Читать книгу Leaving Psychiatry - J. R. Ó’Braonáin. M.D. - Страница 7

Alice laughed. “There’s no use trying,” she said: “one can’t believe impossible things.”“I daresay you haven’t had much practice,” said the Queen. “When I was your age, I always did it for half-an-hour a day. Why, sometimes I’ve believed as many as six impossible things before breakfast.”

Alice and the White Queen (Lewis Carroll)

"Only in psychiatry is the existence of physical disease determined by APA presidential proclamations, by committee decisions, and even, by a vote of the members of APA, not to mention the courts"

Peter Breggin (maverick psychiatrist)

As I write this chapter a current best seller is a certain “12 Rules for Life” by professor of psychology Jordan Peterson, who is also the hottest ticket on the speaking circuit, commanding upwards of fifty to seventy-five thousand dollars per appearance. Now part of the good professor’s shtick is the thesis that our current relativism with respect to truth, the attack on so called “Western” or “Judeo-Christian” values and even the tyranny of political correctness all flow from the postmodernist school, this being the scourge of the current age. And the postmodernist school in turn, whether we are talking Lyotard, Derrida or Foucault et al consisted of disillusioned Marxists who could no longer sustain their former allegiances in light of certain revelations as to the failure of the communist utopian project. The failures to which one might refer are the evidences in the 1950’s and 1960’s as to the brutality of the soviet regime and a material standard of living within the USSR that could not come within a country mile of rivalling that of an middle class white America surfing the wave of post war prosperity, something easily achieved for a nation whose mainland was not invaded to the tune of 20 million dead. Then there was Khrushchev’s 1956 revelations to the international communist world that all was not rosy under the regime. And there were the writings of Solzhenitsyn as another of just two examples.

And so, goes the conspiracy story, the maleficent forces infecting these brilliant young French minds against Western and Judeo-Christian values morphed Marxism into this thing called postmodernism, the latter being equally hostile to the west, yet simply using different dialectical weapons of “deconstruction”, identity politics (read class struggle) and the like. And then the infection spread to the Anglo western world as it had done already by the method of Gramsci, also in a disguised form. By extension what is implied is that certain political forces today to which Peterson is opposed are covert or at least rebranded Marxist Communist, a call to suspicion that in a sense is a recasting of the Mccarthyist upturning of the mattresses to find the reds under the bed. These are the views held by most of the so called “intellectual dark web”, self-styled classical liberals and many neoconservatives alike. And all without exception vie for preening themselves a product of the enlightenment.

Never mind that Marxism itself was a product of the west, a secular Jew situated in a German dialectic in a most enlightenment atheism. Never mind that the youth and academia of a post war France were struggling to find a grip on any moral and ideological firmament after a reign of terror, a mistake of Napoleonic proportions, the fin de siecle and two wars to end all wars, both of which were valiantly fought by the French with the latter war also contaminated by Vichy shame. And so why not at least try on for size the official ideology of those who won the Eastern front and the war in toto. Any port in a storm in a country where perhaps a quarter of all the post war populace had socialist leanings anyway, this proclivity evidenced from a time long before Marx was a glint in his father’s eye. Never mind that Peterson is a deconstructionist and reconstructionist himself in seeing Christ as a Jungian archetype of Christ, as opposed to Christ as the Christ, a definite article, one without a second. Never mind that to the nuanced eye there are considerable differences between those to whom might be given the descriptor postmodern. Never mind that that there many different formulations and expressions of Marxism to whom the postmodernists are supposedly too intimately connected, as “the new skin” of Marxism. And just as Marx was influenced by, and a response to, Hegel, there emerged and continue to emerge different Hegelians. Are leftist, right and contemporary branches of Hegelianism the same given the common root, and despite otherwise having considerable differences between them? And never mind that postmodernity could not have existed in thought much less in name were there not the modernity to which the current crop of “classical liberals” find themselves purporting to be a part of, an enlightenment project that also included the French revolution and the reign of terror. And was not modernity part of the slow creep away from Christian values towards the worship of the individual “me” and the coming to terms with being the happy orphans of a dead God, the victim of our own patricide. And never mind that “Western” in the “classical liberal” sense is not at all synonymous with “Judeo-Christian” either, and there is as great a degree of similarity between the “Judeo..” and the “Islamo..” as there is between the “Judeo…” and the “…Christian”. And one final never mind is the never mindedness to the fact that the so called Judeo-Christian values as having become part of the modern western politics has also been influenced by the Romans and Greeks, and further east besides. Are we to say Pagan Christian values? Or Socialist Christian values after the book of Acts? You see we can build the cladistics of our own ideology as being parented however we wish. All these words are just slogans towards a political end, an attempt to pick the best and prettiest of histories, draw a wiggly line between them and say this is me too.

