ampq - thinking the event, thinking change - a new theory of change for psychiatry - 30 may 2015

Thinking the Event, Thinking Change:

A new theory of change for psychiatry and

psychotherapy

Vincenzo Di Nicola

Éloge à la complexité

49e Congrès annuel de l’AMPQ

• Le Château Frontenac, Québec

• Samedi le 30 mai 2015

• 17h00 à 17h30

Thinking the Event, Thinking Change

Vincenzo Di Nicola, MPhil, MD, PhD

• Psychologue, psychiatre, philosophe

• Professeur titulaire, Université de Montréal

Thinking the Event, Thinking Change

Vincenzo Di Nicola, MPhil, MD, PhD

Conflicts of interest? Many!

• As a psychologist, a psychiatrist and a philosopher – these are domains of inquiry and practice that are by definition critical and sceptical about truth claims and in conflict with each other!

• Not faith-based

Thème : Des neurosciences à l’inconscient (2009)

Philosophy and Psychiatry:Reflections of Mind

Vincenzo Di Nicola

Thème : À la recherche du sens (2014)

Philosopher en clinique : Aider le patient à naviguer entre sens et signification

Vincenzo Di Nicola

Thème : Éloge à la complexité (2015)

Thinking the Event, Thinking Change: Capturing Complexity

Vincenzo Di Nicola

1. Introduce and define the notion of the Event based on the philosophy of Alain Badiou into psychiatric theory and practice.

1. Outliine evental being, a new theory of change for psychiatry and psychotherapy based on the Event.

1. Demonstrate how evental being, a new theory of change, creates a new objective phenomenology for psychiatry and a new definition of the subject with the notion of the evental self.

Pedagogical Objectives

Epigraph

• What will philosophy say to us? It will say: “We must think the event.” We must think the exception. We must know what we have to say about that which is not ordinary. We must think change in life.—Alain Badiou

Ref: Alain Badiou, Polemics, trans. and with an introduction by Steve Corcoran (2006), p. 8.

Alain Badiou

(Né Rabat, 1937)

“Geopoliticus child watching the birth of the new man”

- Dali, 1943

Epigraph

• The philosopher’s treatment of a question is like the treatment of an illness.—Ludwig Wittgenstein

Le traitement du philosophe d’une question c’est comme le traitement d’une maladie.

Ref: Ludwig Wittgenstein, Philosophical Investigations (1953) §255, p. 91.

Ludwig Wittgenstein

(1889-1951)

Épigraphe

• Pour guérir quelle blessure, pour ôter quelle écharde dans la chair de l’existence suis-je devenu c’est qu’on appelle un philosophe?—Alain Badiou

Réf : Alain Badiou, « Préface », Quentin Meillassoux, Après la finitude (2006), p. 9.

Epigraph

• What wound was I seeking to heal, what thorn was I seeking to draw from the flesh of existence when I became what is called “a philosopher”?

—Alain Badiou

Ref: “Preface,” Quentin Meillassoux’s After Finitude, trans. by Ray Brassier (2008), p. vi.

Qu’est-ce que la philosophie?

Deux types de philosophies

• Philosophies et anti-philosophies – Alain Badiou

• Philosophies systématiques et édifiantes – Richard Rorty

What is philosophy?

Two types of philosophy

• Philosophies and anti-philosophies – Alain Badiou

• Systemic and edifying philosophies– Richard Rorty

Qu’est-ce que la philosophie?

Philosophie/ Systématique

Rechercher de la véritéFondement, clarification, consolation

• Plato, Aristotle• Aquinas, Augustine• Husserl, Heidegger• Wm James• Badiou

Anti-philosophie/ Édifiante

Intérroger des véritésDéconstruction, problématisation

• Héraclite• Nietzsche, Marx• Wittgenstein• Freud, Lacan• Derrida, Foucault, Rorty

L’Événement The Event

Event refers to an occurrence or experience in the lifeworld of human beings which is an exception or rupture that opens new horizons in life


This notion of Event derives from Being and Event –the key work of French philosopher Alain Badiou


Being and Event updates and replaces subjective phenomenology, the dominant philosophy of the 20th century that was introduced into psychiatry a century ago through the seminal work of Karl Jaspers


Phenomenological psychiatry became the exemplary model for clinical psychiatry for much of the last century, with many elaborations and refinements by figures as diverse as Eugène Minkowski (France), Ludwig Binswanger (Switzerland) and Ronald Laing (Britain)


Phenomenological psychiatry was an attempt to capture the complexity of human experience and relations in clinical psychiatry – not to simply, reduce or tame them

Objective phenomenology

Badiou’s evental thought outlines a new objective phenomenology for philosophy and the human sciences, including psychiatry

Foundations of phenomenology

• Phenomenology was founded by Edmund Husserl (1859-1938) in Germany

• Further elaborated by his student Martin Heidegger (1889-1976) to become one of the dominant schools of philosophical thought of the 20th century

