Keen, Ernest - Ultimacy and Triviality in Psychotherapy-Praeger (2000)

Ultimacy and Triviality
in Psychotherapy
in Psychotherapy
Ernest Keen
Library of Congress Cataloging-in-Publication Data
Keen, Ernest, 1937–

Ultimacy and triviality in psychotherapy / Ernest Keen.
p. cm.
Includes bibliographical references and index.
ISBN 0–275–96981–9 (alk. paper)
1. Psychotherapy—Philosophy. 2. Psychiatry—Philosophy. 3. Mental
illness—Chemotherapy—Moral and ethical aspects. 4. Conduct of life. I. Title.
[DNLM: 1. Psychotherapy. 2. Defense Mechanisms. 3. Mind-Body Relations
(Metaphysics). 4. Psychophysiology. WM 420 K26u 2000]
RC437.5.K44 2000
616.89′14′01—dc21 99–086182
British Library Cataloguing in Publication Data is available.
Copyright © 2000 by Ernest Keen
All rights reserved. No portion of this book may be
reproduced, by any process or technique, without the
express written consent of the publisher.
Library of Congress Catalog Card Number: 99–086182
ISBN: 0–275–96981–9
First published in 2000
Praeger Publishers, 88 Post Road West, Westport, CT 06881
An imprint of Greenwood Publishing Group, Inc.
www.praeger.com
Printed in the United States of America
The paper used in this book complies with the

Permanent Paper Standard issued by the National
Information Standards Organization (Z39.48–1984).
10 9 8 7 6 5 4 3 2 1
To my teachers, Gordon Allport and Ted Sarbin
Contents
Preface ix
Introduction xi
PART I THEORETICAL INCOHERENCE 1
1. Critical Reflections on Psychopharmacology 3
Professional Considerations 5
The Physical and the Psychological 6
Kramer’s Position 8
Medication as Provoking Interpretation 10
Summary and Conclusions 12
2. Neurons and Narratives 19
The Two Discourses of Psychology 19
From Trauma Therapy 23
From Psychopharmacology 25
Conclusions 28
3. Exploring Theoretical Incoherence 31
Drugs: A Theoretical Vacuum 34
The Psychology of Human Effort 35
Being Ill as a Social Fact 37
Psychology Struggles with Recovered Memories 41
4. Wider Echoes of the Incoherence 45
Introduction 45
viii CONTENTS
The Problem of the Insanity Plea 49

The Problem of Diagnosis 51
Financing Psychological Treatment 52
The Problem of Being a Citizen 55
The Problem behind the Problems 57
PART II ULTIMACY AND TRIVIALITY 61
Preface to Part II 63
5. Narrative, Coherence, and Ultimacy 65
Power and Psychotherapy 67
The Case of Rob 70
Theory 72
Therapy 74
The Creation of Coherence 75
6. Discourse, Therapy, and Science 83
Discourse Analysis as Psychotherapy 83
A Comparison 83
What Can Science Offer Psychotherapy? 85
How Does Psychotherapy Work? 86
What Can Psychotherapy Offer Science? 88
Science and Discourse 91
Social Arrangements 92
7. Trivialization, Ultimacy, and Discourse 95
A Trivialization of Ultimacy 95
The Discourse of Psychiatry and Psychology 98
Power and Knowledge in Postmodern Theory 100
An Irony 104
Summary 106
8. Triviality and Ultimacy in Therapy 109
Ultimacy in Therapy 110
Coherence and Anxiety 111
Self-Respect and Guilt 113
Ultimacy in Practice 114
What Do the Helping Professions Help With? 116
Return to Ultimacy 121
References 125
Name Index 131
Subject Index 133
Preface
The inspiration for this book was not mine alone. I continue to see
thoughtful assessments of modern science and its failure to solve human
problems. My most recent sighting is Thomas Merton (1964):
Neither the ancient wisdoms nor the modern sciences are complete in them-
selves. . . . Wisdom without science is unable to penetrate the full sapiential
meaning of the created and material cosmos. Science without wisdom leaves
man [sic] enslaved to a world of unrelated objects in which there is no way of
discovering (or creating) order and deep significance in man’s own pointless
existence. The vocation of modern man was to bring about their union in
preparation for a new age. The marriage was wrecked on the rocks of the
white man’s dualism and of the inertia, the incomprehension, of ancient and
primitive societies. (p. 70)
It is important here to be clear who the villain is. It is not some rei-
fied abstraction called “science” or some amorphous group of “scien-
tists” but rather humanity’s modern arrogance, combined with the
dogmatisms of the past, that have blended into a malevolent toxicity.
This outcome, which is the center of modernity, does not continue un-
protested. I mention Ghandi here as one of a number of influential
(and an even larger number of uninfluential) protesters. Unfortu-
nately, Ghandi and his fellow travelers have been relegated by the
authorities of modernity to a respectful marginality.
Introduction
I have practiced and reflected on psychotherapy, and I have recog-

nized the various levels of seriousness of its talk. Is therapy obli-
gated to deal with ultimate seriousness? Are symptoms mere
bothers, to be eliminated, or do they reflect deeper issues, even ulti-
mate issues, with which our patients are not successfully dealing?
The central idea of this book is that human behavior engages ulti-
mate issues, such as good and evil, death, and the never-ending chal-
lenge of the question of who we are to become. The experience of such
ultimate issues is by no means easy to endure, and human retreat
into play and other distractions is universal.
It may be an exaggeration to call such retreats by the name “trivi-
ality,” but this term has the virtue of indicating the essentially escap-
ist character of much of human experience. Such triviality may be
necessary, given the human condition, but it has rarely had a name.
Naming it enables us to see how we tack back and forth between ulti-
macy and triviality. I may go for days without an experience of an ul-
timate issue, except insofar as I have known that I must dodge an
ultimate issue in order not to be overwhelmed by it.
The most common version of ultimacy is the question, “Who am I
to become?” Although I worry occasionally about this or that direc-
tion in my life, I can usually dwell on various reasons for doing one
thing rather than another, neglecting what is most centrally at
stake: Who am I becoming in doing one thing rather than another?
I have never met a person whose experience is not approximately
the same. The ultimate issue of who I am to become is in fact always
xii INTRODUCTION
available, and when it is not explicit it is nonetheless close by. In the

process of making even a small decision, the slightest reminder re-
news my consciousness that I am charting a course of life that is
mine alone. No matter how many people are like me, each of us could
have done it all differently.
The calculations about how best to do something are relatively
trivial compared to deciding what to do. The dichotomy between ulti-
macy and triviality is a continuum. Yet I allow myself, or purposively
direct myself, into the relative triviality of how to do something in or-
der not to take up the issue of what to do and its consequences for
who I am becoming. Some such dodges are more trivial than others.
But they all create the self I am becoming.
This description is not meant to describe “the moral life” or “how to
have integrity,” or some such thing. It is meant to describe us all—not
in terms of how we ought to be but in terms of how we in fact are. The
more deeply we commit ourselves to triviality, the less conscious we
are of who we are, but ultimacy, like the possibility of death, strikes
us out of the blue and is never unavailable; no one gets very far away
from ultimacy without deciding to do so—indeed, without working
at it.
In principle, we are never free of ultimate issues as long as we are
conscious, and yet they can exhaust us. They frequently demand that
we make a commitment to being one or another person, a commit-
ment we rarely feel up to. As a nation, we bomb populations, surely
engaging others in ultimacy we would not enjoy. It is frustrating to
take politics seriously, so most Americans trivialize it. This certainly
loosens the reigns for our leaders, who are just as subject to triviality
as we are.
None of this is particularly new in the modern period. What is new
is the existence of professions of experts who claim to be of help with
what we are pleased to call “psychological problems.” As a member of
such a profession of experts, I wonder how often I contribute to the
masking of ultimacy by complying with a patient’s relatively trivial
concern.
For most of human history, religion offered hope and relief within
the framework of ultimate issues. Our secularism, in contrast, is of-
ten proud of having eliminated the tendency to see ultimate issues,
such as moral meanings, in everything. It fails, however, to protect us
from the excessive triviality that is currently rampant.
Of course, there have always been trivialities; play is intrinsic to
human being, and so also is escape. Play and other forms of escape
can, of course, be experienced in their full measure of ultimacy. How-
INTRODUCTION xiii
ever, our highly technical culture may indeed increase the ease with
which we indulge entertainment, as opposed to attending to ulti-
macy. Of central interest here, however, is the complicity of the help-
ing professions in blurring the distinction between ultimacy and
triviality.
Not all human suffering results from physical illness. Psychiatry
and psychology have made a decision that some part of nonphysical
suffering is an illness nonetheless—a mental illness. We now have
practices that promise cures, relief, or abatement of psychological
symptoms. Such symptoms could open the way to dealing with ulti-
macy instead of escaping it, but instead we eliminate them as if they
were mere disease. Lauren Slater (1996) objects to this reduction of
personal struggles to the “pus of life” as if the only healthy human ex-
perience were calm peace of mind.
Our professional version of neglecting ultimacy through excessive
indulgence of triviality is now led by our current practice of psycho-
pharmacology. This technology, however, is not itself the villain;
many factors play a part. As the chemical control of human con-
sciousness becomes an ever more central part of psychiatry, non-
medical psychologists are also exploring the legal maneuvers that
would give prescription privileges to them as well. It is too rarely
asked what exactly is eliminated by the chemical manipulation of
brain events. The experience made to disappear may well be a ver-
sion of an existential issue that ought to be dealt with. It may be, or
serve as, a call to ultimacy.
Of course, there is a place in psychiatry for medications, but the
expansion of this practice far outstrips that place. It is as if people
are intolerant of nearly any fear or sadness at all. As a profession, we
call these experiences “anxiety” and “depression,” list them as symp-
toms of disease, and make them disappear. Current practice, the en-
actment of roles of doctor and patient, is a hasty imitation of the roles
and traditions of general medicine. The theory that justifies this imi-
tation is incoherent, as Szasz (1961, 1970, 1987) and others (Leifer,
1969; Sarbin & Mancuso, 1980) have made quite clear.
A second central idea of this book is that psychotherapy is the
creation of coherence in a place where there had been conflict, chaos,
and confusion. That place is in the experience of the patient. But
whatever incoherence our patients bring us, as therapists we live in
an intellectual home as conflictual and chaotic as those of our clients.
In trying to understand clinical psychology, I have stumbled on
philosophical dualism and its unacknowledged perseveration into
our current work. I have seen drug therapy, in its universe of brain
xiv INTRODUCTION
events and medicalized diagnostic descriptions: it sometimes works

like a miracle and sometimes leads to changes that are irrelevant,
sometimes to a violence of neglect (Keen, 1998, 2000a).
The dualistic rift, between a language of science and a language of
the human experience of effort and freedom, radiates out from a deci-
sively divided metaphysical basis. It echoes through various layers
of theory, practice, social convention, and legal policy. Most of all, it
drives an unacknowledged duplicity in the very language that
shapes our experience as therapists and our lives as persons. Our
theory of brain chemistry (neurotransmitters, DNA regulation of cel-
lular activity, etc.) has nothing to do with the problems people bring
in for professional help (Why do I worry all the time? Who am I to be-
come?). Using physical chemicals to solve mental troubles is hardly
intelligible, even to the practitioner. We know nothing of the relation
of brain events to such human problems. What we do know is tenta-
tive, and most of it is merely ad hoc.
Therefore, the practice of psychopharmacology is a particularly
vivid example of transforming an opportunity for confrontation with
ultimacy into a merely pragmatic exercise in symptom relief. When
practiced as it is usually practiced—over three-quarters of psycho-
pharmacological prescriptions are written by family doctors, not
psychiatrists—drug therapy is blatant trivialization.
This kind of neglect of ultimacy accentuates human triviality. The
neglect to correct our own theoretical incoherence enables chemical
treatments to imitate professional practice. The population, encour-
aged to experience ultimacy as a psychological symptom, can become
intolerant of life’s struggles. The intolerance of unpleasant experi-
ence is fed by the ease of its technological elimination and by the
profits therein. These profits have led the pharmaceutical industry
to intervene in psychopharmacological practice (Healy, 1997; Keen,
1998; Valenstein, 1998). The power and prestige of drug therapy
comes from its convenience, and its convenience motivates its exces-
sive use, which swells pharmaceutical profits and consolidates the
power and prestige of practitioners.
This closed system of mutually reinforcing concepts leaves no
place for ultimacy. The survival of ultimacy, therefore, owes nothing
to our professional practices. Ultimacy survives only because not
everyone is dedicated to escaping it. Some psychiatrists appreciate
ultimacy, as do many others involved in psychological help, but the
growth of pharmacotherapy threatens our access, and our openness,
to ultimate issues. We are certainly, as a population, a culture, and
INTRODUCTION xv
now as professionals, capable of indulging triviality as if it were an

