example, helped us think about our topic, compassion, through an existential lens (Alexandra Santiago Molina, oral communication, October 2023). In another meeting, our presenter spoke movingly and vulnerably about his son’s death, and its relationship to psychoanalytic and religious thinking, taking us from the theoretical to the urgently personal.

Feedback regarding events has been overwhelmingly positive, garnering descriptions such as “valuable,” “unique,” “a huge hit,” and “a vital resource.” In 2024, CP3 plans to continue its speaker series, and is examining the potential to expand our efforts into other modalities. There are numerous opportunities for growth. But all such avenues also carry the dangers inherent in institutionalization, and so we proceed cautiously. For the moment, however, we simply report that we are grateful to have made time and place to be-together-philosophically; to cultivate parrhesia; and to offer one answer to the question of what psychiatry is to do with its philosophers: We bring them to the Center!

Anyone interested in participating in CP3 may contact Michael Miller at millermi@upstate.edu!

Special thanks to Ronald Pies, MD, for his encouragement, activity in CP3, and comments on a draft of this article.

Dr Miller is an associate professor and Director of Psychology Training at Upstate Medical University’s Department of Psychiatry and Behavioral Sciences.

References

1. Szasz TS. The myth of mental illness. American Psychologist. 1960;15(2):113-118.

2. Becker E. The Denial of Death. 2023 50th Anniversary Edition. Free Press; 1973.

3. Habermas J. Knowledge and Human Interests. Beacon Press; 1972.

4. Mills C. Decolonizing Global Mental Health: The Psychiatrization of the Majority World. Routledge; 2014.

5. Aftab A. Conversations in Critical Psychiatry. Psychiatric Times. Accessed January 8, 2024. https://www.psychiatrictimes.com/series/critical-conversations-in-psychiatry

6. Pies R. Epistemic humility in psychiatry: why we need more Montaigne and less Savonarola. Psychiatric Times. October 23, 2023.Accessed January 8, 2024. https://www.psychiatrictimes.com/view/epistemic-humility-in-psychiatry

7. Schneider K. The Polarized Mind: Why it’s Killing Us and What We Can Do About It. University Professors Press; 2019.

8. Aftab A, Ghaemi N, Stagno S. A didactic course on “philosophy of psychiatry” for psychiatry residents. Acad Psychiatry. 2018;42(4):559-563.

9. Meagher S. Public philosophy: Revitalizing philosophy as a civic discipline: report to the Kettering Foundation. January 13, 2013. Accessed November 7, 2023. https://web.archive.org/web/20200214094727/http:/api.ning.com/files/C*75Xw4bA4cU7vHOHSzlLRmkdBskXa9IzuVBCJKtjhmSgMrQy8tWTu1s9vqumPuG2gyJfaPzwWJ1Tu4*NoJIUVYUXtPpC37/KetteringreportfinalcorrectedFeb2013.pdf

10. Kierkegaard SA. Concluding Unscientific Postscript to Philosophical Crumbs. Cambridge University Press; 2009.