Phenomenology in psychiatry

• Phenomenology has now had several generations of pioneering psychiatrists apply philosophical method to clinical practice


• Edmund Husserl inspired Karl Jaspers’ phenomenological psychiatry (1913)

• Martin Heidegger’s Being and Time (1927) inspired Ludwig Binswanger’s existential analysis exposed in his famous case of Ellen West (1943-1944)

• Jean-Paul Sartre’s reading of Heidegger in Being and Nothingness (1943) inspired the social phenomenology of Ronald Laing in The Divided Self (1960) and Self and Others (1961)

• Karl Jaspers (1883-1959)

• PhenomenologicalPsychiatrist

• Professor of Philosophy

• General Psychopathology

Phenomenology and existential psychiatry

Phénoménologie et psychiatrie existentielle

• Ludwig Binswanger (1881-1966)

• « Daseinanalyse »

• « Der Fall Ellen West »avec multiples lecteurs (Foucault, R.D. Laing)

Phenomonology and existential psychiatry

• Ludwig Binswanger (1881-1966)

• Existential analysis

• « Der Fall Ellen West »with many readings(Foucault, R.D. Laing)

Phénoménologie et psychiatrie existentielle

• R.D. Laing (1927-1989)

• Psychiatre et psychanalyste

• Philosophie et psychiatrie existentielle

• Psychiatrie critique

Phenomenology and existential psychiatry

• R.D. Laing (1927-1989)

• Psychiatrist andpsychoanalyst

• Social phenomenology

• Critical psychiatry


• Our generation now has the inspiration of Alain Badiou’s objective phenomenologyoutlined in Being and Event to revision psychiatry today

Being and Event: Ontology

• Badiou’s work is based not on a critique or rejection of fundamentals

• Critical theory – Frankfurt School• Anti-foundational – Richard Rorty

• Badiou returns to fundamentals, to ontology – the science of being

Trauma and Event: A Philosophical Archaeology

• I recently conducted philosophical investigations supervised by Badiou for my doctoral dissertation, Trauma and Event (2012)

• We re-examined trauma by contrasting it to the Event

With Alain Badiou in Saas-Fe European Graduate School, Saas-Fe, Switzerland – 2008-12PhD, European Graduate School - 2012


• We were struck by the parallels between Event, as Badiou defined it, and trauma, the subject of my work

• In his definition of Event, I seized the key idea of rupture

• For Badiou, Event heralds novation – bringing into the world something new

• Trauma, too, is a rupture


• Rupture – abîme, breach, break, caesura, chasm, interruption, hiatus – is the link between these two notions

• Whereas Event opens a breach that leads to novation – the emergency of novelty and change

• Trauma occurs when the breach shuts down the capacity for novelty and change, leading to repetition and stagnation


• Event opens up – expands outward – to a world of new possibilities and

change

• Trauma closes down – withdraws inward – foreclosing adaptation and change


Open closed open. Before we are born everything is open

in the universe without us. For as long as we live, everything is closed

within us. And when we die, everything is open again.Open closed open. That’s all we are.

—Yehuda Amichai, Open Closed Open


• Event opens up – expands outward – to a world of new possibilities and change

• Trauma closes down – withdraws inward – foreclosing adaptation and change

• A consequence of these investigations led me to reflect on the problems of psychiatry with change

• Whether in clinical psychiatry (i.e., psychopathology)or interventions (e.g., psychotherapies)we have no theory of change!


Whether in clinical psychiatry (i.e., psychopathology)or interventions (e.g., psychotherapies)we have no theory of change!

• Description is not explanation – cf. Thomas Insel’s critique of DSM5 – e.g., describing processes, procedures,

steps is not the same as explaining them

– cf. behavioural slogan: Insight does not equal behaviour change


Whether in clinical psychiatry (i.e., psychopathology)

or interventions (e.g., psychotherapies) we have no theory of change!

• Procedural knowledge or wisdom is not theory – cf. empiricism – e.g., methods and procedures neither

explain (insight) nor instruct (theorize) – e.g., Why Lacan and not Klein?

Why DBT or CBT? Why flooding instead of SD?

(The answer is edifying vs. systematic philosophy)


Whether in clinical psychiatry (i.e., psychopathology)or interventions (e.g., psychotherapies) we have no theory of change!