ultimate good.
I have had to think about psychotherapy both as a conversation
and as a science. Science itself, of course, plays a role in our practice,
but the closer one looks, the less clear is that role. The language of
therapy is inevitably in the format of narrative; the language of sci-
ence is inevitably in the format of Kepler’s clockwork universe. Psy-
chology has, from the very beginning, been an awkward combination
of these two languages, now appreciating the moral choices of mental
life and now discovering the mechanical causes of behavior. Psychol-
ogy’s history, from William James (1890) forward, has struggled with
this problem. In recent decades, the continued expansion of psycho-
pharmacology has made the problem less visible. Thus its toll on the
coherence of our knowledge about our own practice becomes, ironi-
cally, invisible.
I begin, in chapter 1, with psychopharmacology. This practice and
this science leap the mind-body gap like no other, offering physical
treatment for mental symptoms, pragmatically having learned that
some kinds of cases respond well to some kinds of medication. This
practical fact conceals a theoretical conundrum, but the conundrum
is hidden from patients. Increasingly, as more and more doctors pre-
scribe more and more psychiatric medications, the theoretical vac-
uum seems unremarkable to practitioners, to the public, and, as we
become more specialized, to theorists in the helping professions as
well.
Psychiatry, as an entire profession, has become deeply involved in
this practice, and it should be involved in the conundrum as well. Pe-
ter Kramer (1992), while very much a practitioner, offers us a conver-
sation about how we are to understand the fact that manipulating
chemicals in the brain produces mental changes we can call “relief ”
and “treatment.”
This discussion continues in chapter 2, adding the phenomena of
trauma and therapy (Herman, 1992) to our reflections. Here some of
the implications of the mind-body problem emerge; they remain ro-
bust. What is the relation between physical treatment and mental
result, between the “physio-neurosis” of trauma and the “psycho-
neurosis” of trauma? Psychotherapy as well adeptly shifts from a
discourse of choice to one of determinism, without apparently miss-
ing a beat. It is possible to say to clients that they could not help feel-
ing such and such; this is a matter of causality. We also challenge
them to decide what they are going to do; that is a matter of choice. It
is hardly new that some things are beyond our control and some
xvi INTRODUCTION
things are not. What is new are the sciences of each, which engage
discursive patterns that defy translation from one to the other, even
as our practice makes the leap—as if we knew what we are doing.
In chapter 3, I enter the postmodern critique of much of social sci-
ence. In an effort to clarify our theoretical incoherence, I move to less
professionalized matters, to commonsense data, such as lifting a
weight or being ill. This return to everyday common sense is an effort
to return to elementary issues, and in this process we come to appre-
ciate that the conundrum between the mental and the physical in-
volves inevitably also the social. In this fuller context, the
controversy of recovered repressed memories of incest supplies us
with a vivid case of the interpenetration of the mental (memory), the
physical (past event), and the social (familial and legal). This discus-
sion also engages ultimacy insofar as entire self-concepts are at
stake. Incest is an arena that causal explanations trivialize and in
which the language of experienced choice makes ultimacy vivid. In
dealing with death, the opposite may be true; causal language is the
purveyor of ultimacy, and human choice can become trivial.
In chapter 4, the incoherence of our psychological science is fur-
ther seen in social phenomena such as the insanity plea, the process
of diagnosis, the routines of financing psychiatric treatment, and be-
ing a citizen. Again, we indulge common sense as a way to see the
real life meaning of our theoretical abstractions. Mental and physi-
cal reality, and the resulting moral and mechanical talk, lead us to
see beneath everyday experience, where there continues to be an un-
recognized theoretical puzzle.
In part II of the book, our focus becomes the connection between
theoretical incoherence and practical problems, especially those of
psychotherapy. Some of the struggle in psychotherapy is moral, as-
suming human freedom and envisioning possibility, while some of it
is scientific, assuming a universal network of causality and con-
demning us to necessity. These struggles engage the same theoreti-
cal puzzle and the same theoretical duplicity.
Life as we can understand it seems simply to have both features.
Science has captured center stage from other determinisms, such as
original sin or the rehearsal of human frailty. Science comes from the
desire to see order. The seeing of order is a seeing of one kind of coher-
ence; it is a challenge to figure out all the intricacies of what we call
the “natural order,” and human intelligence delights in discoveries
that allow the expansion of order finally to the vast reaches of the
universe.
INTRODUCTION xvii
But science, so far at least, has not mastered the renegade im-
pulses of human freedom, the most telling of which are obvious in hu-
man experience. Unlike the clockwork production of human
behavior, freedom invokes a singularly human ability to become
aware of purpose, a property of behavior that leads to ultimate ques-
tions about oneself. These questions, this ultimacy, is not the whole of
life; there are also causes that simply are, with no purpose, no mean-
ing. But ultimacy is never absent from human behavior and experi-
ence. It can be ignored, but it does not go away.
Both morality and rationality are human creations that would
limit human freedom; they too structure life and produce order.
These orders of tradition can be seen as more or less binding, but the
freedom to imagine beyond the order, to create something new and
fantastic, is as native to human experience as the desire for the secu-
rity of order. At a practical level, struggles with morality and with
the causes of behavior become entangled. At a theoretical level, this
entanglement becomes as obscure as metaphysical dualism (Keen,
2000a). This obscurity mirrors anomalies of life: freedom in the con-
text of order, or order in the context of human freedom. Our everyday
understanding of these anomalies has no single theoretical lan-
guage.
When I say that psychotherapy is the creation of coherence, I am
saying that psychotherapy is an effort to help, allow, or facilitate a
person whose life is incoherent to map out a plan for coherence. This
human task is everyone’s task, and in doing so every human creates
his or her own ultimacy. The order of natural necessity frames the
freedom of human possibility, which is where we decide what mat-
ters. Thus we deal in the currency of ultimacy. In terms of concrete
lives, this task becomes the task of answering the question, “Who am
I to be?”
In chapter 5, I describe psychotherapy with Rob. There is nothing
particularly remarkable about Rob’s problem or the therapy that
tried to deal with it. But concrete clinical data, as is true of everyday
experiences, shape our prospective theory in terms that name what
is already inherent in human experience. Problems in psychother-
apy are discussed in chapter 6, using the concept of narrative—a
relatively recent way to think about therapy, about science, and
about the self. Clinical data are considered here, in the hope, again,
that concrete experience can tell us what we need to know about dif-
ficulties in current theory. Furthermore, we need to test the extent to
which both narrative and conversation—phenomena of psychother-
apy—might feed back into science as well. In chapter 6, this explora-
xviii INTRODUCTION
tion brings us directly into contact with postmodern and narrative

interpretations.
The discussion of psychotherapy is continued in chapter 7, where
“ultimacy,” as a concept, comes into focus. The talk in therapy, the
narrative-self and the treatment routines, all speak to yet another
doubleness, that of surface and depth. On the surface, a symptom is a
symptom; when symptoms are lived by persons, however, their con-
text in the narrative constructions of the person supplies a context of
depth. That depth harbors human purposes—the patient’s, the
therapist’s, mine, and yours—and it leads us directly to ultimacy,
which is absent from much psychologized, technologized, and phar-
macized treatment.
The unspoken reference to ultimacy in medicine lies in the pres-
ence of human purpose within the frame of the reality of death. The
discourse of psychiatry and psychology speak more immediately of a
different ultimacy, that of madness, which leads individuals into in-
comprehensibility. We see in our critique of these discourses an in-
convenient fact that is rarely spoken, namely, that death and
purpose and madness are implicit referents in matters of physical
and mental health. At the same time, all of us understand the ulti-
macy of purpose, as well as of madness and death. This ultimacy le-
gitimates the professions of psychology and psychiatry. Such
legitimation, I argue, is similar to discourses like those applied to
military operations, such as the bombing of the former Yugoslavia in
1999. There we cannot avoid speaking of death, and thus of purpose
and ultimacy, but our technological emphasis leads to the trivializa-
tion of death—and of every ultimacy.
Finally, in chapter 8, ultimacy and trivialization offer a sort of
summary that amounts to a critique of the treatment professions.
Too often our patients adapt their life problems to our professional
offerings, and too often we engage in a modern conspiracy to bury ul-
timate issues by taking their superficial expressions literally.
Part I of the book, therefore, describes and documents a theoreti-
cal incoherence embedded in psychotherapy—but also, more impor-
tantly, in the culture at large. We tolerate this incoherence because
we have learned that life proceeds as if there were two realities, men-
tal and physical, free and determined, extended in space and not ex-
tended in space. We seem to have no difficulty applying one reality,
matter—that is, medication—to treat the other reality, mind, in the
routines of drug therapy. Part II of the book, then, examines psycho-
therapy and proposes a “narrative psychology” that seeks to make
the incoherence of psychopathology, which is related to the incoher-
INTRODUCTION xix
ence of Western common sense, into coherence. Along the way, I offer
a critique of psychiatry as a profession and of psychotherapy as a
process. As in other postmodern critiques, the use of language in de-
scribing what we are doing reveals itself as a complex, discursive
sleight of hand, one that contains familiar paradoxes—from dualism
to heretofore unrecognized twists in the ultimacy of human experi-
ence and the experience of human ultimacy.
PART I
Theoretical Incoherence
CHAPTER 1
Critical Reflections on
Psychopharmacology
How are we to understand the role of medication in the practice of

clinical psychology? How can we compare (1) feeling better because
medicine makes you feel better with (2) feeling better because you
now understand what your options are, how you formerly misper-
ceived them, and why?
Taking drugs to deal with psychological anxiety and depression is
often helpful. But neglected by the profession are certain costs of
medication, costs that are apparent when we take ultimacy seri-
ously. Ultimacy is that dimension of human experience that refers to
ultimate issues, such as human mortality and cosmic mystery. All
human experience occurs to particular persons, each of whom is em-
bedded in a world full of meaning, but each of whom is also adrift,
alone, on a sea of indeterminacy. Every person is not only mortal but
fundamentally ignorant of the origin, destiny, and meaning of the
cosmos. Not everyone dwells on ultimacy, but no human is immune to
the impact of mortality and mystery.
Funerals, religious rituals, near brushes with death all provoke
the sense of awe and the profound anxiety of not really knowing who
we are supposed to be—for however long we are here. These experi-
ences may always accompany events we witness, work we do, and
selves we experience ourselves being. They are interrogatory. They
ask of us what we are going to do and who we are going to be. Such
questions are strenuous.
“Who am I to become?” is a question no one escapes. Of course,
daily life is full of tasks and obligations that structure the openness
4 THEORETICAL INCOHERENCE
of the future. Facing that openness and its questioning of us can al-
ways be postponed, but two features about that postponement
hover, at least at the edges of our experience. First, a time will come
when the question will have been answered because our life will
have been completed. Second, we are free until that time to move in
many directions, and we must chose now. We are always writing our
own obituary; every choice we make is a part of the answer to the
question of who we will have been.
Since human experience is always centered in a particular moral
narrative, ultimacy is always with us. We are its debtors, its slaves,
and its victims. Postponing serious thought about who to become
flees the existential awareness of ultimacy, and such flight is ubiqui-
tous and inevitable. It is a holding action; it buys time—time to
think, to wonder, to play at scripts already written, time thus to in-
dulge the chronic inconclusiveness of our own unattended ultimacy.
In the course of life we all catch snags. Such snags are sometimes
opportunities to experience anxiety or depression more fully and to
follow its urgent message to take ultimacy seriously. In our current
culture, however, we are as likely to take our anxiety to a doctor as to
think about it, as likely to have it medicated away as to listen to the
ultimate questions embedded in our distress.
One of the most thoughtful of the many advocates of psychoactive
medication is Peter Kramer (1989, 1992). Unlike many who argue
that current knowledge of neuropsychology makes all former ap-
proaches obsolete, or who apply neurochemical theory to all psycho-
logical issues, Kramer is at least capable of sensing the far-reaching
implications of this increasingly dominant practice.
For some depressed or psychotic patients, therapy is barely possible without

drugs, immensely helpful with them; drugs allow certain patients the men-
tal relief necessary for concentration on hard problems. Other patients, once
the issue of medication arises, focus on physical diagnoses and drug effects
rather than heartbreak, and some feel well enough on medication to opt out
of therapy we think they need. (Kramer, 1989, p. 49)
We may, therefore, ask how we might understand the difference

between Kramer’s two cases. In the former case, drugs can make it
possible for an individual to, with the help of a guide, explore his or
her history, the narrative dimensions that led to his or her current
life, and see what can be changed and what cannot. In the latter case,
drugs lead to such effortless improvement, especially in comparison
with the struggles of redefining one’s historical and current life story,
CRITICAL REFLECTIONS ON PSYCHOPHARMACOLOGY 5
that the treatment virtually precludes such work. This is the possi-
bility psychopharmacological enthusiasts fail to take seriously.
Psychopharmacology today is practiced over three-quarters of the
time by family doctors, not by psychiatrists. These doctors often do
not have the time, nor the inclination, to explore whether one’s cur-
rent narrative actualizes the person one is supposed to become. They
may feel their job is finished if they persuade the patient to remem-
ber to take the medicine. Remembering to take medicine simplifies
solving my problems—to the point of triviality.
It is tempting to say that we are dealing here with two types of
people: some are open to ultimacy; others are enchanted with trivial-
ity. We would have to say that we are looking at two kinds of narra-
tive life-constructions. The first narrative puts one in a world where
life asks questions, to which one’s life is the answer. The other narra-
tive puts one into a world of “making the grade,” “being somebody,” or
just getting through a day, all of which trivialize life. Certainly medi-
cation guarantees nothing more than symptom relief.
To explore this issue, we need to engage both (1) a general value
question and (2) a professional psychological one. The general value
question is that quite personal one already noted: What kind of self
ought one be? Any answer to this question must be seen as not only
shaped by the culture we live in but by a number of internalized, so-
cially constructed concepts, which we may see not as cultural but as
“natural” or “scientific.” All of these “givens” are raw material out of
which we fashion our personal lives. The task is to take seriously our
own adoption (or re-creation) of them.
The second, professional, question is about practice: When is phar-
macological treatment appropriate? Whether to offer or accept drug
therapy cannot be separated from the issue of what sort of person
one ought to be. The technical question is contextualized by the first
question and hence is never really independent of it. But it addresses
what we, in the profession, do, rather than what the client does.
Sometimes the professional agent prescribes medicine in the spirit
of an antibiotic. Infection? Take an antibiotic. Depression? Take an
antidepressant. At other times, professionals engage reflective is-
sues of possible and necessary courses of action, thought, and feeling.
Here we shall dwell on the professional question first and then re-
turn to the personal value question, and the self, later.
PROFESSIONAL CONSIDERATIONS
There is, of course, some kind of correlation, correspondence, or
congruence between what we call a person’s “neurophysiology” and
his or her “psychology.” We do not know how to unravel the complex

ways in which each causes the other, for each operates at multiple
levels at once. It is possible to imagine, for example, that even as an
excess of a brain chemical may cause a temper outburst (body caus-
ing mind), an experiential event with strong meaning may raise the
level of another chemical (mind causing body).
However, professionals have empirical knowledge of a rough cor-
relation between a chemical like dopamine, on the one hand, and an-
ger as an experience, on the other, and it may be possible to know that
a particular client prone to outbursts of temper has significantly
higher-than-average dopamine activity in certain places in his
brain. Without knowing whether the anger caused the chemical odd-
ity or the other way around, we may be able to establish for sure that
a medicine lowering his dopamine activity also lowers the frequency
of his temper outbursts. It also, let us say, raises his tolerance for am-
biguity in social situations and also his patience, as measured by
psychological tests.
Would we be obliged to give such a client the medicine that does all
these things? If he said he wanted to have more patience and to toler-
ate more ambiguity, should we think of the medicine as a legitimate
medical treatment for his problem?
In the short term, this issue is simply one of a measurable symp-
tom that can be corrected by chemical intervention. This is as rou-
tine in medicine as giving a drug that lowers blood pressure to
patients with hypertension. If there is any ethical question here at
all, it would seem to be only why more people with hypertension (or
temper outbursts) do not get a drug. There is no obvious reason to
question whether one should lower blood pressure, which can cause
heart attacks and strokes. What exactly is the difference between
this circumstance and the chemical control of anger? Anger too can
be shown to be implicated in the occurrence of heart attacks and
strokes.1
THE PHYSICAL AND THE PSYCHOLOGICAL

