Abstract
Longtime readers of Theory & Psychology will be familiar with the distinction between epistemic and ontological types of social constructionism (Edley, 2001; Edwards, 1997). Epistemic constructionists assert that the “real world” (including human activity and social life) cannot be directly represented in language. What this means is that there is always going to be a gap between our descriptions and the phenomena we are allegedly describing (though many strong epistemic constructionists likely would not phrase it in this dualistic way). Many who hold this view believe that constructionist researchers who study psychological phenomena should focus on historical and cultural shifts in the discourse used to denote human beings’ attributes, activities, and experiences, or else analyze the pragmatic contexts in which psychological language is used.
By contrast, ontological constructionists—of which Mikkel Borch-Jacobsen, the author of Making Minds and Madness, is one—think there is no such necessary gap between psychological descriptions and the realities that they name. This is so, the “onto-constructionist” asserts, because our words, along with the practices with which they are intertwined, actually produce the phenomena they describe, at least when it comes to human kinds. Ontological constructionism (usually called by other names these days) is much more in vogue at the present time than is the epistemic version. Those who take this approach claim that the various types of persons listed in diagnostic manuals, discussed at case conferences, interpreted in therapy sessions, and even discovered through experimental research, are at once socially constituted (and thus historically and culturally variable) and eminently real. It is this basic idea that connects the 17 essays in Making Minds and Madness, most of which have been published before in French or English. In these essays, Borch-Jacobsen uses examples from psychoanalytic, “recovered memory,” psychopharmacological, and other forms of therapeutic practice to argue that psychiatrists and those in allied fields interact with their patients to “make up” (to use the philosopher Ian Hacking’s phrase) the forms of personhood embodied in the modal patient-types of a given era.
Many psychologists, philosophers, and social researchers who have distanced themselves from epistemological constructionism while supporting the ontological variety have done so partly out of a desire to sidestep the former’s worrisome associations with (philosophical) idealism and relativism. Borch-Jacobsen, who is a professor of French and Comparative Literature at the University of Washington in Seattle, doesn’t appear to share their anxieties. Rather, he seems to have two other motives. The first is to challenge the approaches used by some noted historians of psychiatry. He is critical of their predominant focus on how experts’ nosological categories and diagnostic practices change over time, as well as what he sees as a recent swing too far in the other direction, such that an excessive emphasis is placed on the role played by patients. For Borch-Jacobsen, the production of persons as historically specific types of clinical entities is a function of the interaction between patient and therapist; thus, historians should study the particulars, and elucidate the dynamics, of this process.
His second aim is to debunk psychoanalysis’ self-image as an empirical science in which narrative reconstructions of patients’ histories accurately represent the past and thereby articulate the “truth” of patients’ inner lives. For many years, Borch-Jacobsen has made psychoanalysis the prime target of his critical energies (he was a combatant in the “Freud wars”), so it is not surprising that seven of the essays in this book focus on classical psychoanalytic theory and practice. He faults Freud and his mentors for not acknowledging that what they were really doing was making up narrative histories to explain their patients’ current troubles and symptoms, introducing these reconstructions to the patients, who were highly suggestible, and then pointing to a patient’s “fabricated” (yet real) embodiment of the psychoanalyst’s “interprefactions” [sic] as proof of the latter’s veracity. Steeped in these founding narratives, generations of analysts and patients have gone on to collude with one another to rediscover, amplify, and create new variations of these “artifactual” [sic] forms of pathological personhood.
One cannot help but be impressed that Borch-Jacobsen (or anyone) is still finding new ways to challenge the image of Freud as a something like a scientific realist, and to contest the status of psychoanalysis as anything like an empirical science. Given the topics of some of his other books, one must assume that Borch-Jacobsen is knowledgeable about the narrative, interpretive, and linguistic turns that have influenced psychoanalytic thought and practice on both sides of the Atlantic (how well acquainted he is with relational approaches is less clear). Yet he does not mention them much here, except to argue briefly that even “narrative” analysts like Spence and Schaefer did not face up to the ultimate implications of their revisions: “that repression, the unconscious, infantile sexuality, and the Oedipus complex are just tall tales, ‘Just So Stories’” (p. 152). He does not acknowledge that for many years now, numerous psychodynamic theorists and practitioners (from neo-Freudian revisionists, to object relations theorists and self psychologists, to intersubjectivists) have subtracted many such “tall tales” from their understanding of what they do, while still asserting that there can be healing value in the psychoanalytic process.