Conclusion:

• Currently, we cannot adequatelyexplain (gain insight) or instruct (theorize) change in psychiatry and psychotherapy


Event is a pivotal notion that offers psychiatry and psychotherapy – from psychoanalysis to family therapy to cognitive therapy –

• a theory of change (evental being)• a new definition of the subject

(evental self)• therapeutic practices (evental

therapy)

Evental Psychiatry La psychiatrie événementielle

The name that Badiou proposes for this bold project is:

« La psychiatrie événementielle »

Evental Psychiatry

Badiou affirmed that the author’s proposal opens a broad new horizon for philosophy and for psychiatry

Emergence of the Evental Self

• Event requires three things:

– it must occur/be experienced– it must be named (acknowledgement – which

is why “testimony/witness” is so important)– it must be integrated into our lives – we must

be faithful to it

• Fidelity to the Event makes us subjects, what Badiou calls a “subject to truth”


• An evental psychiatry will be a science of “subjectivizable bodies”

• Badiou describes this as the “pivotal concept” of his philosophy


• Badiou describes 3 types of subjectseach with key processes and emblematic situations:

1. The faithful subject2. The reactive subject3. The obscure subject


• These types of subject fundamentally define the “attitudes” or possibilities of responding to the situation (Badiou’s description in Being and Event, BE I), the world (his description in Logics of World, BE II) or the predicament in my psychiatric formulation

• Badiou calls these attitudes subjectivations that “prescribe” the 3 type of subjects


1. Incorporation within the body - the subject responds with enthusiasm for what is new,

with active fidelity to the event, which is “a perturbation of the world’s order”

- this is the hallmark of the faithful subject

2. Indifference to the event - this reactive, conservative position typifies the reactive subject

3. Hostility to all that is new or “modern” - this intense response to “the new body as a malevolent foreign irruption that must be destroyed” - the obscure subject wants to maintain tradition at all costs


The faithful subject is marked by porosity (cf. Benjamin), open to radical change and witnessing (e.g., Paul of Tarsus, Primo Levi, Agamben) of desire through processes of absorption/incorporation.


Two responses occur when porosity becomes a threat: dissipation or mimesis. These responses are described through these pairs: centrifugal vs. centripetal, dispersal vs. containment and evacuation vs. encapsulation.

The reactive subject, who is marked by dissipation, experiences rupture as trauma through a process of dispersal/evacuation.

The obscure subject is marked by mimesis, whose emblematic experience is paranoia, triggered by failed attempts at containment/encapsulation.

Evental Therapy

• Evental therapy means entering people’s predicaments to see if it could be an evental site for them

• Accompany them in the Event

• How to prepare for it, how to recognize it when it happens, what to call it, and how to prepare for and to live new lives in the face of the Event

Evental Therapy

• I call this process Evental therapy

• The experience is Evental being out of which an Evental self emerges

• The quality that is required for living through an Event is fidelity

Model Events

1. Enhance uncertainty

2. Introduce novelty

3. Encourage diversity

Evental Analysis

• Evental analysis:

• The event has occurred • novelty has been introduced …• new and different ways of living are

encouraged• what Badiou calls fidelity to the event

Evental Analysis

• This is often missing in many therapies

• It means following people over time or studying what happens after an Event occurs in their lives (follow-through, rather than follow-up)

• Not encouraged by the current models of brief interventions, “episode de soins” and operational end-points

• Isolated and professionalized practices and the retreat of the helping professions into the institution (retreat from the community mental health movement)

• It is possible in community practices or practices which decrease the boundaries and barriers between people and providers of health services

Evental Therapy

Clinical practice

• E.g., Richard Mollica Director, Harvard Program in Refugee

Trauma• Follows a group of Cambodian refugees in his

Massachusetts community for decades• Mollica doesn’t close their cases and he doesn’t

make diagnoses• Imagine – a mainstream psychiatrist at one of

the world’s premier medical faculties who doesn’t use diagnoses or medications, an expert in trauma who doesn’t diagnose PTSD!

Evental Therapy

Clinical case

• “The Memory Clinic vs. the Forgetting Clinic”

• Female adolescent refugee from Iraq, 14 yearsSx: oppositional, rebellious, Dx: PTSD

• What do you want?I want to forget!

• Intervention: This is the memory clinic! - “Je me souviens”

• Reply: I’m in the wrong place. I want the forgetting clinic.

Evental Therapy

• “The Memory Clinic vs. the Forgetting Clinic”

• Prescription: View film, “Eternal Sunshine of the Spotless Mind”

• Formulation:Complex – war, displacement, migration, cut-offs –

behavioural manifestationsNo evidence of PTSD or traumatic impacts

• Recommendation: Witness, destigmatize, remove PTSD dx, capture complexity

Evental Psychiatry

Conclusions

• Re: Change

• If we can capture complexity and normalize it, people don’t need to change as much as they – or others – think they do

• Change is based on the Event, predicated on rupture which may be experienced as a traumatic closing down or an evental opening out to novelty through adaptation and new constructions of the self

Evental Psychiatry

Conclusions

• Evental Psychiatry offers:

• A theory of being (ontology) based on the Event

• A theory of change – Evental being

• A new definition of the subject – Evental self

• Therapeutic practices – Evental therapy

ampq - thinking the event, thinking change - a new theory of change for psychiatry - 30 may 2015

Health & Medicine

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