Drug treatment and psychotherapy are significantly different inter-
ventions, but the difference is not limited to their characteristics as
therapeutic techniques. The difference is also philosophical and
moral. As a first step, we must appreciate the interaction between
what Western science has called “mental” and “physical” aspects of
life. A systematic treatment is beyond our purposes here, but Kra-
mer offers us a case example that will reveal at least some of the
practical aspects of “mind” and “body.”
I recently had occasion to do marriage counseling with a couple in which the

husband labeled the wife overly aggressive and controlling, while the wife
complained that her husband was insufficiently sexually motivated. (1989,
p. 50)
Kramer,2 who refers to this case as a “typical family therapy” issue,

proceeded to think about the therapy appropriate in such a marital
difference. Then, “a few weeks into our work, I saw an incidental re-
port from a gynecologist indicating that the wife had high testoster-
one levels.” This led him to ask:
Do we take this datum into account in deciding how much change in aggres-
siveness or sexual demand we will expect in her? (Or, before that decision, do
the hormone levels influence our belief about the accuracy of the two
spouses’ reports of the causes of their conflict?) For a psychotherapist in this
case, might there be an ethical difficulty—a question of good or bad
faith—in ignoring the research on “high-T” women? (1989, p. 50)
Let us leave aside, for the moment, the ambiguity of the causal
question. We do not know whether the “high T” (testosterone) made
the wife more sexually demanding, whether her psychological han-
dling of sexuality made her seek out sexual stimuli that over time
raised her testosterone, or whether a third factor (perhaps a change
in diet, or even of a cultural nature, such as excitement about femi-
nism) increased both her testosterone level and her sexual demand.
Let us merely ask, practically and ethically, what we want for the
woman and her husband. If there were a drug that would lower her
testosterone, making her less aggressive and controlling, and less
demanding of sex from her husband, and if this therapy accom-
plished what the clients want, should we simply prescribe it?
Some clients want relief from what is bothering them, and they
care little about understanding themselves, their troubles, or even
their lives, beyond what is of most obvious interest to them—enjoy-
ing life more, being symptom free so as to work better, having a less
conflicted marriage. Such clients have internalized the triviality of a
culture that says these things are available without much introspec-
tive struggle or self-understanding. Are we bound to accept this
point of view and simply give patients what they want, when it is
technologically possible?3
I think not, in this case. A good marriage involves each partner
coming to see who the other is, each accepting the other, even as each
is seen clearly and accepted. We must in fact wonder if the marriage
will be as good if one partner simply changes to some less trouble-

some configuration through chemistry.
In some cases, the alternative to drugs is a lot of work, perhaps
more than the results are even worth. Ultimacy, for example, is
strenuous. Seeing the ultimate dimension in being a husband or a
wife puts serious demands on people. Yet conflicted marriages often
involve demands that are better tended if the parties do that work,
and if the marriage does not break up. The marriage may even flour-
ish if the pair undergoes the strains of telling one another the truth.
When I understand my partner’s struggle with her question of who
she is to become, and she understands mine, we will know whether to
stay married; if we do stay together, it will be with deeper empathy.
On the other hand, we might assume as professionals that avoid-
ing that truth, or avoiding the task of deciding together exactly why
clients stay together, may guarantee less misery in the longer run.
What is our professional obligation here? To work in the world of hu-
man freedom is to work on ultimacy/triviality, and it is to engage pa-
tients within a framework of freedom. To work in the world of
physical causality is to put the correct causal agent into the matrix of
causes in order that people will be more symptom free.
The two worlds, the discourses of mental life and of brain chemis-
try, are metaphysically different. The metaphysical question has
now appeared as a professional-ethical one. From the point of view of
this book, to work exclusively in the world of causal agents (chemi-
cals and neurons) is to trivialize the problem and the experience of
those who suffer it. Yet that may be their preference. There are no
easy answers here.
KRAMER’S POSITION
Kramer’s medical loyalties are unmistakable, but he has an argu-
ment as well. First, he notes that once one becomes attuned to the
biological possibilities of every symptom one sees in the clinic, one’s
psychological listening for the nuances of meaning is compromised.
One becomes less astute as a psychologist. At the same time, how-
ever, he states:
Ignorance of physical causation is not a boon; in today’s world it is a form of

bad faith. . . . Psychiatric medication is truly one of the “miracles of modern
science.” Not to consider physical disease and treatment is malpractice, not
just legally but morally. If attention to the physical didn’t work, the dilemma
would disappear. The point is, it does work. If we are good at what we do, we
will consider the physical again and again. (1989, p. 54)
Kramer here is not denying a difference between physical disease

and other kinds of problems that presumably are better conceived as
developmental and psychological. He is, however, saying that physi-
cal disease cannot be ruled out. An example of a physical disease,
very much like depression, that can appear in one’s life is hypothy-
roidism. There are also anemia, diabetes, hepatitis, malnutrition,
multiple sclerosis, syphilis—and even influenza—that can appear as
depression. But the physical disease Kramer has in mind is a disease
of brain chemistry, which somehow causes only depression and
which the application of physical medicine apparently cures. We do
not actually know of such a disease, but doctors behave as if we do.4
An example, in contrast, of a developmental and psychological (as
opposed to a physical) problem would be a “characterological” de-
pression that developed as one’s very general and central style of
coping. Such a depression would have emerged from a childhood of
loneliness and crucial early losses, in the face of which this style has
become a coping strategy that is fundamental to the person’s entire
identity and life.
For physical diseases, in contrast to characterological ones, medi-
cine works more reliably. Our obligation is to try it, even if we cannot
tell for sure whether the disease is really physical rather than char-
acterological.
Following Kramer’s advice might be very risky, however, depend-
ing on what the medication actually does. Suppose, for example, that
our observation that “it works” describes mere symptom abatement,
without any real understanding of why the symptoms go away. The
possibilities of what is actually happening here are numerous. First,
it may be, as inexperienced physicians so often say, that a “chemical
imbalance in the brain” is corrected by the medicine, which selects
for its action the site in the brain just where the problem lies. This
seems unlikely, since we know very little of any such sites, and since
any medicine that crosses from the bloodstream into the brain ap-
pears everywhere in the brain at once. Of course it may do different
things in different places by interacting with different chemical
states of affairs, but we know little of them either.
Second, the disappearance of a symptom like depression may be
an example of the placebo effect, which is commonly observed in re-
search. According to much research, whatever may have caused the
symptom’s appearance, it disappears whether the pill is an actual
psychoactive chemical or a placebo, which is chemically inert and
does nothing psychoactive as far as we know.
But the third possibility is even more telling. Suppose the disap-
pearance of the symptom is a chemically induced shutdown of cer-
tain functions that create the symptom we see, such as depressed
mood. But such functions also control other biological processes that
are significant to other functioning, thus causing side effects. The
frequent presence of anticholinergic side effects (dry mouth, consti-
pation, blurred vision, urinary difficulty, excessive perspiration), for
example, guarantees such (at least) short-term interference. The
side effect disappears when the medicine is stopped. But for some
frequently used drugs, longer-term, extra-pyramidal, side effects
have also been observed, such as Tardive Dyskinesia (a disorder
involving uncontrollable body movements). This side effect does not
disappear after the medicine is stopped and thus appears to be the
result of some unspecified brain damage.
According to one theorist (Breggin, 1991), it is quite possible that
this is not a side effect. The early stages of such brain damage may
produce symptom removal, while the later stages produce Tardive
Dyskinesia. This theory is also unproved, but that sort of ambiguity
afflicts most of the theory that guides our current practice of giving
psychoactive medicine.
This ambiguity is made more devilish because of the theoretical
distinction between physical and mental spheres. While such a dis-
tinction is nearly inevitable in Western medicine and theory gener-
ally, it is also widely recognized as an inadequate metaphysical base
for either psychology or medicine. Nevertheless, as a functional dis-
tinction, it remains useful, even if it is often misleading and never
satisfying. This issue is explored at length in Keen (2000a).
MEDICATION AS PROVOKING INTERPRETATION

Putting these metaphysical matters aside, Kramer’s attitude is
pragmatic: he argues that the medicine sometimes offers an inter-
pretation. What he means is that a drug may work like a cotherapist,
giving patients a new look at the world, at their lives, jolting them
out of repetitive perceptions that psychotherapy may never be able
to budge. He offers us the example of a patient for whom insight
seemed quite unlikely, given her history and symptoms. Even medi-
cation seemed unpromising, since, as noted above, developmental or
characterological depressions are not supposed to respond to antide-
pressants. But he tried drug therapy anyway. After taking the medi-
cine for a while, this patient came to say, “It wasn’t just my husband,
it was me.” She realized that she had created many of the conditions
that were making her symptomatic, and that she did not have to live
that way.
This sequence of events leads us to a more complex problem than
the polarity set up earlier between (1) feeling better because the
medicine makes us feel better and (2) feeling better because psycho-
therapy has helped us to understand our options and the people in
the world with whom we are in conflict, how we formerly misunder-
stood them, and why. Now we have to ask whether Kramer is right,
whether sometimes the medicine makes it possible for clients to un-
derstand things better, just as psychotherapy might—only more
quickly, and with less trouble, struggle, and expense.
Of course, seeing a marriage more clearly, whether through men-
tal or physical means, can be helpful. The ultimacy that is tapped in
the patient’s realization that “It wasn’t just my husband, it was me”
is not very likely to develop in the case of pharmacological treatment,
which is usually explained to patients in medical terms: antibiotics
cure infection; antidepressants cure depression.
Potentially, she could have seen much more clearly her own and
her husband’s trivialization of their differences. By undercutting the
trivialities, they could have entered into a conversation with each
other in a spirit of ultimacy. Failing to do that allows them to solve
the immediate problem without becoming more aware of stakes that
really matter, and will continue to matter, to them.
We must, in addition, examine the context of roles, power, tradi-
tion, and ideology to see clearly whether taking medicine ought to be
a step in psychotherapy, as Kramer seems to be suggesting. The role
Kramer played in the above scenario was the traditional medical
role. Taking his own advice, he did not neglect to “consider the physi-
cal again and again”; he prescribed medicine not immediately prom-
ising for a patient whose disease he saw as “characterological” rather
than “physical.” When it worked, he concluded that “she evidently
had suffered a treatable ‘biological’ depression after all.” Hence, it
appears that the medicine stronger than talk was required.
But there is more to see here. To understand what happened in
this case, we must see the events in a narrative stream. The plot of
the narrative may have been a trivialization of deeper issues, such as
a plot embedded in the culture and activated here with little reflec-
tion. The persons enacting their roles did what they did “in role,” as
moves in a structured space between doctor and patient. If we look at
what happened in this way, we see people enacting medical themes
like treatment, martial themes like pushing back evil forces of dis-
ease, protective themes like making the streets safe for sane people,
and even educational themes like telling people something they

didn’t know. Both parties may have done what they did within a cul-
turally limited set of plot-consistent possibilities.
No doubt the doctor had suggested, subtly or strongly, that she, the
patient, was (or at least could be) in control of the situation of which
she claimed to be victim. She did not reply or seem amenable to per-
suasion, perhaps because the doctor’s suggestion pronounced a pos-
sibility inconsistent with any plot that she had ever considered.
Nevertheless, she kept doing what she was doing until he finally
gave her medicine. Do we know what it meant to her? Can we rule
out the possibility that she expected a prescription and that his com-
pliance with her expectations seemed to obligate her to comply with
what she thought were his expectations?
In the practice of medicine, we are happy when we make a diagno-
sis, prescribe a treatment, and get a result, confirming the body of
knowledge called medicine. In cases like this, we are in a different
world of guesses, mutual hopes and fears and expectations, all of
which contribute to what happens. The usual medical situation is
less ambiguous than psychiatry, because we in fact have clear evi-
dence about what the treatment does and why. In psychiatric situa-
tions like this one, the results of any given case say little about the
nuts and bolts of causality and cure, for the mechanistic plot may be
vastly overshadowed by the dialectical relationship, concretely expe-
rienced by two particular people and profoundly channeled by a plot
both know—but may not realize how well they know it.
In medicine, our scientific knowledge makes it respectable not to
examine the personal interaction in its dialectical detail, for the me-
chanical relations among disease processes and agents, and among
treatment processes and agents, are seen as relatively independent
of the psychological plot. Insulin relieves a diabetic crisis whether
administered by a doctor or a priest.
In contrast, in the psychiatric setting, the roles and plots are more
decisive, the facts are more ambiguous. Yet the interpretation of
medicine doing its work is no less confidently pronounced by doctors
who want to believe that medical, not psychological, facts account for
the outcome. We do not know whether they are right in that belief,
but we can certainly see how that belief indulges a triviality and pre-
cludes a fuller realization of what is going on.
SUMMARY AND CONCLUSIONS

All these fairly common ambiguities become quite complex in any
given concrete clinical situation. Let me pose again the two ques-
tions we began with, and that seem to emerge from what has been
said. The first question was, and is: What kind of self ought one to be?
The self is a combination of psychological (mental) and physiological
(physical) factors. We know human freedom in our mental experi-
ence of it; we know the limitations of that freedom and the mechani-
cal causalities of the world through our own bodies—and sometimes
our mental life as well. William James eventually dealt with the am-
biguity of human free will by deciding to believe in free will.
This decision, he argued, changes one’s life. The decision worked
like nothing in nature, but such phenomena are common in human
experience. We would today call them “self-fulfilling prophesies,” or
perhaps simply attitudes about our range of human freedom. People
can and do experience the effect of their own freedom, but doing so
engages them in what we are calling ultimacy. In contrast, the expe-
rience of solving the problems of life with pills does something quite
different to the self-experience of every psychiatric patient taking
drugs, which is the vast majority of them, and that experience must
be clearly understood, at least by professionals, ideally by patiants
as well.
One conclusion from these facts must be that psychopharmacol-
ogy engages deception of patients by doctors. This is hardly new in
medicine, but doctors usually were aware of the deceptions and their
value in practice. In psychopharmacology, the doctors appear to be
deceived themselves as well by the simplified account of symptoms
offered by pharmacentical corporations. This extra layer of duplicity
can no longer be absorbed as a part of medical practice. It becomes an
unethical situation driven not by treatment goals but by corporate
profits.
For some patients, drugs are magic. My wife’s irritating com-
plaints simply don’t irritate me any more. My fears about my incom-
petence don’t frighten me, and my fatigue with the unfairness of life
no longer burdens me. I don’t know how the drugs have changed me,
but I am happier, and I like it. For others, drugs are artificial. I still
believe my husband shouldn’t criticize me, but I no longer stand up
to him. We don’t fight, but maybe we should. Maybe he should
change. With the introduction of the drug, what happens between us
changes, but neither of us has done anything about what is at stake.
All that—whatever it is that is at stake—changes, because the drug
changes me, and I’m not the person I was.
For other people, drugs cure a disease the way an aspirin cures a
headache. For yet others, drugs help escape the reality of a stressful
job. They may allow my boss to push me around without my objec-
tion. All of these possibilities have to do with the self I am and what I
think about it. These possibilities invite an appreciation of ultimacy.
But they are not brought up in pharmacological practice. For these
are all versions of the very personal, but also very general cultural,
value question: What sort of self ought I be?
The second question with which we started, and which again
emerges, is about professional practice. Pharmacological therapy
can be enormously helpful in psychiatric practice. However, our sys-
tematic knowledge of this practice is limited to the efficacy of drugs
in symptom abatement. In fact, our conclusions about clients’ experi-
ences of self reveal that much more is at stake than the disappear-
ance of symptoms. After taking a psychotropic drug, I cannot help
but wonder whether what I do is really mine or what I should do in
terms of becoming who I should be.
Psychiatry today tends strongly to neglect such psychological is-
sues and to focus on what drug should be used for what symptoms.
Perhaps it is the competition among corporations for a share of the
lucrative drug market (Healy, 1997) that has driven research into
this extraordinarily narrow focus in psychopharmacological re-
search. Whatever its cause, the limitations of our current knowledge,
compared to our apparent confidence, constitute something of a pro-
fessional anomaly.5
Unfortunately, the practice of drug therapy occurs in the office of
family doctors and primary-care physicians three-quarters of the
time. Therefore, specialized psychiatric knowledge about medicating
patients often does not enter the arena where most drugs are pre-
scribed. Nor are there well-funded and developed research projects
about the psychology of drug therapy. The economics and the science
of psychopharmacology thus interact to prevent such an approach.
Healy notes that
there are health schemes in the United States (and probably elsewhere in
the West in the near future) in which the only act of a psychiatrist that is re-
imbursed is the act of prescribing. Lengthy amounts of time put into manag-
ing nonspecific aspects of care count for nothing. (Healy, 1997, p. 262)
I fear we can count on this pattern to continue and to produce in-

creasingly trivial psychopharmacological practice.
NOTES
1. The famous case of Rafael Osheroff reveals that this is no idle ques-
tion but rather a legally dangerous one. It is possible to sue a doctor who
does not prescribe antidepressant medicine. Healy (1997) describes the

landmark case as follows:
The political, social and medical issues involved in the treatment of depression came
together in the 1980s in a set-piece drama, a court case about the adequacy of the
treatment afforded Rafael Osheroff. . . . [T]he arguments on Osheroff ’s behalf were
that there now exist proven treatments for the management of the depression he
clearly had and that an unwillingness to prescribe accordingly had cost him dear and
would cost both the psychiatric profession and society dear if the lessons or the case
were not taken to heart. (pp. 1–2)
2. I discuss this case also in Keen (1998), chap. 4.