Now this book is far from being either a defence or critique of Marx, Marxism or Marxoid thought here. Specifically, I cannot engage with the strength of any putative connection between what Marx thought and said, the horrors that might be said to have been committed in his name and the avant-garde continental philosophers of the latter half of the twentieth century. It is beyond the scope of this book, my experience and my learning, though my intuition suggests to me such an association is at least somewhat misplaced and frankly silly. But I will say I’m bemused at the ignorance of others to notice what I think is a far stronger and pernicious assault on the traditional Christian values and presents a stronger push to relativize truth. But this is not from continental philosophy. It goes instead by the name of pragmatism and its evils hide in plain sight, even hidden from those who think it to be benign and live out the philosophy daily. Peterson, incidentally, despite all his virtues which I duly acknowledge, is a pragmatist.

You see the story begins with Charles Sanders Peirce (from whom we get the term pragmatism, and later pragmaticism. When he thought the former term was being misused he invented yet another “ism”). Peirce, an American philosopher and chemist, once wrote in 1878 an article on epistemology titled “How to Make Ideas Clear”. Well I must confess his article was not always clear to me, and I dare guess many others who may read it. And I wish to make clear myself that Peirce held a belief in truth existing beyond the particular bearer of the truth. He held faith to a positivist eschatology that someday somehow science will irresistibly approach a point where belief (as a truth assertion) will be held without the possibility of an argument that would prevail against it.

That said, this eschatology was obviously an article of faith without empirical evidence. It also in no way could be interpreted as a correspondence theory of truth, where truth exists “out there” as something to be discovered and our beliefs must accord to it in order to be “true”. He saw belief (qua an assertion of truth) as having a psychological utility in discharging doubt, the resultant being a sense of peace for a time, a comfort with the thought held, this comfort being the affective side of belief. Doubtless this is all carrying a survival value and could be argued to be part of the Darwinian project, another pan explanatory “ism” extremely pervasive at the time and one that remains so to this day.

He (Peirce) also makes a number of other statements that point towards a concept of truth in the here and now that is our daily life, even the life of the scientist. And that is that belief or truth is a function of the utility of the belief. It is true if it works for the singular or collective “you”. The repeatability of science points towards a truth which is utilitarian, not a communing with an ontological truth “out there”. X is true because it works, not because it is true.

e.g. “Consider what effects, which might conceivably have practical bearings, we conceive the object of our conception to have. Then, our conception of these effects is the whole of our conception of the object”

In other words, if it is practical to believe in x and ascribe to X the word “true”, then believe in x.

Someone who was greatly influenced by Peirce and had both the intellect and the clarity as a wordsmith to take pragmatism to the masses was William James. James meta-philosophical project was to save those who carried what he called the “tender minded” philosophic temperament from the “tough minded” ones. That is to say he wished to save the humanities and spiritually minded philosopher from the corrosive effects of materialism, scientism and the excessive austerities of pure logic, much as Kant and Wittgenstein tried to do the same in their own and far better ways. Pragmatism was James answer as a happy mediation towards both the tender and the tough. James pragmatism can also be encapsulated beautifully into his story of the squirrel in the published account of James second lecture.

“Some years ago, being with a camping party in the mountains, I returned from a solitary ramble to find everyone engaged in a ferocious metaphysical dispute. The corpus of the dispute was a squirrel — a live squirrel supposed to be clinging to one side of a tree-trunk; while over against the tree’s opposite side a human being was imagined to stand. This human witness tries to get sight of the squirrel by moving rapidly round the tree, but no matter how fast he goes, the squirrel moves as fast in the opposite direction, and always keeps the tree between himself and the man, so that never a glimpse of him is caught. The resultant metaphysical problem now is this: DOES THE MAN GO ROUND THE SQUIRREL OR NOT? He goes round the tree, sure enough, and the squirrel is on the tree; but does he go round the squirrel? In the unlimited leisure of the wilderness, discussion had been worn threadbare. Everyone had taken sides, and was obstinate; and the numbers on both sides were even. Each side, when I appeared, therefore appealed to me to make it a majority. Mindful of the scholastic adage that whenever you meet a contradiction you must make a distinction, I immediately sought and found one, as follows: “Which party is right,” I said, “depends on what you PRACTICALLY MEAN by ‘going round’ the squirrel. If you mean passing from the north of him to the east, then to the south, then to the west, and then to the north of him again, obviously the man does go round him, for he occupies these successive positions. But if on the contrary you mean being first in front of him, then on the right of him, then behind him, then on his left, and finally in front again, it is quite as obvious that the man fails to go round him, for by the compensating movements the squirrel makes, he keeps his belly turned towards the man all the time, and his back turned away. Make the distinction, and there is no occasion for any farther dispute. You are both right and both wrong according as you conceive the verb ‘to go round’ in one practical fashion or the other.”“