One of the most interesting aspects of the book is the way the author constructs accounts of the micro-dynamics of doctor–patient interactions in an effort to flesh out what Hacking (1995) has called “looping effects.” These are the processes through which patients respond to their doctors’ interpretations and attributions by coming to embody them, sometimes with a vengeance. The doctors, in turn, react to their patients’ (often compliant but also innovative) enactments by modifying their descriptions and diagnostic criteria accordingly, and so the loop continues. Drawing on the seminal work of social psychologists like Sarbin and Rosenthal, Borch-Jacobsen argues that making up people, in therapeutic and institutional contexts, takes place mainly through patients being receptive to suggestion, and that all psychiatric treatment thus has a lot in common with hypnosis. But his view of the workings of suggestion is a radically rationalistic one. He sees the patient as, above all, an active and willing participant, a manipulative agent who chooses to play an acquiescing role: “It is not le suggestioneur who provokes the receptivity to suggestions; it is the suggestionné himself who disinhibits himself … who makes himself passive” (p. 112). Borch-Jacobsen claims this paradoxical dynamic is endemic not only to psychoanalysis, but also to other forms of treatment. For example, in an essay titled “A Black Box Named Sybil,” he gives a shocking account of the genesis of a notorious multiple personality case-turned-bestselling book (Schreiber, 2009), which is considered by many to have provided the template, and perhaps even the impetus, for the subsequent swell of MPD cases diagnosed during the late 1970s and 1980s. Whereas some would point to the facts revealed by Borch-Jacobsen in this essay as evidence of a stunning lack of professionalism on the part of “Sybil’s” therapist, and even a victimization of the patient, that is not where he wants to go with this. Rather, he frames Shirley (the patient’s real name) as someone who “decided to be ill” (p. 90) and thus factitiously made it so. In other essays, he generalizes these dynamics, applying them to a wider range of patients and therapies. This depiction of patients as rational strategists who collude with their therapists’ enacted fantasies seems to imply that their manifest suffering is little more than an expression of what the existentialists called bad faith. Yet in the introduction to the book, Borch-Jacobsen himself acknowledges that “the patient’s symptoms are always distress signals, calls for help …” (p. 7). This appreciation of patients as suffering human beings who want to be disabused of their distress (even as they are also attached to it) is, unfortunately, missing in many of the subsequent essays.
I am sympathetic to the ontological constructionist’s view that the difficulties that bring a person into treatment may be less fully formed—more inchoate—than conventional ideas about psychopathology (e.g., that clinical entities are ahistorical natural kinds) lead one to believe. Such an historicist view leaves room for the kind of suggestion-and-looping effects that Borch-Jacobsen, following Hacking and others, helpfully elucidates. But in Borch-Jacobsen’s depictions of them, the psychological types that ostensibly come to be embodied in individual persons through these interactive social processes don’t seem like full, three-dimensional human beings. Trenchant as his essays are, he has not succeeded in completely disabusing me of the intuition that there is something unsatisfying and incomplete about the idea that people are made up primarily by how they are described. This may be due, in part, to his writing style, which at times seems to privilege rhetorical flourishes at the expense of complexity or depth. But I suspect some of my concerns may apply to ontological constructionism in general. Epistemic constructionism does have its problems, but at least some versions of it enable us to recognize that there can be an infelicitous, even tragic, gap between the nature of a person’s vulnerabilities and strengths, and the attributions that are made about her by both experts and laypersons. This gap exists, even if we grant that a person’s “nature” cannot be separated from (or even emerges out of) what she is reacting to, and can only be represented in language that bears traces that go well beyond the “given.” To put it simply: often, there might not be just one perfectly or indubitably correct diagnosis (if by “correct” one means veridical or pragmatically superior), but some diagnoses are less correct, or more wrong, than others. About such misapprehensions, and their deleterious effects, the onto-constructionist has relatively little to say.
Such reservations notwithstanding, Making Minds and Madness is an engaging and often entertaining book. It is by turns incisive and irritating, brilliant, and glib. The author’s penchant for hyperbolic aphorisms can be off-putting and weakens the force of otherwise persuasive points. Nonetheless, he does make a contribution with these essays, and they should be of considerable interest to many theoretical, critical, and psychoanalytic psychologists.