3. For those of us who don’t need to take drugs every day, it may be
easy to pronounce judgments on those who do. I hope that such judging is
not what we do when we seek to explore why people use psychiatric drugs.
Such a decision comes from as many kinds of circumstances as there are
psychopharmacological patients. Deciding to let drugs help is not just a de-
cision to join patienthood. It may be a decision to do one’s work better, be
kinder, or make life easier for others. But even if it is only a decision to
make life easier for myself, such a decision has to be understood in the con-
text of a life, a narrative that one enacts and is, and a narrative that may
be so conflicted or chaotic that the strongest among us would not turn
down a little chemical help.
4. An enormous gap separates psychopharmacological hopes from sci-
entific reality. This gap is masked by practical successes in daily practice,
but these successes are closer to what we have known about alcohol than
to what we would need to know in order to prescribe with any precision in
psychopharmacology.
We have a vocabulary of drugs—naming genus, species, and
strength—that enables us to prescribe antidepressants for depression and
anxiolytics for anxiety, sometimes even to rank-order the probability of
success with various drugs in particular cases. But in fact our knowledge
of how one particular molecule affects which cell, group of cells, organs, or
regions of the brain is mostly absent and at best spotty. Even when we
radio-label a molecule to see where in the brain it has bound to a neuron,
we still don’t know which of the regions really count, what that binding
has done at any site to other chemicals in the region, and so on. Depression
does not happen, as far as we know, at a place in the brain.
Even more perplexing than these ambiguities is our lack of precision in
describing a psychological anomaly or the psychological effect of a com-
pound administered to the brain. One depression is like another only in
very general terms; human sadness refers to and emerges from an infinite
variety of circumstances. However, our current practice is categorical: it
treats every depression like every other depression. An alternative model,
dimensional instead of categorical, reveals different degrees of various as-
pects of depression in different cases: it indicates that a degree of depres-
sion is accompanied by a degree of anxiety, of various kinds under various
circumstances. We might appreciate this variation of states by thinking

dimensionally instead of categorically. Sensitive psychiatrists may have
this appreciation, but it has no place in psychopharmacological theory.
It is not remarkable that the science of drug therapy is very new and
undeveloped. What is remarkable is the confidence of the profession,
which increasingly trains its candidates in pharmacology and decreas-
ingly in psychology, and the bragging of pharmaceutical advertising,
which shamelessly promises effects it cannot deliver. The best scientific
research done by pharmaceutical corporations is scientifically flawed by
orientation toward the market, which operates, like doctors do, in terms of
categories and diagnoses instead of the many, rich, and decisive dimen-
sions of human experience.
This is the most recent and most costly price paid for the medical model
in psychiatry. One case of measles may be pretty much like another. They
have the same cause and course. To assume as much about depression is to
perpetrate a scandalous simplification.
5. As if the categorical versus dimensional error were not enough, psy-
chopharmacology is a prime candidate for “the placebo effect.” “Until very
recently, nearly all of medicine was based on placebo effects, because doc-
tors had little effective medicine to offer. Through the 1940s, American
doctors handed out sugar pills in various shapes and colors in a deliberate
attempt to induce placebo responses” (Blakeslee, 1998a). The power of pla-
cebo is illustrated in the following case:
Mr. Wright . . . who was found to have cancer in 1957 was given only days to live. Hos-
pitalized in Long Beach, California, with tumors the size of oranges, he heard that
scientists had discovered a horse serum, Krebiozen, that appeared to be effective
against cancer. He begged to receive it.
His physician, Dr. Philip West, finally agreed and gave Mr. Wright an injection on
a Friday afternoon. The following Monday, the astonished doctor found his patient
out of his “death bed,” joking with the nurses. The tumors, the doctor wrote later, “had
melted like snowballs on a hot stove.”
Two months later, Mr. Wright read medical reports that the horse serum was a
quack remedy. He suffered an immediate relapse. “Don’t believe what you read in the
papers,” the doctor told Mr. Wright. Then he injected him with what he said was “a
new super-refined double strength” version of the drug. Actually, it was water, but
again, the tumor masses melted.
Mr. Wright was “the picture of health” for another two months—until he read a de-
finitive report stating that Krebiozen was worthless. He died two days later.
(Blakeslee, 1998a, p. D1)
Our current scientific response to this phenomenon is quite variable.

We do understand it, in a way. The brain economizes its information-
processing tasks by expectations, whose neuronal activation patterns in-
tersect with activation patterns coming in from the rest of the body. “If
there is a mismatch, the brain tries to sort it out, without necessarily des-
ignating one set of patterns as more authoritative than another,” said
Kinsbourne (quoted in Blakeslee, 1998a).
Medical science fails if it neglects the cultural context that gives mean-
ing to symptoms of illness and to applications of healing. “I can only say
that cultural differences affect ulcer treatment, even though ulcers are the
same the world over,” offers a scientist who compared 122 double-blind
placebo-controlled studies from all over the world. Using the same proce-
dures, placebos worked somewhere between 0 and 100% of the time, de-
pending on the culture. Interestingly, placebo healing was 60% in
Germany, only 6% in Brazil; and the United States fell at about the world
average of 36%.
If medical science fails to take culture seriously, it is because we under-
estimate the body’s own role in its healing, and we neglect the effect of ex-
pectations in the mind on the performance of the body in its own healing.
In other words, medical science, limiting itself to physical factors, exagger-
ates the role of technological mastery when it comes to actual healing and
curing.
If this is true in medicine, how much more important must it be in psy-
chiatry? If mental life affects the outcome, often decisively, of the treat-
ment of asthma, allergies, joint repair, pain, and even hair growth in
balding men, then how very foolish is our assumption that chemicals are
the most important active ingredient in psychopharmacology, where the
target symptom itself is mental.
In another article, Blakeslee (1998b) reports:
“The thing that trumps everything is the enthusiastic physician,” said Dr. Dan
Molerman of the University of Michigan. For example, one study offered the same
drug to patients with identical symptoms with one difference. Some were told by
their physicians, “This drug has been shown to work,” while others were told, “I am
not sure if this treatment will work—let’s just try it.” The first group of patients did
much better, Dr. Molerman said. “The physician is an agent for optimism and hope
and a great inducer of beliefs.”
It is possible, or necessary, in light of these considerations, to inquire

into the role of popular beliefs in the practice of psychiatry, and even psy-
chiatry’s own manipulation of these beliefs—which is, perhaps, a legiti-
mate part of the practice of psychiatry. To the extent that psychiatry
depends on popular beliefs, its efficacy is more analogous to witchcraft
than to surgery. Beyond that, however, it is clear that placebo-induced
symptom reduction is harmful to people whose symptoms are in fact about
something to which they should pay attention.
In self-defense, psychiatry might respond differently from any other
branch of medicine, for symptoms like those of depression can come from
childhood circumstances that have actually ended and are quite irrelevant
to current life. But this judgment would have to be made one case at a
time, which it rarely is in current psychopharmacological practice.
CHAPTER 2
Neurons and Narratives
THE TWO DISCOURSES OF PSYCHOLOGY

I have made the argument (see Keen, 2000a, for an elaboration) that
the mind-body problem, inherited from centuries of Western philoso-
phy, leaves the psychological sciences with serious conceptual diffi-
culties.1 Because this problem has its most vivid presence in
philosophy, psychologists of the twentieth century have felt justified
in neglecting it. Psychology’s American ancestor, William James,
would not have planned twentieth-century psychology as it occurred,
for he fully appreciated the mind-body problem; it was a problem, he
thought, that we must live with. Mental and physical phenomena are
fundamentally different and yet somehow intertwined. He did not
think the problem had to be solved for psychology to develop, but he
did think that either body or mind without the other was an incom-
plete catalogue of the subject matter of psychology.
Heidbreder (1933) notes that James explored various metaphysi-
cal theories of mind, and ends by rejecting them all,
and by contenting himself, for the purposes of psychology, with “a blank un-
mediated correspondence, term for term, of the succession of states of con-
sciousness with the succession of total brain processes.” In other words, he
accepts both states of consciousness and brain processes as phenomena in
the natural world. (pp. 162–63)
For James, the unexplained relation of body and mind was a philo-
sophical problem, not a psychological one. James never, however, be-
lieved that reducing the subject matter of psychology to the object

world, or to anything that could be measured in an objective way,
could replace dealing with the mind.
John Watson believed exactly that it could. In the history of psy-
chology, it was the energy and doggedness of Watson that set the
agenda for the development of American psychology, not the inclusive-
ness and optimism of James. Of course, Watson’s work, three decades
after James’s, built on the functionalism of the Chicago school and on
the bandwagon impulse to overthrow Titchener’s mentalistic theo-
ries, in the spirit of America’s independence from its European roots.
Psychology’s first century in America has taken many turns, but it
has not improved on James’s tolerance for the ambiguity of sus-
tained psychophysical parallelism. Thus we have, at the beginning of
the twenty-first century, a hidden continuation of the mind-body
problem, accompanied by a denial that it has anything to do with the
future of psychology.
Watson’s approach dominated the first half of the twentieth cen-
tury in American psychology. Watson was certain that behaviorist
psychology could answer the most important questions in psychol-
ogy; all he had to do was predict and control behavior successfully,
and it seemed to cost nothing to neglect mental life. After him, Skin-
ner defined psychology with the same behavioral limits, with the fo-
cus on physical movement in physical space and time.
Both Watson and Skinner claimed that if one wanted to study
mental life, the behaviorist language should be used to approach the
task. Hence they both invited the extension of their framework into
mental life, but neither did anything particular to develop the actual
science of mental life. The language available a century ago to do
what behaviorists could not do was that of philosophy or, in psychol-
ogy, Titchener’s structuralism. Both were left behind as the early
century’s enthusiasm for behaviorist psychology created depart-
ment after department and career after career.
However, this behaviorist center in American psychology could
not hold. By mid-century, partly because of the successes of gestalt
psychology in Germany but most immediately because of the enor-
mous popularity of the translation from the French of Piaget’s de-
scription of mental development, cognitive psychology was born.
Jerome Bruner and others (e.g., Bruner, Goodnow and Austin,
1956) spearheaded the overthrow of the decades-long dominance in
psychology of behaviorism.
Thus logic, perception, and other features of mental life—as con-
trasted with overt behavior in physical time and space—came to be
NEURONS AND NARRATIVES 21
central, rather than marginal, in American psychology. There had

been intelligence testing, clinical work with the perception of Ror-
schach inkblots, and extensions of animal learning models to human
beings, but none of these had led to the explicit focus on mental life
that Piaget made vivid in his observations and documentation of the
behavior of his own children.
Cognitive psychology now studies mental life, but because the
methodology remains scientific in the behaviorist sense, there are
serious limitations on what in mental life can be studied scientifi-
cally. Thus one’s logical abilities, which can be discerned in behav-
ior, are included. So also speech behavior, decision making,
perceptual discriminations, memory, and many other mental
events have been routinely studied in the second half of the twenti-
eth century, whereas they were beyond our methodological reach in
the first half.
Thanks to behaviorism, science still requires a quantifiable be-
havioral index of mental life. Such measurement allows us to test a
hypothesis. But much of mental life still escapes such measurement.
In clinical work, for example, the nuances in one’s personal narrative
of one’s own life and how that narrative is subject to change are
clearly crucial for therapy. They continue to be “mental” in a way not
translatable into physical measurements; nonetheless, they are lu-
cidly comprehensible to a listener or to oneself. This sort of “mental
life” is explicitly subjective, and objective manifestations of it appear
in mere human talk, of which the content is too particular for the
purposes of science. Much of the fabric of mental life continues to
defy investigation by science.
This is not accidental. The language of, say, an experiential narra-
tive, is explicitly different from the language of science, and that dif-
ference is insurmountable. This difference creates limits to our
ingenuity in measuring the variables of clinical work; this difference
is metaphysical. There are additional limits. We can do science on
neurons and chemicals in the brain, and we can understand when
someone says he is depressed because no one loves him, but we can-
not translate back and forth between neurons and narratives. The
discourse of experiential phenomena in subjective space and time is
not translatable into a discourse of scientific phenomena in objective
space and time. These two discourses are incommensurable.
This incommensurability is the key symptom of our unacknow-
ledged, neglected, and even denied mind-body problem in psychol-
ogy. Yet we do know a fair amount about how events understood in
one language affect events understood in the other language. For ex-
ample, we know that fear can be conditioned, which is to say that sci-
entifically understood procedures for creating fear under certain
conditions will lead to an experientially understood experience we
call fear.
An “adrenaline rush” is an experience named by its chemical
cause. “Conditioned fear” is a caused behavior named by its experien-
tial appearance. In these phrases, the terms “adrenaline,” “cause,”
and “conditioned” belong to scientific discourse, while the terms
“rush” and “fear” are experiential terms.
The former (adrenaline, cause, conditioned) are operationally de-
fined, and they have a place in the body of knowledge we call science,
which is organized according the framework of causality—Kepler’s
“clockwork universe” in its modern theoretical presence. The latter
set of terms (rush, fear), experiential terms, mean what they mean as
subjective experiences, which we know experientially—as part of
that flow of human awareness of which we are conscious, and whose
language eventuates in narratives and in struggles with relation-
ships and decisions.2 This experience is not a part of Kepler’s clock-
work universe; it is a part of the universe of human goals, choices,
disappointments and commitments. Fantasies and stories may en-
gage neurons when they are experienced, but their reality is not that
of neurons. Chemical events in my brain may engage our experi-
ences, but their reality is not that of narratives.
The difference is most obviously in the discourse within which we
understand narratives and neurons, but the formats of our under-
standing in turn are shaped by the discourse. These incompatible
formats of the two languages create the most stubborn loci of incom-
mensurability. Caused events are understood within a causal for-
mat; chosen events are understood in a different format. We make
moral judgments about chosen behavior, or we classify their logical
status. In contrast, we seek to find causes of illnesses and other such
life events. Causal connections are irrelevant to moral and logical de-
liberations about alternate courses of action, and moral and logical
deliberations are irrelevant to caused phenomena.
Yet we move back and forth between these two frameworks every
minute of every day, with great alacrity. In what follows, I will dem-
onstrate points at which we are usually aware of this crucial differ-
ence. They are provoked by our knowledge (including scientific
knowledge) of human experience and behavior (including moral
judgments and decision making). It is in psychology that this duplic-
ity is most fully seen and most inescapable.
FROM TRAUMA THERAPY