In the above excerpt from James, his claim to truth and belief rest upon a clarity with which the problem is stated, and is a better illustration of what Peirce wished clearly to say. In what sense is the question asked, that the man goes around the squirrel? It hinges upon a definition of “going around”. There’s a third option also. After Einstein and without any aether or universal reference frame it might be as true to say that the man’s legs move yet he does not go anywhere, as the squirrel, tree and indeed the whole universe orbit around him. Perhaps in the 22nd century there can be additional formulations of man, squirrel and tree, bounded only by our imagination and the new scientific paradigms that may come…or may not as the case will be. But as is clear in the example and in further of James lectures, truth is not arrived at by a clear sense in which terms of the proposition are made. Neither does truth find it’s ground in clear grammar providing a correspondence between words about the world and the world as it is. No, for James truth is entirely instrumental. It is as true to say that man revolves around squirrel as squirrel revolves around man depending on the ends to which the question is asked and what one wants. James, in the land of the free marketeer capitalist and contra the Marxist temperament, even accords to truth the descriptor “cash value” and also additionally writes….

“Any idea upon which we can ride, so to speak; any idea that will carry us prosperously from any one part of our experience to any other part, linking things satisfactorily, working securely, simplifying, saving labor; is true for just so much, true in so far forth, true instrumentally. This is the ‘instrumental’ view of truth.”

And where the anti-communist conspiracy might have it (and probably has it correctly) that certain Marxist infiltrations entered into the universities, media and the like by Gramsci ‘s inspired “march through the institutions”, pragmatism also had its inroads into the same institutions in the United States by John Dewey and his disciples, even leading to the foundation of American public school education and social work.

Dewey, a democratic socialist with friends in high places and philosopher of many areas, was the last of the trio of classical pragmatists, classical pragmatism having taken root and flourishing as the first home grown American philosophy. Not surprising for an atheist, Dewey also rejected truth as an ontological, dare I say transcendent, state of affairs, that knowledge is or ought to be a correspondence between the reality out there and how it might be represented in the mind or the collective “sciences”. Instead truth was for Dewey, as it was for James and Peirce before him, that that is the case when we reliably get the outcome we are wanting. Truth is teleological where the architect of telos is mortal man.

Now I’m not stating that Pierce and James’ pragmatism was entirely as it could be cynically interpreted. On a deeper reading it was actually quite nuanced and I confess not to have read the entire corpus of their works. It’s entirely possible, though this is very much to be doubted, that somewhere they might have inserted a caveat not to be taken too seriously. That having been said, we are at least discussing the effects of their pragmatism, a reading of their pragmatism which by their own lights is the “cash value” of their philosophy on truth.

Now what on Earth has this to do with psychiatry I hear you ask.

Firstly, I take it as a given from my own experience that psychiatry has no faith or sincere interest in objective transcendent truth, never mind the good or the beautiful.

Secondly, I take it as a given that contemporary psychiatry is dominated by North America, its publication machine and the DSM. To the extent to which it exports its ideology beyond its borders and to the extent psychiatry is bio-political (as is certainly the case), American psychiatry colonizes other nations. It does this under the guise of caring words just as it does using propaganda words such as democracy, rights etc. And these other nations welcome becoming colonies.

Thirdly, when the effects of a various philosophies are found to be existing in an Anglo nation and can be attributed either to being manufactured locally or to have been imported from the European continent, it is the more parsimonious conclusion that the effects are from the local philosophy (i.e. pragmatism), though this of course is not to imply other influences are impossible (Marxism, postmodernism, other isms).