Judith Herman (1992) points out that our mid-century under-
standing of “combat fatigue” came from research by Kardiner and
Spiegel (1947) and others who proposed that the nucleus of such
traumatic neuroses was a “physioneurosis.” This term seems to sug-
gest that the physiological (i.e., physical) part of the human being
bears the effect of the trauma and that the psychological (i.e., experi-
ential) symptoms—chronic hyperarousal, temper outbursts, startle
reactions, and nightmares—are each a further effect of a change in
physiology.
If we assume, as James did, that all mental events have some physi-
cal representation in the brain and that brain events and mental
events run in parallel, then Kardiner’s term suggests that in cases of
severe trauma at least, the hormonal and other physiological systems
are not merely parallel. Physiology is there first, as in the hyperstimu-
lation of the sympathetic nervous system left over from prior traumas.
“Thus traumatic events appear to recondition the human nervous
system” (Herman, 1992, p. 36). This would suggest that the parallel-
ism of mental experiences and physical brain events is altered by
trauma. If we assume simultaneous operations at the physiological
and mental levels, Herman’s suggestion is that parallelism becomes
something else; one causes the other. The change in the physical re-
sponse, acquired independently through trauma, changes the physio-
logical machinery, regardless of our mental life.
For example, it may be the case that increased startle response
thus is both (1) psychological (mental—hearing a noise, feeling of
fear) and physiological (neurotransmitters, glandular action, inner-
vation of musculature) but that (2) the interaction between events
we call mental (hearing a noise) and events we call physical (muscu-
lar contraction) has changed. Because the trauma has affected the
physiological system, the noise (the initiator of the startle) cues a
muscular reaction not only more quickly and more strenuously, but
the variety of likely physical reactions to noise is decreased and the
actual response becomes more stereotyped. In the psychology of
learning, we might say that this stereotypy is produced by physical
adaptation. Certainly the chronic hyperarousal of such trauma vic-
tims suggests that those events we understand as physiological not
only limit our responses to stimuli but shape them in the direction of
emergency defensive reactions, all of which can be understood scien-
tifically within a framework of causality.
“Physioneurosis” may therefore be an apt term, in contrast to
“psychoneurosis,” a Freudian term that would seem to suggest that it
is mental events we must understand if we are to interpret what we

once called “traumatic neurosis” and now call “post-traumatic stress
disorder.” Is the Freudian term, “psychoneurosis,” therefore less ap-
propriate than “physioneurosis”?
Certainly not, for the mental experience of terror is necessary for
such conditioning. The difference between combat and other experi-
ences is the meaning of the noises, people seen, stories heard, and
recognition of where I am (on a battlefield), who else is here (the en-
emy), and why (to fight a war)—these contextual meanings are men-
tal. Had I been asleep, dreaming of fireworks remembered from
home, the reconditioning of the nervous system would be very much
less drastic. While nightmarish dreams of combat may “appear to be
based on an altered neurophysiological organization” (Herman, p.
39), the psychological—that is, mental—grasp of the meaning of
“combat” is as necessary for the physiological alteration as the
physiological alteration is necessary for the mental experience.
Much of human and animal behavior seems to be approachable
within either format. Much behavior is considered, motivated by
thoughts and values, and yet appears to be as automatic as a reflex
arc. Neither the expansion of the reflex-arc model nor the model of
considered choice supplies a sufficient format for psychology. Both
are needed; both are used. Our rules as to which format to use in vari-
ous cases are implicit and unwritten, but we manage nonetheless to
hold psychology together.
Certainly one of the ways the coherence of psychological knowl-
edge is maintained in the face of ambiguity about whether to use a
mental or physical format is thinking and speaking probabilistically.
A drug user has a higher probability of drug use than a nonuser, yet
the voluntary component remains, side by side, with caused tempta-
tion. We declare our knowledge of such phenomena to be probabilis-
tic, which is another, a third, way of formulating knowledge without
solving the format problem.
Another strategy of psychologists is to follow the lead of the ob-
served person or animal. Sometimes they (and we) behave automati-
cally, sometimes intentionally. In fact, Freud’s observations of
“repetition compulsion” offer an excellent example of behavior that
seems to be both at once. Less clinically, I may have a compulsion to
gamble, and increasingly so as I lose. But in fact I can intentionally
stop any time. Freud’s work leads to an answerable question: Why do
we need in memory, fantasy, dream, and in child’s play to reenact the
traumas we have experienced? Freud’s explanation in terms of in-
stinct, as “a compulsion inherent in organic life to restore an earlier
state of things” (Freud, 1920, p. 47), is less useful than the notion of
“mastery.”
To stay with Freud’s observations of “repetition compulsion,” vol-
untary repetition yields an experience of mastery. It may seem com-
pulsive (that is, compelled, caused rather than chosen), but “the
earlier state of things” to be restored is the elimination of the sur-
prise of the trauma. Such an effort is mental, voluntary, and chosen
as much as it is compulsive or caused, in the sense of scientific cau-
sality. We may also say, however, when considering the automaticity
of repetitive dreams, that such events are caused as much as, or even
more than, they are chosen.
As an interim conclusion, we may say that the interaction be-
tween that part of ourselves that is mechanical (such as muscles and
limbs, even hormonal events), on the one hand, and that part of our-
selves (such as consciousness) that orchestrates the course of one’s
life, on the other hand, can sometimes be an interaction between dif-
ferent things (body and mind), between different aspects of the same
thing (mental and physiological functions of the person), or even be-
tween different levels of analysis at which is it possible to see “a sys-
tem” (von Bertalanffy, 1968; Illich, 1976; Engel, 1980).
The question that is never asked is as follows: Which format is ap-
propriate in any given case of speaking about human behavior as a
whole? Is it to be the format of mental analysis, which discriminates
between rational and irrational, desirable and undesirable, moral
and immoral? Or is it to be the format of physical analysis, where the
discourse gives us causality, functional contingencies, etc.? Or are we
forever condemned to speak probabilistically? What we in fact do is
use both formats in a seemingly mixed fashion, but one that is nei-
ther acknowledged nor clearly understood.
Perhaps it goes without saying that as soon as we introduce the
obligations and challenges of ultimacy in thinking about human be-
havior, the problem is yet more extreme. Physical and causal dis-
courses have a much diminished (and different) place in human
ultimacy.
FROM PSYCHOPHARMACOLOGY
In addition to our theoretical understanding of psychological
trauma, we may look at psychopharmacology for a vivid arena of
mental-physical interaction. Our first consideration is the placebo
effect. When a doctor gives a patient a prescription that is supposed
to address his problem of depression, the initial reaction to the medi-
cation may be the same whether it is an active antidepressant or a

sugar pill. There clearly is a psychology operating here,3 even
though the doctor is certain to tell the patient that the changes he
will experience are caused by the correction of a chemical imbalance
in the brain.
The effectiveness of the sugar pill will be less reliable in the longer
term, perhaps, but this “placebo effect” may or may not have involved
a change in brain chemistry. We do not know whether this common
outcome occurs because of an actual change in the physical brain
chemistry of depression or merely in the patient’s mental formula-
tion of what he is experiencing.
Related to these data are phenomena of meditation and other
spiritual disciplines. Concentrating or meditating clearly change
mental experience. Regular practice of ritualized versions of with-
drawing from the everyday world in the quest for personal re-
newal or enlightenment are successful enough to suggest that
more than the mental state of the practitioner is changed. It is al-
together plausible that his or her physiology is also changed. This
may be a fairly permanent change, one that can affect subsequent
perception and behavior in well known ways, including, of course,
enhancing the ability of the practitioner to concentrate or medi-
tate.4
We know that people do cure themselves from, say, depression, by
this technique as fully as by taking antidepressant medicine (Nor-
den, 1995; Robertson, 1997; Gendlin, 1981), but we do not know
whether these two approaches change the brain physiology in the
same way. We do not, of course, know what brain physiology to look
at for depression. However, the possibility that psychological and
chemical interventions have similar effects on the brain has been
demonstrated by Baxter et al. (1992), who found that treatment
leads to a significant increase in metabolic activity (and therefore
increased activation) in the prefrontal cortex and the basal ganglia
for highly symptomatic obsessive patients. This is true whether
they were treated with SSRI antidepressant medication or by be-
havior therapy. Assuming that behavior therapy involves some de-
gree of refocusing of attention, systematically and over time, these
data suggest some similarity in pharmacological and nonpharma-
cological treatment for obsessions.5
Beyond research findings, the clinical findings include a variety of
reactions to drug therapy. Some of these findings can be attributed to
a chemical effect, and some involve one’s attitude toward taking psy-
chiatric medicine at all. As argued in chapter 1, some patients con-
sider drugs magic: My fears of my incompetence don’t frighten me,

and my fatigue at the unfairness of life no longer burdens me. For
others, drugs are artificial: I still believe my husband shouldn’t criti-
cize me, but I no longer stand up to him. We don’t fight, but maybe we
should. For yet others, drugs cure disease the way an aspirin cures a
headache. For some, drugs help escape the reality of a stressful job.
Others would say, they allow my boss to push me around without my
objection. Others find they do nothing or that the side effects are in-
tolerable.
All of these possibilities have to do with the self I am, what I think
about myself, and hope and fear about myself. These mental realities
are related to the mental realities we see after we take a drug, inter-
preting it as a panacea, crutch, cure, or escape. Between the mental
expectations and the mental results of psychopharmacological treat-
ment lies the actual administration to the brain of substances that
interact in complex ways with existing brain chemistry.
The most important question to ask, I think, is the effect on the
narrative self, on that currently experienced, remembered, and an-
ticipated self that is seen from within, and through the eyes of others,
over time. Some of myself remains the same, and some of it changes.
The drug may bring changes in relationships, in mood and style, per-
haps in life’s direction, but our understanding of the effect of phar-
macological therapy must be in narrative form, for that is how we
experience our lives.6 Time is not filled with random events; they are
emplotted—with surprises, of course, but also with plans, second
tries, reactions from others, hopes, and fears, all of them related
through belonging to the common story of my life. It is in this story
that we each must decide what is ultimate and what is trivial. Ulti-
macy is recognizable: Who am I to be? Triviality disguises itself as
more important than it is.
The incommensurability between this sort of understanding
and the tortured logic of our rudimentary knowledge of brain
chemistry comes from several sources. The elaborate traditions of
defining and evaluating self-narratives are made up of a much
richer language for interpreting a life narrative (Sarbin, 1986)
than the fragmentary knowledge we have of brain chemistry. They
are also cast in a format of human experience, as opposed to the
format of science. This difference is the difference between a his-
torical and a scientific understanding, for which our old meta-
physical categories of mental and physical life are such inevitable
summaries.
CONCLUSIONS
Has our sampling of our knowledge about trauma treatment and
psychopharmacology enabled us to see differently the format issue of
our knowledge? Some behavior and experience is caused; some is
chosen; some is physiological, or even mechanical; some is mental,
considered, and voluntary. Some behavior and experience appreci-
ates ultimacy; some conceals ultimacy with engaging trivialities.
Drug therapy may reveal ultimacy, but the more common concern
with chemicals, physiology, side effects, and so on tend to generate
another layer of triviality.
The neuron and the narrative affect each other; each conditions
the other, with such complexity that it seems that a third format for
our knowledge is necessary. Perhaps probabilistic thinking, which
simply tries to stay very close to the quantified data, solves our con-
ceptual problem by eschewing both the experiential/voluntaristic
format and the causal/mechanical format, and by speaking in the
grammar of statistics.
The issue, however, is more than one of language. We have two lan-
guages, with two formats; they are each self-contained and incom-
mensurable with one another. Intellectually, this duplicity is
incoherent. Beyond that, existentially, this doubleness distracts our
attention from more ultimate issues and creates a focus on another
layer of triviality. The professional attitude of indifference toward all
this incoherence and triviality seems to me a professional disgrace.
NOTES
1. Sacks (1970) puts the matter this way:
We have always two universes of discourse—call them “physical” and “phenomenal,”

or what you will—one dealing with questions of quantitative and formal structure,
the other with those qualities that constitute a “world.”. . . We can usually tell a man’s
story, relate passages and scenes from his life, without bringing in any physiological
or neurological considerations: such considerations would seem at the least, supere-
rogatory, if not frankly absurd or insulting. . . . Usually, but not always: for sometimes
a man’s life may be cut across, transformed, by an organic disorder; and if so his story
does require a physiological or neurological correlate. (p. 50)
Sacks argues, however, that even when there are such symptoms, this
“does not detract in the least from their psychological or spiritual signifi-
cance” (p. 130). Indeed, the particular music heard during a seizure, as
sometimes happens, is not random music; it is meaningful to the individ-
ual experiencing it. This sort of “personal epilepsy” is a contradiction in
terms, for epilepsy is stereotyped and impersonal, while these symptoms
are very personal. “And yet such epilepsies do occur,” according to Sacks,
who notes also that they were observed by Hughlings Jackson, then
Wilder Penfield, who stumbled on a method to provoke such hallucina-
tions, which would “be experienced, lived, as compellingly real, in spite of
the prosaic atmosphere of the operating room.” Ultimately, Jackson re-
ferred to them as a doubling of consciousness, a “mental diplopia.”
I am aware that multiplicity of discourse has always existed across cul-
tures and across cultural domains within a culture. Certainly postmodern
thought makes clear that the totalisms of modernity are wrong-headed, if
not dangerous, sources of dogmatism. Notwithstanding the provocative ar-
gument of Schrag (1997), I insist that tolerating multiple discourses does
not mitigate the need for some unified understanding in order to act re-
sponsibly in the world.
Even if lacking such an understanding is inevitable, one need not lack a
respect for the multiplicity of discourses. That in itself constitutes a kind
of unified understanding, although maybe not one that meets modern re-
quirements. What is particularly egregious in dealing with this question
are such practices as offering an aesthetic critique of religion, or pharma-
cological treatment of a psychological problem. Both apply irrelevant
meanings without knowing it; each assumes that its own particular dis-
course is capable of comprehending another, and both therefore fail to take
seriously the meanings created by and grounded in another discourse.
They are thus prone to be more than simply irrelevant; they are likely to
be reductive, totalizing, and even violent.
Schrag also points to the fact that Descartes’s notion of “self as a mental
substance remains forever undecidable, perpetually deferred, destined to
become a vacuous concept” (p. 13). See also Keen (2000a).
2. Of course “fear” can be operationalized in an experiment as a rat’s
not taking the shorter, electric-grid route to the food. In this operational
definition, it is possible to measure fear and thus to explore experimen-
tally its antecedents and consequences. But this is not a translation; the
word “fear” here is a metaphor, indeed a mere inference, not the name of
an experience. The rat’s behavior tells us about the experience of fear in
the same way that measuring my temperature tells me about the experi-
ence of being ill. The entire fabric of experience is bypassed; none of the
narrative properties of experience are dealt with. Even more egregiously,
of the meanings of the world that are summarized in the term “fear,” the
behavioral one is taken as indicating the entire range and as summarizing
them all in terms merely of degree—of “how much” of this behavior can be
observed. Fear actually involves meanings, embedded in a context that is
temporal, personal, and social—a rich matrix about which the behavioral
index is entirely silent.
3. In chapter 6 of Keen (1998), I ask whether psychology is the active
ingredient in psychopharmacological practice. It is certainly not the only
active ingredient, but it is certainly, always, an active ingredient. This in-
evitable mix is the human situation, the exploration of which seems to de-
pend on one or the other (psychological or physical) language. It is telling

that psychology almost never takes advantage of both at the same time;
that would require that we explore their relationship, which is beyond us.
4. Pointing to the selling power of the popular drug Prozac, Robertson
(1997) has described ways some of the effects of Prozac can be had without
ingesting the drug. These include diet, exercise, and such other activities
as focusing on feelings and learning what provokes them, especially non-
depressive ones.
5. I would like to point out that neither the chemical treatments nor
the behavior therapy used by Baxter et al. (1992) involve the personal (de-
pressing) meanings that engage, and are engaged in, the production of
symptoms. These meanings usually have nothing to do with being a sub-
ject in Baxter’s experiment, nor do they follow the routines suggested by
Robertson (1997) or Gendlin (1981). Depression, like all psychiatric dis-
eases seen clinically, inevitably engages, perhaps is caused by, the narra-
tive stream of one’s life as experienced, formulated, and enacted by the
patient.
6. In any given case, our understanding of the effects of drug therapy
may engage the personal narrative of the patient, or it may not. This de-
pends entirely on the doctor. Doctors who simply prescribe drugs to elimi-
nate “symptoms” (and who therefore treat symptoms as free-standing
phenomena, independent of one’s life narrative), have not even a hint of
the larger understanding. It is not even attempted in 70 to 80% of pre-
scriptions, which are written by nonpsychiatric, and often overworked and
rushed, primary-care physicians. The error in treatment here is concep-
tual. “Symptoms” are not signs of a “disease” the way a fever is the sign of
an infection (see Sarbin and Keen, 1998). They emerge from grappling
with conflicts, remembering our histories, making decisions, failing to live
up to our own standards, and other such ultimacies of life, all of which are
most understandable to us in narrative form. Such narratives are often ne-
glected both before and after the prescription of drugs.
CHAPTER 3
Exploring Theoretical
Incoherence
“A professional disgrace”—strong language. It is, in fact, language