Fourth, Pragmatism qua truth being what is useful was an invitation to a power hungry hedonistic epistemology that was too much for modern (and post-modern) Americans to resist. It seeped into all areas of its culture and indeed even into psychiatry. It is evidenced by the words psychiatrists use. It placed a perverted epistemology in an unholy marriage with an ethics that would be unable to resist becoming perverted in kind. It is a question of human drives and motivations as to what people wish the truth to be in being directed to a desired end, ends often impacting upon other persons. In this sense pragmatism is necessarily a political philosophy. And the will towards a desired truth is the manifold upon which psychiatry can slide incoherently and effortlessly between appeals to reified truth as a science of the objective world (an appeal to scientific legitimacy), and also an appeal that the truth can be whatever is according to some other self serving end that it wishes (the continuance of power cloaked in the language of care, patient values etcetera). The truth is my truth. And who am I? I am the psychiatric guild. And the truth I trade in derives its “cash value” from verification. And who verifies? It is the guilds of psychiatry that verifies. If psychiatry verifies its own truths, it creates its own capital. And who owns the capital? The guilds do. Domestically they are monopolies. Internationally they are oligarchies. And then the public take these false “truths” as fact, via a focus on what the guilds call science at the time in a game when the doublethink makes opportune to invoke the word “science”. Surely this is an economy that can only survive as long as the metaphorical mint keeps printing the metaphorical cash, always borrowing on a future that never arrives, a society where the will to real truth has lost the “cash value” of a former age. This is the age where Oprah can speak of “my truth” and “your truth” with nary anyone taken aback at the horror of three hundred million truths, and few wishing to champion even the notion of “the truth”. This is the age where psychotherapies are more concerned with what “works for you”, as opposed to a confrontation with “what you are” or “who you should be”.

Fifth; Take a critical look at all the uses for the words pragmatic and pragmatism and their variants or subtexts in the psychiatric literature. It is everywhere. What follows is but one particularly egregious example from the Australian literature, a country where I once worked for a time, citing American psychiatric intelligentsia of course, this being consonant with my thesis.

The 2013 Royal Australian & New Zealand College of Psychiatrists (RANZCP) Mood Disorder Guidelines is the specimen to be studied, at its time the most up to date international guidelines in print. It remains perhaps the largest undertaking into mood and its disorders, so long in the planning that the previous guidelines were published a full decade prior. Weighing in at greater than one hundred pages, with more than a thousand references and a few dozen committee expert authors and advisors, it includes the claim to have consulted widely with many stakeholders including the laity.

The first section titled “Classification of mood disorders” opens with subtitle

“A pragmatic approach to mood disorder classification.”

It continues; “There is growing consensus that psychiatric diagnoses are akin to social constructs (Insel, 2014; Zachar and Kendler, 2007). It is nonetheless appropriate for the structure of this guideline to adopt an accepted mood disorder taxonomy because, (i) there is broad agreement about definitions, and (ii) diagnostic terms have accrued valuable meaning through scientific (e.g. clinical trials) and social processes (e.g. advocacy). (See: Figure 1). Using the terms as pragmatic organising constructs should not translate into their reification – the optimal classification of disorders must await a quantum leap in our understanding of the aetiology and pathophysiology of abnormal behaviour.”

The references are these.

Insel TR (2014) The NIMH Research Domain Criteria (RDoC) Project: Precision medicine for psychiatry. American Journal of Psychiatry 171: 395–397.

Zachar P and Kendler KS (2007) Psychiatric disorders: A conceptual taxonomy. American Journal of Psychiatry 164: 557–565.

We will dispense at the outset with the words “akin to”. This is written I suspect to allow one to evade critique by denying having made a definite statement, only something akin to the statement. The same is the case with the word “consensus”, as I suspect were I to say the consensus is the RANZCP they would say “no not us”, and have me running down labyrinthine alleys searching for the target.

The RANZCP guidelines are a lesson into the dangers of secondary reading and that bloating an article with references (or a book, hence my refrain) neither adds to the weight of scholarship or the strength of argument. You see neither the Insel or the Zachar and Kendlar articles state anything like approaching that diagnoses are akin to social constructs. Insel speaks of the DSM, “like other medical disease classifications”. His article is thoroughly wedded to the so called medical model and it would dishonour the man to suggest a social constructivist subtext that clearly is not present. It simply posits that medical science (under the RDoC framework) will grant the tools to reorganize a taxonomy of mental illness that would be an improvement on the existing one. There is not one single mention of any psychiatric disorder being etiologically either a psychological or social phenomena, much less specifically a “social construct” designed by a consensus group of powerful stakeholders.