stronger than necessary as soon as we understand that the profes-
sion is “disgraceful” only in what it claims for its knowledge. When
we professionals recognize the partiality of our perspective, we are
not disgraceful at all. But in this chapter, we shall focus on the inco-
herence of our thinking. This recognition is demanding; it includes
the relativity of knowledge to the discourse we use. This relativity in
turn is related to how discourse is shaped by positions we hold, and
by their interests in the mix of conflicting interests of modern society.
To realize these relativities and these interests, and the impres-
sive role played by language and discourse, is to give up calling
claims “fraudulent” and “absurd,” except insofar as they pretend to
be “objective truth.” Appreciating these relativities is to think in a
way currently referred to as “postmodern.” Such a label can mislead
as well as clarify; let me explain what I mean when I use it.
Most postmodern analyses of discourse demonstrate that a dis-
cursive slant on reality serves the interest of those who use that dis-
course.1 Every perspective on reality pulls some aspects of reality
into focus and obscures others. We all use, depend on, and define the
world through a certain discourse, and we are all committed to that
definition in the same sense in which we are all “committed to real-
ity.” I may be committed to the reality of psychosis as a clinical phe-
nomenon, and this commitment will seem not to have been a value
choice but rather a matter of professional training. It is both.
Such a commitment bears differences and similarities to a relig-

ious commitment. A difference is that every religious commitment
includes a worldview in which loyalty to “that reality” is a carefully
taught virtue. The temptation to stray into other worldviews is regu-
larly described by religious teachers as evil, as human weakness, ig-
norance, and error. Aspiring believers are also taught they have a
special opportunity to know an ultimate truth, one that speaks to
their profoundest anxieties.
In contrast, the discourse of the treatment professions is a dis-
course of scientific determinism and technological mastery does not
advertise them as sacred, and the anxieties to which they offer a so-
lution are seemingly less ultimate than one’s fear of evil, of being
evil, of being punished for evil, and one’s hope of absolution from evil.
The scientific community may, like religion, offer special promises
that are designed to help recruitment, but the ultimacy of science is
likely to be described in terms quite different from that of its relig-
ious counterparts.
The appeal is to common sense, which is, at millennium’s begin-
ning, quite secular. The rewards are not so much a special privilege
accorded to members of a community of believers as mere matters of
being right instead of wrong, respected and paid well instead of con-
demned to less advantageous employment and station. One’s loyalty,
then, is not attracted and secured by promises about ultimate myster-
ies and existential anxieties but rather by the more mundane advan-
tages of self-interest, such as employment and income. However,
later (chapter 7) we shall see how science—especially medicine, in-
cluding psychiatry and psychology—implicitly trades on its own ver-
sion of ultimacy. We shall see that this pretense is not all pretense,
and yet triviality appears here too.
Over the centuries of modern scientific growth, this “soft sell” had
moments of “hard sell,” such as the Darwinian controversies, and
certainly military demonstrations of the destructive power of scien-
tific knowledge. In the nineteenth century, scientific theories often
had deep and personal meaning to people, which is less obviously
true today of, say, Lockean politics or Adam Smith’s economics. But
scientific and quantitative thinking was insinuated incrementally
into Western culture with the work of these modern theorists, so that
by the middle of the twentieth century truth was largely defined as
scientific truth—and scientific truths are multiple and practical.
Many sciences, each with its usefulness, replaced the truisms of
former faiths. The multiplicity of sciences often obscured the unity of
EXPLORING THEORETICAL INCOHERENCE 33
“Science,” and yet through these many satellites we all came to be

“Scientific” in the modern sense.
The latest innovation within science to have an impact compara-
ble to those of the earlier biology, psychology, chemistry, and atomic
physics is psychopharmacology, which is a continuation of moderni-
ty’s technical mastery of those parts of our lives that seem to get out
of control. Still, no matter how refined becomes our clinical applica-
tion of chemical medicines for mental troubles, we have seen that our
understanding of what we are doing is incoherent. Sometimes it cre-
ates triviality. The mental phenomena controlled by drugs are not
themselves things as much as they are our access to things, our con-
sciousness of things—our grasp of, attitude toward, and interpreta-
tion of things, and of the world of things, and of people, and values,
and everything else. Once we affect what we call “the mind,” not with
arguments and ideas—as we did in early modernity—but with
chemicals applied by practitioners, we affect our perceptions of eve-
rything. We are also crossing a denied but inescapable dualistic
boundary between body and mind, manipulating no longer “the
world” but our very awareness of it.2
This absence of intellectual rigor in grasping the meaning of drug
therapy leaves such broad intellectual gaps that we are in danger
now, as we were sixty years ago in the even more hasty rush to lobot-
omy, of practicing violence in our treatment. The theoretical incoher-
ence, then as now, was concealed behind issues of practical
convenience and short-term success. Trivialities signaled decades
ago, for example, in the simple matter of the overprescription of
drugs (Greenblatt & Shader, 1971), seem minor in comparison. Now,
as a half-century ago, our theoretical muddle of medical procedures,
philosophical silence, popular demand (that we do something), and
conflicted moral opinions about the status of drug-induced happi-
ness is at once the occasion of enthusiastic confidence cheek by jowl
to a kind of ignorance, to which we too quickly turn a blind eye.
One option is to assume that the mental sphere and the physical
sphere are really different, to treat them separately and tread very
lightly in that region where one affects the other. This policy would
mean that we should apply mental therapy for mental distress and
physical therapies for physical distress. It excludes psychopharma-
cology altogether.
Current practice understandably rejects this option. But the rush
simply to medicate those human troubles we call mental illnesses,
asking no further questions, enacts not only a proud agnosticism but
also a certain glib and trivial theory that tells us nothing. In fact, in
spite of exciting advances, neuroscientists know little more about

mind-body relations than the medical cliché offered to patients that
“you have a chemical imbalance in your brain.”
This approach says that we do not assume there are two realities
or that they must be treated and understood separately. It is to ig-
nore mental life in its “mentality” and to pretend that the language
of things describes mentality as well as it describes things. It is also
to pretend knowledge of one reality.3 Pharmacotherapy is not alone
in following an inexplicit and unformulated intuition that the hu-
man person is somehow a whole and that our theoretical incoherence
should not bother us. Nevertheless, we operate within that incoher-
ence. Our ability to affect the mind by treating the body should force
us to reconceptualize the entire substructure of categories within
which we work. We at once enact dualism and deny it.
The idea of “function” is our traditional way to use a metaphysi-
cally neutral language, so that taking Valium affects my functioning
the way that putting oil in a crankcase affects that of my car. This ap-
proach is very much like common sense, which does not make onto-
logical commitments, because it does not ask ontological questions.
However, it also ignores the possibility that our actions make com-
mitments within a serious, and even dangerous, theoretical vacuum.
DRUGS: A THEORETICAL VACUUM

Practical and popular practices, such as drug therapy, in the ab-
sence of coherent theory, have a kind of rushing momentum, made
worse because they are so convenient. Between 1988 and 1993 the
number of patients receiving psychotropic medication for their “de-
pression” doubled. The trend continues. More and more frequently,
the immediate mental problem in clinical practice may be alleviated
without noticing a less immediate mental problem, or a problem in
terms of living life.
Most psychological symptoms stem from an attempt to deal, or not
to deal, with very basic but often ignored psychological issues. A gen-
eral version of all these issues may be stated as the question, “Who
am I to become?” When both doctors and patients fail to notice such
underlying questions, they collude in ignoring psychology, and likely
also in ignoring important human struggles. Such practice increases
the likelihood that both the doctor and the patient may invest in a
self they have not thought much about. Patients often overcome
their reservations in the face of medical confidence, and they under-
standably adopt an enthusiasm for the relief they feel. Doctors are
only too happy to be of such help. But such a pattern may cause much
more trouble at a later time (see Keen, 1998, chapter 8).
Both the neglect of the linguistic (if not metaphysical) incoherence
in pharmaceutical enthusiasm and the refusal to cross the meta-
physical line by refusing to prescribe or accept drugs are possible al-
ternatives. More urgent, however, is the difficult task of recon ceptual-
izing the problem so that we may be better able to see what we are
doing.
In general, we need a narrative, a kind of plot, or story that some-
how connects mental life to physical life, within the same frame of
reference. The narrative frame of “disease” and “chemical imbal-
ance” makes limited sense, because it fails to incorporate questions
like “Who am I to become?” The narrative of my personal sadness
and depression also makes limited sense in that it fails to address
physiological events. To recall the central role of both such questions
implies some recognition of our sense of our free will, as well as our
sense of our materiality. Together, these guarantee that our human-
ity remains central.
How do we, and how can we, think across the mind-body gap in our
discourse? Can we arrive at a comprehension that would enable us to
understand psychopharmacological treatment in a way that can pro-
tect us from such poor practice, and still (1) satisfy our desire for con-
venience, (2) follow our temptation to ignore hard theoretical
questions, and (3) avoid trivial distractions that conceal existential
symptoms? We shall, as professionals, have to give something up.
THE PSYCHOLOGY OF HUMAN EFFORT

Suppose we take advantage of common sense and daily experience
in order to reconceptualize the relationship between what we inevi-
tably call “mental decision” and “physical effort.” There is, in weight
lifting and elsewhere, a natural harmony between my deciding to act
and the mechanics of my body.4 If the weight is too heavy, there is
nothing wrong with my decision not to lift; my free will is operating,
but physical fact overcomes the normal operation of the mental deci-
sion. I cannot follow through with the desired natural psychophysi-
cal harmony. That interruption, in turn, can be removed easily by
decreasing the amount of weight.
However, suppose I am paralyzed by anxiety or depression be-
cause I don’t know who I am to become; my unspoken confusion in-
hibits my ability to study, to get up in the morning, or to sit still while
I concentrate on getting something important done. In contrast to a
physical disruption of the usual psycho-physical harmony, I have a
“mental” problem. The mechanics of behavior are working, but the

decision is impaired. These failures are analogous not to having too
heavy a weight but to having been conflicted about lifting the weight
or in some other way having failed to decide to.
Considered this way, a pharmaceutical agent may remove that
mental blocking of my doing what I should do, or of recognizing what
I should recognize. But any success in such therapy depends on how I
conceptualize what I am up to. If I assume the current medical inter-
pretation, my inability appears as merely a symptom of a disease
that prevents me from doing many things. The treatment suppresses
the symptom, leaving me free to do some of them again.
But it also fails as good therapy. The “symptom” is not like an op-
portunistic disease; it is a systematic part of who I am. Even if drug
treatment makes it possible for me to get up, perform various duties,
and “do things,” it also neglects to ask what to do. What is important
for me to do? Reflectively: Who am I to become? This is to neglect the
context, and the meaning, of the symptom. Most of all, this practice
will continue to neglect the hard mental work of asking hard ques-
tions.
The only way to avoid this outcome is to change our thinking, the
thinking of doctor and patient alike, from “symptom relief ” and to
the task interfered with by the symptom, even as I may take medi-
cine to suppress a symptom. In fact, it is especially important, if I
take such medicine, that I attend to the existential conflict and the
masked issue expressed in the symptom. Otherwise, the treatment
may well solve the problems created by the symptom but neglect or
exacerbate those that caused it. Such treatment also, therefore,
avoids further neglected psychological work.
As an analogy, consider the role of nutrients in the maintenance of
our ability to cope with life. No one believes that nutrition can be
avoided or that it is irrelevant to weight lifting. Indeed, nutrition is
not trivial, and symptom relief may be as necessary as nutrition for
some people. But no one believes that nutrition solves life’s existen-
tial problems. Nor can we say that drugs solve life’s problems. If we
say that such life problems lie behind symptom production, if the
symptoms are those of struggling with life problems, then the phar-
maceutical removal of the symptoms is the removal of the struggle
through a symptom, but it does not guarantee there will be a re-
newed or clarified engagement in the struggle. It may help the per-
son no more than nutrition does.
It also indulges the fantasy that a change in the physical realm,
like reducing the weight, restores the natural harmony, as if the deci-
sion to lift the weight were not central to the intended act. In ordi-
nary life, the decision usually is central.
In practical terms, this line of thought leads us to say that pre-
scription of drugs to suppress symptoms without attending to life
problems is no better treatment than giving people food. Psychother-
apy is therefore an obligatory accompaniment of pharmacotherapy;
to prescribe medication by itself is to offer a palliative, in the worse
sense of that derogatory term. To tamper with the machinery of the
mind in an effort to deal with the self is like tampering with the ma-
chinery of sound in an effort to deal with the content of a message. It
is to punish the telephone for bringing us bad news. It runs the risk of
unconscious violence, as surely as did lobotomy.
BEING ILL AS A SOCIAL FACT

Medical disease and how we experience it offer us inevitable clues
to how we do, and may, deal with psychological troubles. It also offers
us a window, uncluttered by psychology, for looking at the social di-
mension of these events. Being ill is a social fact. It has a presence in,
and meaning for, the life of others, and the sufferer knows what these
meanings are. When I am sick, I am as chagrined at (or pleased by)
these meanings as much as I am chagrined at (or pleased by) the
pain and inconvenience in my own personal life. Like the mental and
physical aspects of life, sociality is a discourse. Instead of the ration-
ality and morality of mental life or the quantitative relations that
are enacted in the physical body, sociality engages roles, rules, cus-
toms and shared definitions of the sacred and the profane.
Perhaps we can increase our purchase on the puzzling relation-
ship between mental and bodily events by noting that bodily symp-
toms are enacted within a social environment. 5 They are
experienced by me as being seen by others, with whom I already have
a tradition-laden relationship. But the symptoms change me; they
change my future possibilities, and hence they change the meaning
of my past. They change “who” I am and “who” I am to become. Thus,
they change how I am to be understood by others. Of course, we also
must situate the “who I am to become” in this dense social matrix of
being understood by others in light of traditions and values. For
these complications of self, Erikson’s term “identity” is particularly
useful.
The sociologist Talcott Parsons (1951) described the “patient role”
as surrendering oneself to the care of a physician. However, this is
hardly all I do when I am sick. Being ill, like all of life, is active; it en-
acts my self, in a way that I grasp where I come from and where I am
going, for which we use the term “narrative.” As my illness becomes
a social fact and I know it, I must cope, as Frank (1993) points out,
with my illness by altering my “identity,” or my “personal narrative,”
by telling the story of my illness. This “is the attempt, instigated by
the body’s illness, to give voice to an experience that medical dis-
course cannot describe” (p. 18). We might add that mental discourse,
where we struggle with morality, free will, rationality, and their de-
viations, can describe only with difficulty the social dimension of
such experiences.
Such giving voice through narrative is not limited for long to a de-
tached mental observer, occupying Parsons’s “sick role,” reporting to
a doctor or to others the body’s experiences. When the disease is truly
serious, early in the game I have to recast my sense of who I am, a
sense that is inescapably bodily. I must incorporate and express my
body’s illness in personal and human terms. It is work, like mourning
a loss, like reinventing a self. Literature on having socially salient
diseases like cancer (see Morris, 1998) reveals that the experience is
more than physical and more than psychological; it is also social. We
tell the story—a social act, born of physical and psychological events
but eventuating in profound social dynamics that are there from the
beginning.
Except for work like that of Kleinman (1988a, 1988b) and Castillo
(1997), this universal act of giving of voice is a professionally ne-
glected part of having illnesses and of, for however long, surviving
them. Frank comments:
The truth of stories is not only what was experienced, but equally what be-
comes experience in the telling and its reception. . . . Stories are true to our
experience. . . . I have read personal accounts that I considered evasive, but
that evasion was their truth. (p. 20)
Not only is medical discourse partial and yet presumptuous about