And what of Zachar and Kendlers paper? Having been published pre DSM 5 in 2007, it’s a curious choice, with both authors publishing widely since. For Zachar this has reached its peak as a contributor in a multi-perspective wonderful series of articles in 2012 in Philosophy and Ethics in Humanities and Medicine. Suffice to say for now, Zachar sides with the American psychiatric guild and its colonies (Australia included) on the side of philosophical pragmatism. To use Allen Frances baseball metaphor of truth, he thinks the reality of an umpire’s call lay in how he uses it (Frances was chair of the various DSM IV committees). Or to speak of psychiatry, he considers models and explanations as more or less as a means to an end. For Kendler, he was a task force member of DSM IV and a member of the psychotic disorder working group, the group in which one hundred percent of its membership were in receipt of monies from the pharmaceutical industry. He also was part of the DSM 5 mood disorder working group 2007-2010. His views on the DSM are sympathetic at the very least, even whilst paying lip service to their imperfection. The cited 2007 article speaks of a need to revise the DSM for sure, though posterity has shown this revision to the DSM 5 be modest, to capture more people under diagnostic umbrellas than in earlier editions, and the DSM has continued to underwrite psychiatric diagnoses as bona fide medical illnesses. The article takes us on a journey not of consensus to social constructs but of many ways in which psychiatric classification may be considered. The authors do this by comparing 6 sets of dipoles as dimensions of categorization. (Causalism vs descriptivism, Essentialism vs nominalism, Objectivism vs evaluativism, Internalism vs externalism, Entities vs Agents and Categories vs Continua). Nonetheless at the end of the day and of the article the use of the word “construct” is endorsed as being synonymous with that of a scientific hypothesis that can be empirically tested within a scientific framework. The authors make no statement as to their diagnoses being a consensus held (presumably by a powerful interest group) and thus a “social” construct.

Returning to the RANZCP guidelines and the quoted text above; we need be clear that social constructivism is essentially antithetical to metaphysical naturalism. Water as being two parts hydrogen to one part oxygen is not socially constructed. It is a fact of the world, as is its boiling point at a given pressure. As is the location of brain in the skull and not the chest and the fact that it contains certain component parts that if ablated will result in blindness etcetera. The list of these natural facts are endless. They are not established by opinion of an individual or a consensus group or contingent in any way on the same. Compare this with social construction in the ordinary language use of the term. Though both made art and placed paint upon the canvas, the distinction between the baroque and rococo periods is a matter of social construction, as are endless lists of human belief and behaviour in fashions and politics. A bone is either broken or it is not. The sport played in which the bone was broken is a social construction, as is its rules. Whether unhappiness is to be seen as part of the human condition, a challenge to change one’s life or to be medicalised as if it were disease (though it is not), this too is a social construction.

Now the psychiatric guilds wish to have their cake and eat it too. They are forced to acknowledge that they can no longer claim all psychiatric diagnoses to be naturalistic medical facts of the world of a broken body or brain. The evidence simply is not there. Yet they hold onto pretences to scientific legitimacy and an appeal to the status quo whilst holding out a faith that “the optimal classification” would involve greater knowledge of the “pathophysiology” i.e. they are nailing their colours to the wall that mood and its disorders are naturalistic phenomena whose pathological mechanism is yet to be discovered, whilst acknowledging it isn’t at this time. The acting “as if” to a pragmatist is all that matters, as we have discussed above. Why? Because to act “as if” if directed to a given end of prosperity to the guild is the end of the journey to truth. The rest is just persuasion and propaganda, again to a desired end. It’s pragmatism through and through, where pragmatism is what one does when one has abandoned all principles. Pragmatism is the philosophy of choice for the merchant. It is a trading of the staff of Aesculapius for the caduceus of Hermes.

Perhaps I could make my point clearer by an analogy with religion. Imagine that some grand ecumenical council were to convene and issue the following edict;

“There is growing consensus that our faith in anything transcendent is akin to social constructivism and by extension God or Gods probably don’t exist as such. It is nonetheless appropriate for the way of life of humankind to continue practicing, living in hope and dying for faiths following the status quo mix of religious doctrines because, (i) there is broad agreement about the operational notion of the God or Gods as defined, and (ii) religious ways of life have accrued valuable meaning through sacraments and observed “miracles” (e.g. prayer, fasting, confession, healings and resurrections etc) and social processes (e.g. churches, monasteries, martyrdom, faith based wars, charities, alliances of church and state, orphanages etcetera). Using the notion of God or Gods or anything supernatural as a pragmatic organising construct should not be reified and translate into their genuine faith or belief in them as existing beyond their identity as akin to a social construct – the optimal determination of theological truth must await a quantum leap in our understanding, a miracle never before experienced”.