“the real truth,” but a personal narrative may be partial and pre-
sumptuous. We do not have to choose between these partial truths,
but we must see the larger human realm that each bespeaks and de-
cide, in any situation, which is the relevant truth. Medicine’s master-
ing nature is at times decisively relevant, but often likely more often,
possibly always—the personal face-off with human materiality and
contingency is of deeper and more urgent relevance.
Listening thus becomes the first duty of professionals assigned to
preside over human suffering.6 What they hear and what is created
in the hearing may well be more important than the scientific project
of mastering nature. The human ability to control and cure disease

may seem less sentimental and more decisive than a person’s indi-
vidual experience. But beyond that ability lies the other, inevitably
personal—even if universal—need to deal with human materiality
and, finally, mortality.
To valorize the mastery of nature to the profound neglect of the
personal, which is both more immediate and more ultimate, is to
celebrate what we do well even when it leads us into that human ar-
rogance of accepting the mastery of nature as the North Star of our
human journey. Perhaps we can eventually master nature, eliminate
disease and geriatric deterioration, and achieve eternal personal
life. But if we fail to ask that intensely personal and inescapable
question of why we do so—whether, that is, we should become im-
mortal—we will have furthered human welfare only modestly, if at
all.
In contrast, to ask that question of our patients and of our-
selves—why is this life important?—is to speak to both immediate
and ultimate concerns, concerns that must come both before and af-
ter the project of mastering nature. The mastery of nature, as glori-
ous a project as it may seem, ultimately begs such questions for any
individual patient, and for treatment professionals in general, as
why to do so. Technicians and researchers work for us, the human
community, not the other way around. Perhaps we have failed to de-
mand their attention.
Professionally, the act of listening, of asking questions and hear-
ing answers, is an act of community building. If I, a professional,
share my stories as well, so much the better. What is created is an im-
mediate community, embedded in a larger one, which indeed handles
the phenomenon of death rather poorly. Too often, having a fatal dis-
ease means being expelled because of one’s sin of vulnerability, or be-
ing condemned for the sin of dependency. However, the community
created in the act of listening is a community that can overcome the
hopelessness and isolation usually inflicted on those who are dying,
who are psychotic, or who frighten us by reminding us of our own ul-
timate weakness.
Genuine listening contrasts with medical practice as we know it
now. We now assume that it is the doctor’s knowledge that is most im-
portant, and sometimes it is. But it is nearly universal that in taking
a medical history the doctor interrupts whatever does not bear on
the medical story. So we patients, who may really want to tell the
story our way, who want to re-create whatever coherence life had be-
fore the assault of the present problem, nevertheless assume that
the doctor’s agenda is predominant. She is, after all, the profes-
sional, the doctor, the agent of science, who can, maybe, master this
disease.
Insofar as this is true, we have accepted Talcott Parson’s definition
of the “sick role.” In the short run, we also reduce our life crisis to
technical matters for which we have able technicians, and we have
defined ourselves simply within the cultural project of mastering na-
ture. In the face of the glories of this mastery, therefore, we may feel
guilty insisting on our personal story, as if the doctor, the technicians,
and the cultural project of mastery dwarfs my experience of myself.
Sometimes, however, my need to make sense of the world reasserts
itself and comes forth by formulating, telling, and being heard. It
comes forth in conversing about my personal narrative, the narra-
tive of my self as ill, as mortal, as a part of my larger narrative self.
This need for coherence does not have to aim for ultimate victory
over nature. Indeed, such distractions as these sometimes indicate
exactly our professional failure, of mistaking the means for the ends.
Ricoeur (1986) is among contemporary theorists who recognize that
the technical processes of “my disease” are known to us because we
care about selves, not about diseases. Furthermore, I may care about
my future, but my mortality never has and probably never will dis-
appear.
Hence the patient ought not to feel guilty for interrupting the
medical narrative. Rather, medical science ought to feel guilty when-
ever its agents substitute their discourse for ours, whenever they as-
sume that our work is secondary (however secondary it may be to
them), whenever they forget they are dealing with selves. Doctors do
not seem to understand that in telling and having one’s story heard,
one establishes a new identity to replace the former one now
wrecked by disease. Nor do they usually grasp its importance. It is
very rare indeed that they are of any help in such matters.
The new “narrative identity” created in telling the story of my ill-
ness creates a self as personal, vulnerable, moral, and human: an
identity very different from one’s healthy self, and different from the
proud identity of “the doctor” (Kleinman, 1988b). Ricoeur (1986) un-
derstands that being in medical trouble liberates us from pride. “In
place of an ego enchanted by itself, a self is born” (see also Frank,
1993), and that self stands as the end for which medicine is being
brought to bear. That self also stands, collectively, for our human
situation, which is human exactly because we each have a narrative
identity to which to give voice. Our lives each express that voice, a
voice that is heard through the vicissitudes of a lifetime. That voice
contributes to a social narrative of humanity that will ground psy-

chological and existential struggles for others.
PSYCHOLOGY STRUGGLES WITH RECOVERED

MEMORIES
This brief tour through the psychology to the sociality of being
medically ill reveals aspects of the experience that are also present
when “the problem” is called “mental” instead of “physical,” when the
analogy is failure to decide to lift rather than having too much weight
to lift. Mental and physical failure each engage one of the two dis-
courses, or both of them, creating a kind of coherence that becomes
more lucid if we appreciate the social dimension of our experiential
life.
This social dimension might be described in terms of the many
narratives that guide social actors in a culture, but it embraces more
than narratives. It is also made up of vivid power relations, which in
most societies enact hierarchical social structures. Psychology has
been the turf on which much of the enormously conflicted matter of
recovered repressed memories has been played out. The categories of
psychology, or of any science, are ill equipped to handle such conflicts,
which are cultural, political, historical, and which inevitably enact
also alternative and personal narrative constructions of reality.7
The typical episode in this painful conflict involves a daughter,
now grown, probably in therapy, who recovers the memory, or thinks
she does, of her father as an incestuous rapist. Many, but not all,
therapists support their clients in seeking legal redress for such cru-
elties, and many, but not all, accused fathers refuse to acknowledge
such histories. It may be a court, therefore, that arrives at a conclu-
sion—in, say, a personal damages suit. It hardly needs saying that a
court is the last place where the psychological intricacies of such an
issue can usefully be worked out.
The reason for this is that courts have no leeway for ambiguities
that emerge in human memory, repressed or not, recovered or not.
Legal procedures in our culture deal with hard-edged categories,
such as “guilty” or “innocent.” There is little likelihood that legal pro-
ceedings will, for example, convict a father of emotional neglect, per-
haps physical or psychological or financial abuse. These are rarely
crimes, while incest most assuredly is.
The narrative construction of one’s childhood as incestuous may
be literally false even if the father is guilty of (other) moral trans-
gressions of great magnitude. If father is declared innocent of incest,
the daughter is by implication declared guilty of lying, and more
than one father has countersued for damages. Both fathers and
daughters have traditional, as well as recently organized, support
for their claims. It is a social, legal, psychological, and social mess.
How can one come to terms with such complexities? Conceptual
clarity is difficult enough; concrete social, legal, psychological, and
moral clarity is nearly impossible. Part of the problem is that every
case is different. The legal system supposedly considers every case
on its own merits—but of course the system does not really do so. The
legal notion of “precedent” allows a judicial decision, proceeding, or
course of action to serve as a rule for future determination in similar
cases. This linchpin of legal process clearly encourages generaliza-
tion from one case to another.
Like the legal context, science has become accustomed to a phe-
nomenon as being either real or not, a truth claim as either justified
or not. Psychology, in its claim to be a science, has sometimes rushed
in with claims of truth supported by science, but its support does not
have the weight of physics and chemistry. Both fathers and daugh-
ters may deceive themselves. Each may offer absolutely sincere but
incompatible versions of the same remembered (or forgotten) story.
Both the causality of scientific discourse and the morality of experi-
ential discourse can be brought to bear on either side, used against
the other, and offer an alternate explanation of the other’s behavior
(causal: he’s in denial, she’s under the influence of feminism; or
moral: he’s trying to escape his guilt, she’s blaming me for all her fail-
ures). We can see that this is an ugly scene.
At the general level as well, science is brought to bear for one side
or the other. Loftus and Ketcham (1994), in a book arguing against
recovered repressed memories and dedicated “to the principles of sci-
ence, which demand that any claim to ‘truth’ be accompanied by
proof,” portray human memory in a way that invalidates its accu-
racy:
Memories don’t sit in one place, waiting patiently to be retrieved; they drift
through the brain, more like clouds or vapor than something we can put our
hands around. Although scientists don’t like to use words like “spirit” and
“soul,” I must admit that memories are more of a spiritual than a physical
reality: Like the wind or breath of steam rising, the cirrus and stratus of
memory exist, but when you try to touch them, they turn to mist and disap-
pear. (p. 4)
These authors not only use psychology in this metaphoric way but
appeal to the scientific concreteness of data and experimental rigor.8
This pretended “scientific” relevance is no less or more telling or de-
ceptive than the metaphorical language above. Experimental rigor

has not been, and cannot be, applied to incest. On the other side,
Hovestad and Kristiansen (1996) offer very plausible corollaries in
well established and scientifically studied phenomena for repressed
and recovered memories. But, of course, they did no controlled, ex-
perimental studies on incest.
In this controversy, like so many others, psychology—that is, the
scientific discipline, with findings that may be as conclusive as any
in science can be—offers an inconclusiveness that is heartily aug-
mented, in this as in many cases, by the deeply felt principles and
high personal stakes on both sides.
This controversy is useful because it tells us of the power of narra-
tive, not only in personal lives but also in legal processes. It is possi-
ble to get to the facts of the matter in a case now and then. However,
several other issues are at stake, issues that involve people’s identi-
ties as well as matters of fact. The matters of mere fact—independ-
ent of identities, separate from the contexts and narratives that
inform identities—will not stand alone. These narratives, born of
personal experience but shared and recognized socially, organize our
understanding of social life, indeed of all life.
Stories certainly determine what we think the facts mean or are.
Indeed, it is only these stories that make the facts meaningful or
make them facts at all. If the “postmodern critique of social science”
means anything, it means that human perception, cognition, and
memory are all heavily influenced by factors beyond the simple facts.
Values, vested interests, and narrative context must be seen as cru-
cial determinants of many scientific conclusions, indeed of the data
themselves. This should be the distinguishing characteristic of all
social sciences, as opposed to physical sciences, and it is decisive
wherever mental life interferes with the mechanisms of physical,
physiological, chemical, and neurological data. Part of the very func-
tioning of the brain is made up of personal factors that compromise
the clockwork.
NOTES
1. A very interesting account that bridges behavioral and verbal-
mental events in the creation of psychological symptoms is that of Capps
and Ochs (1995), who bring discourse analysis to the clinical phenomenon
of panic.
2. There is a current opportunity to explore not only the world but also,
once again, our awareness of it. It has been called “the postmodern cri-
tique.” For a helpful discussion of the effect of postmodern thought on con-

temporary theory, I recommend Schrag (1997).
3. There may indeed be one reality that underlies what our divided dis-
course has made into two incommensurable realms, but to pretend that ei-
ther language is adequate to some such underlying metaphysical
substrate is to be philosophically naive. Yet that is what the treatment
professions commonly do.
4. This “natural harmony” is part of a larger unit of “purposive act,”
which is part of being who I am, and so on. I have reduced these unities to
the molecular units of “decision” and “mechanics” because these two as-
pects of behavior often vary independently, and because they are
common-sense correlates of mind-body dualism, with which we are, by dis-
course if not by reality, inflicted.
5. To incorporate the social dimension into the analysis of behavior has
been the object of social psychology. I recommend the work of Sarbin,
among countless others (Sarbin & Keen, 1998) and Keen (2000b), which is
about Sarbin.
6. Listening was my professional recommendation after an extended
contemplation of drugs, therapy, and social power in Keen (1998). In a way
it sounds simple, but the professional change that I think is necessary is to
put aside technical expertise long enough to discover what the illness
means to the person suffering it. Indeed, exploring this issue with patients
need not take a lot of time. Simply bringing it up legitimates and provokes
further thought by the patient, who can tell you later what he thinks he is
going through.
7. In the summer of 1998, I participated in a panel at the American
Psychological Association in San Francisco on “Recovered Memories of
Childhood Abuse—Making Sense of Contradictory Claims,” a topic on
which I recommend Alpert (1995), Contratto and Gutfreund (1996), and
Brenneis (1997). This literature makes the radicality of the disjuncture be-
tween experiential and scientific discourses especially vivid. There are
other examples, described later in this book, but this controversy creates
more heat and less light than most. I do not pretend to avoid this common
failure, but it does seem that our professional failure to recognize the in-
commensurability between discourses as different as personal memories
and social science condemns us to hateful attitudes. The way out of the
conflict to some common ground requires exactly this recognition.
8. It is possible to ignore Loftus’s and Ketcham’s (1984) rhetoric and
simply read their data. But doing so leads you to other data that say other
things (for example, the ambiguity of the data seems to suggest to psy-
chologists that the science of memory is unlikely to bear convincingly on
most specific cases). Data are a source of probabilistic generalizations.
They cannot tell us what is truth in any simple sense.
CHAPTER 4
Wider Echoes of the

Incoherence
INTRODUCTION
This chapter concludes the first part of this book. Below I restate the
incoherence that emerges from the dualistic structure of Western
discourse. I then examine its operation in very commonplace appli-
cations of psychiatric and psychological language. Our examples are:
(1) the insanity plea, (2) the diagnosis of insanity that facilitates it,
(3) the further use of diagnosis to trigger insurance payments for
psychiatric and psychological treatment, and (4) the simple act of
making intelligible to ourselves as citizens the absurd injustices
that characterize the modern world. In all of these commonplace rou-
tines, we see a conventional but, upon examination, incoherent pro-
cess. That incoherence is born of the incommensurability of multiple
discourses. An example is the use by psychology and psychiatry now
of a deterministic (scientific) framework, and now a moral frame-
work that assumes free will.
In their daily reckoning of our personal experience, recognition of
public events, and reflection about natural events, all modern per-
sons tolerate the incoherence embedded in an implicit dualism in the
common discourse. Even though we stumble repeatedly upon this in-
coherence, it is so familiar as to seem unremarkable. But it is re-
markable. We can understand why it is with us, even if we cannot
undo the historical origins that condemn us to it. Most importantly,
our lack of acknowledgment of this implicit dualism leads us to be
sloppy thinkers, psychologists, and citizens.
Let me begin by stating some very general facts about language

and meaning. These facts are obvious, but they are so frequently ne-
glected as to be revelatory. First, language is more than a coding sys-
tem for the remembering and communicating of perceived objects.
Prior to that activity, language tells us what is, and what is not, an
object. Second, an object’s label is part of a network of labels that
make up units much larger than the single object, and such units dic-
tate the meaning of every object in the collection. Language thus
shepherds the human meaning not only of objects but also of catego-
ries of them, categories of categories, all the way to the whole of what
is intellectually comprehensible to human beings.
Third, language thus shapes meaning, and in so doing it creates
the meaning of the world; it creates all meanings in the world, of eve-
rything in the world. Words create the world itself, insofar as it (the
world) is meaningful.
Fourth, the world that is created by language contains much more
than objects. Relations between objects, names for atmospheres, for
feelings, for virtues, for diseases—each of these categories carries
names, nouns, which carve out units from the flux of experience,
make it whole, hold it still, and describe its attributes. Language re-
lates each such abstract entity to other abstract entities through the
same network of meaning. The world is constructed by and in lan-
guage, and language shapes and is shaped by human communities,
so that we now say, much too easily but not wrongly, that reality is so-
cially constructed.
Given these propositions, I want to restate the theme of the book
so far. Ultimacy and triviality are opposite poles of a dimension of hu-
man experience. Triviality passes for matters of importance and ulti-
macy is on most days invisible because our understanding of our
psychological lives, at the millennium’s turn, is shaped by a culture
dominated by slogans designed to maximize corporate profits. Mar-
keting replaces serious thought in shaping the terms of our under-
standing of our own experience. This results in a palpable
incoherence, especially in the treatment professions.
Those of us in the West, and in other parts of the world as well, who
live in “the” world of that language, actually live in at least two
rather different worlds at once. That is because we must deal with at
least two different discourses. Let me call them “natural language”
and “scientific language.” These names are not appropriate for the
metaphysical dualism of Descartes, but they do name the discourses
that give us the two worlds we inherited from him.
WIDER ECHOES OF THE INCOHERENCE 47
The dualism of Descartes greatly advanced what became natural