Surely we would be aghast to read such a thing and question the seriousness, logical and moral coherence of those who would say such nonsense. A move towards a view of religion as socially constructed by a mortal consensus group must surely be followed in lockstep by an immediate move towards apostasy and an overnight dismantling of the church. The want to avoid a vacuum would offer no excuse to fill the void with the ghost of what came before that moment of terrible consensus, when the substance of the ghost is found to be meaningfully lacking. Similarly, from the revelation that psychiatric diagnoses are social constructions must follow a dissolution of all the pretences of psychiatry to science and to medicine. And the mad, bad and sad would need return to the community from whence they came as persons amongst people. Any doctor reaching for the prescription pad would need admit that s/he is practicing at best cosmetic psychopharmacology, at worst placebo medicine. An expert class of professional liars would be superfluous. Naturally with the death of psychiatry what would follow wold be the death of the link between it and the state. Society would need find other ways of managing misery and deviancy. Whether or not society is successful in this endeavour is immaterial to the fact that what is socially constructed must properly return to its home in society.

Why Psychiatry is a Secularised Exorcism?

The state and the church never separated. The church was simply replaced by psychiatry. The transaction between an enquiring patient and their doctor might go something like this.

Patient “I feel poorly and have a cough”

Doctor (having auscultated the chest, viewed the X ray and other investigations) “you have pneumonia”

Patient “and what is pneumonia?”

Doctor “in this case it is an occupation of certain parts of your lungs with bacteria and the outcome of the war between the bacteria and the immune system, that being pus and such”.

The reader will note the linearity in the explanation, and the appeal to something real. Yet take what might be a dialogue between patient and psychiatrist

Patient “I have a low mood, poor sleep, poor appetite and life has lost its lustre”

Psychiatrist “You have major depressive disorder”

Patient “and what is major depressive disorder”

Psychiatrist “major depressive disorder is when you have low mood, poor sleep, poor appetite and life has lost its lustre”

The reader will note the circularity here, that the diagnosis fails to point through, as it were, to something beyond the symptoms and signs. Rather the symptoms and signs point only to themselves, they are denotatively void. Now the reader may object and suggest the symptoms and signs of depression point towards some truly causal and explanatory event or thing in the world. Yet the thing in the body does not exist, there being for example no chemical imbalance causal to the depressed mind, no neuroplastic change in the brain causally related to an addicts drug use, no dopamine deficiency in the ADHD brain unmolested by drugs. And events in the sense of providing explanatory power are empty or at best partially formed explanations. Am I coughing and sick because I am old, or because someone similarly sick coughed upon me? This transfer of coughing does not define bacterial pneumonia. Does it really say anything to say I am depressed because I was raped or because of unrequited love, having been fired from my job or the bank to have foreclosed on my mortgage? These may play their causal roles in their way to the mood that I feel, though this is not to say depression is these events, certainly not in the way it is presented by the psychiatrist and accepted by the patient with the ontological force as pneumonia is pronounced upon the patient. Usually the antecedent events and speculations as to their causal significance are an afterthought or in any case secondary to the symptoms and signs as defining the diagnosis. And yet the shared experience between psychiatrist and patient alike, the belief, the affect, is as if none of these deep intractable problems existed. The psychiatric diagnosis is pronounced as a recognition of a “this” that is “there”, as real as a bacteria and the purulent expectoration from one’s lungs. It is as real as the invisible demon for those who believe in possession, that malevolent other that is in the patient yet not a part of them. To be sure I’m not proposing anything supernatural is going on in psychiatry. Yet to speak of persuasion and suggestion, of placebo, faith and empty belief is too banal. It does not capture the magic here when the non-existent other is invoked and given an ontological status far beyond its due. The psychiatric pronouncement makes something real that remains unreal. The magic is in the ritual and its impact upon the world. And psychiatrists, those most unholy of demonologists, create the demon whose exorcism they seek credit. This sort of bewitching can only be done be master pragmatists