science. The astounding successes of science in the modern period
led to a proud claim that only scientific language bears truth, as well
as to considerable scientific hostility to traditional truths. This in
turn drove our inherited dualism into an unacknowledged and
deeply concealed rift that now underlies both modern science and,
more obviously, everyday life. Science remains proud of its nondual-
ism, while presupposing it in simply enacting science’s own program
of observing nature. Natural language, which came first, adjusted to
science and has come to be equally unconscious of its dualism.
Although our focus is on two realms of discourse, the languages
come to us also as separate worlds, two distinct phenomenological
spatio-temporal places within which we reckon the meanings of our
experience. The mechanical nature of the universe, as seen by Kep-
ler, became one pattern for understanding this place, the world. In
contrast, earlier patterns of meaning had already made the same
space into a moral one, where events are voluntary instead of caused.
The rapid development of natural and social sciences in the West
following Descartes was a development of a competition between sci-
ence and everything else. Science vied with and conquered royal
truth pronounced by monarchs. Science vied with and conquered re-
ligious faiths and cosmologies. “Myth” and “superstition” became
denigrating names for what had been important abstractions in re-
ligion, such as “faith” and “revelation,” and this denigration under-
mined the worldly authority of religion’s faith and revelation. Faith
and revelation no longer have authority in the secular world, even
though they are still present. Their lack of authority now attaches to
their very names, “myth” and “faith,” which stand in the modern
world as meaning “erroneous” or “fanciful.”
The debate about evolution, for example, early in this century was
a struggle for authority to name such things. The world created by
such language as “faith” and “revelation” was under attack by sci-
ence, which asserted that human beings did not come from God but
from evolution. This still-remembered debate was a part of the prog-
ress of science in its historical habit of reinterpreting human experi-
ence and re-creating the human world. Just as “royalty” became
mere privilege and faith became mere superstition, the mind is now
becoming, a century later, merely the brain.
Cartesian dualism, as a theory of reality, is decidedly out of date.
Hardly anyone claims to be “a dualist,” a claim that commits one at
least to a doctrine of two realities, body and mind. This doctrine un-
fortunately creates the problem of how the two are related. When we
quickly say that there is just one reality—“the person,” let’s call
it—we find ourselves dividing this person up, in spite of ourselves,
into bodily manifestations and mental ones. We understand the hu-
man body as we understand all bodies—scientifically. But side by
side with scientific language lies the earlier “natural language” of
mental life, free will, morality, and human responsibility.
We do not know if these two events, mental and physical, are dif-
ferent manifestations of the same underlying reality. Some scien-
tists believe, for example, that “mind” and “brain” are two names for
exactly the “same thing.” That thing tends to be seen by scientists in
scientific terms, as if natural language, like myth and superstition,
can be ignored. These scientists eschew “mentalism.”
On the other hand, some critics of science see the world as basi-
cally lucid in natural language and science as merely skimming that
surface in a way that fits its methods. These critics eschew “scien-
tism.” No one of either group knows how to reduce successfully the
language of, say, the brain, which “exists” in a material world of cau-
sality, to the language of the mind, which “is” the interior of a being
exercising will in a moral world.
I bite an apple. The experience is mental, but the apple is physical.
They are “the same event,” and yet they are also vastly different. A
physical apple, the force of teeth, ratios of resistance, and so on, are
understood in terms of one language we have. The experience of de-
ciding, then intending, then actually biting and tasting and smelling
the apple, and then deciding to share it is understood in terms of a
second language we have.
The same event takes place in time. If I remember the event, I
make the past present. Does my remembering reproduce in the brain
what it reproduces in my mind? Surely yes, to an extent, for we have
much correlational data. As a mental person, my mind remembers,
anticipates, and jumps around the temporal map from past to future
at will. This pattern violates the temporal events of physical time, for
physical time is in fact a steady repetition of identical moments,
regularly succeeding one another in one direction only. Physical time
does not reverse itself, but in remembering and anticipating I can
violate its temporal order, and I do so every waking minute of every
day.
The argument so far is that we construct the world in language
but that the language we have inherited from history is, in actuality,
at least two languages. Each constructs the world differently—one
physical, causal, and mechanical, the other moral and experiential.
In what follows, I will describe how this duality creates familiar
problems often encountered in so-called mental sciences, such as

psychology.
THE PROBLEM OF THE INSANITY PLEA

Contemporary pleas of “innocent by reason of insanity” are to be
seen against a historical backdrop of an early modern culture that
generally presumed free will and personal responsibility for behav-
ior. Over time, legal consideration of cases must have kept stumbling
on one or another set of circumstances that demanded ways to miti-
gate legal outcomes like the death penalty. Theoretically, we could
have invoked such notions as “fate” and “tragedy,” but such thinking
did not lead to a way to obviate such a harsh punishment. Science
eventually did what these notions could not: it created the insanity
plea.
The state of one’s inner life was also not originally seen as an ex-
planation of malfeasance, except as it could be formulated in relig-
ious language. Hence, there were sinners, and less frequently
witches, who were (sometimes with regret) burned because they had,
much to their personal misfortune, become possessed by demons.
This also facilitated what we now call “scapegoating,” which had for
centuries combined religious language with what was to be the be-
ginnings of scientific psychiatric language. Madness, as it was called,
was the result of possession (Foucault, 1965; Szasz, 1970).
In the nineteenth and twentieth centuries, notions of “mental ill-
ness” progressively replaced the religious subtext of words like
“madness” with the scientific subtext of medical science. Perception
followed language, and we began to see such people differently. Mad-
men and madwomen ceased being “evil” and became “sick.” The in-
sanity plea in courts of law was an obvious corollary of this historical
change. Like other legal maneuverings, persons accused of murder
and other serious crimes came to opt for a medical diagnosis instead
of a death sentence.
An exemplary contemporary case is described by Meloy (1992) in
his encyclopedic study of the psychopathic mind. This case eventu-
ally became Colorado v Connelly (No. 85–660) of the U.S. Supreme
Court (Ennis, 1986). Connelly was a diagnosed schizophrenic who
waived his Miranda rights to remain silent and consult a lawyer, and
confessed to serious crimes. He later claimed to have been com-
manded to say what he did by voices, auditory hallucinations. Such a
plea, by such a client, could plausibly lead to recanting his confession
in court. That recantation, if granted, could plausibly lead to the ver-
dict of innocent by reason of insanity.
In spite of its potential for abuse, very few seriously argue that
there should be no insanity plea. We do believe that people generally
make their own decisions and are responsible for them. But we also
believe, with the help of the deterministic theories of scientific psy-
chiatry, that individuals are sometimes overwhelmed by inner psy-
chological processes we call “disorders” and that such people should
therefore be excused from personal responsibility. Both personal re-
sponsibility and deterministic scientific explanations are, in any
given case, plausible, and after embracing in principle the determi-
nist exceptions to legal culpability, we must depend on experts to dis-
criminate the one kind of case from the other.
In this exemplary case, everything hinged on the legal status of
Connelly’s confession. The confession, of course, implied free will,
and thus guilt, but the hallucinations imply no free will. The court
must deal with this issue. Unlike in many such cases, the experts in-
cluded the American Psychological Association, presumably hoping
to clear up the confusion. The APA stated:
Behavioral science does not use or rely upon the concepts of “volition” or
“free will.” Accordingly, Dr. Metzner was not testifying as a scientist when he
testified that respondent’s command hallucinations impaired his “voli-
tional capacity.” Furthermore, even if Dr. Metzner only meant to testify that
command hallucinations are, in a statistical sense, coercive, his testimony
finds no support in the professional literature, and is contrary to clinical ex-
perience. (Ennis, 1986; quoted in Meloy, 1992)
What is the APA saying here? Confusion continues to reign. Is the

APA supporting Connelly, arguing that since there is no free will at
all, the psychiatric testimony that Connelly’s command hallucina-
tions impaired his “volitional capacity” cannot be called scientific
and will find no support in the scientific community? According to
this view, then, if a court of law deals with human volition and per-
sonal responsibility, it does so only by violating science. If we assume,
as every legal scholar does, that criminal prosecution does deal with
human volition and personal responsibility, science must then be ir-
relevant. If this is true, why have scientific testimony at all? Much
more than the mere status of the confession is left unintelligible.
Common sense offers us a patch for this rift in our coherence
which states that free will is usually the relevant language but that
sometimes determinism is, and that psychiatric testimony is sup-
posed to determine that issue. But the APA does not understand it
this way, for it says there is never free will; most citizens do not un-
derstand it this way either, for madness never replaces the person
but only modifies our judgment of him or her.
This conceptual confusion is the fault neither of Dr. Metzner, who
argues for “impaired volitional capacity,” nor of the APA, which says
such an argument is nonsense because there is no such psychological
reality as volition. The confusion comes to us historically from the
fact that whereas the scientific model of everything is mechanical
and causal, it has been superimposed upon by, and finally sits side by
side with, commonsense notions of free will as old as recorded his-
tory.
THE PROBLEM OF DIAGNOSIS

A court of law is only one of many arenas where the incompatibil-
ity of these two languages and world designs is somehow reduced to
one in order for society to carry on its business intelligibly. Payment
for psychological and psychiatric services is another. Here again we
see that the professional expert is crucial to making a decision upon
which turns the giant wheel of “medical necessity,” the engine that
justifies insurance coverage, without which treatment would often
not take place at all. The professional, expert judgment here is ren-
dered in the form of a diagnosis. Without a diagnosis there will be no
insurance dollars spent, and if no insurance dollars are spent the
vast majority of psychiatric and psychological treatment would
grind to a halt.
Diagnosis is a scientific procedure.1 Since it is descriptive instead
of explanatory, the causal framework in scientific diagnosis is more
implicit than in the case of the insanity plea. However, it is present in
a way as consequential as the insanity plea, when it is part of the in-
sanity plea.
Beyond that, its consequences may be merely financial instead of
punitive. The treatment establishments of our culture, which de-
pend on diagnosis, involve many more treatment providers than is
true of the insanity plea. In addition, such treatment involves an
enormous portion of the population. Whole professions, careers, and
institutions of modern life depend on such protocols and procedures
as diagnosis. Medical science is our model.
Does the incommensurate character of the two worlds, scientific
and traditional, create as much conceptual chaos here as it does in a
court of law? Of course, intellectual comprehension requires a single
context of meaning and world design, or at least a means of system-
atically and unambiguously translating from one to the other. The
world of responsibility and human morality, on the one hand, and

the deterministic world of science, on the other, do not have this
means, so one of them is finally, but unconsciously and surrepti-
tiously, jettisoned.
In the end, Connelly was convicted and sentenced because he was
thought to be guilty, but the elaborate safeguards meant to yield a
“fair trial” in his case made different claims. A decision was suppos-
edly made on very technical grounds, but finally it appears to have
been a mere judgment, quite independent of the technicalities.
One might say that in a legal setting this is always true and that
no evidence, scientific or otherwise, does more than tilt the balance.
Juries must always decide the case in the face of conflicting evidence.
But in the mechanics of financing psychiatric or psychological treat-
ment, we see not individual cases but mental-health policies that af-
fect nearly everyone who holds a full-time job, and her or his family
as well.
The task of moving from “someone’s judgment” to “scientific re-
spectability” in mental health payments falls to the procedure of di-
agnosis. In the end, that too remains someone’s judgment, but
presumably not merely that. Since diagnostic manuals were pro-
duced by the American Psychiatric Association after World War II,
there has been an effort, increasing since 1980, to make diagnosis
into a scientific process rather than someone’s judgment. The codifi-
cation of symptoms of disease entities, the specification of how long
the symptoms must be there, their severity expressed as far as possi-
ble in quantitative terms, and the exact number of such symptoms
required to declare officially the diagnosis—all these trappings in-
crease the reliability of diagnosis.
Reliability assures us that professionals will agree about what to
call a certain condition. It is a necessary component for scientific
treatment of illness. Whether such an agreed-upon label names a
real disease, however, is another component of the scientific treat-
ment of illness. This is the issue of validity. In these cases, it is very
much in dispute (Szasz, 1961, 1970, 1987; Sarbin and Mancuso, 1980;
Sarbin and Keen, 1998).
FINANCING PSYCHOLOGICAL TREATMENT

Beyond the trappings of diagnosis, the elaborate bureaucratic
checking of professional credentials, the time-consuming paper-
work, the attempts to codify descriptions of patients so they can be
seen to fit into diagnostic categories—all these “safeguards” protect
insurance firms more than they protect clients. Industrial finance is
bound to produce bigger and better safeguards than is our concern

for fairness to people accused of committing crimes.
Bigger and better they are. Finally, all managed care and insur-
ance companies have to answer to hearty market competition. If
they protect their profits by making claims harder, more obviously
than they protect their subscribers, they will lose business. Their
customers thus become the biggest “jury” of all. But we professionals
also know which diagnoses will yield immediate payment, as op-
posed to those that will yield delays or even denial of funding. The
sure-fire diagnoses for funding are those where refusal would
amount to market embarrassment and eventually to a loss of busi-
ness. That is, symptoms like suicidality and abuse of children are
certain money triggers. Perhaps this is because of the human costs,
but more persuasively, it is because the competition within the mar-
ketplace of insurance plans makes the human costs obvious.
Managed care organizations play the two languages off against
one another with instructive, and profitable, results. Treatment pro-
viders and potential patients find themselves in a bureaucratic
world where insurance payments are contractual, where the parties
all voluntarily enter into agreements that funds will flow from cus-
tomers to company, and then under certain conditions back to cus-
tomers or their therapists. The system, by being contractual,
assumes free will on the part of all parties. The conditions of pay-
ment, on the other hand, assume that some medical event has been
caused by unnamed factors beyond the control of anyone. We see
here nothing more complicated than people choosing to protect
themselves against what is beyond their control, and other people
setting up contractual agreements to help them do so.
However, insurance companies maximize profits if they minimize
payments, so it is in their interest to make sure that such disease
events are in fact caused and not chosen. A diagnosis by a qualified
professional states that the only choice being made by customers is
to activate their insurance; they must not be choosing to have condi-
tions that require treatment, and they must not be able, without
therapy, to chose not to need treatment. These conditions are mod-
eled on routines developed for physical disease, where they are cer-
tainly more applicable. For psychological conditions, however, many
more choices are made by clients that bear on their diagnosis than is
the case in physical disease.
Existing side by side within the rational insurance arrangement
are voluntary contracts for insurance, and involuntary psychological
breakdowns. We understand these two events, one chosen and one
caused, as different kinds of events, and we are clear that they bear a
routine relation within the insurance format. At the same time,
there comes to be a psychotherapeutic relationship, which is an-
other, but different, mixture of caused and freely chosen events. The
therapist is there voluntarily, as is the patient, attempting to deal
with what allegedly is a disease, an event whose origin is seen as me-
chanical and caused, which is to say that it has nothing to do with the
moral dilemmas or free personal choices made by anyone.
Of course, psychotherapy does have much to do with moral dilem-
mas and personal choices, for this is the framework within which the
patient understands his or her life. This understanding is the same
understanding that the patient had when he or she voluntarily en-
tered the insurance contract or sought a job that had some reason-
able degree of medical coverage. Both of these parts of the entire
situation are intelligible not as mechanical or caused events but as
strategic decisions made by persons in a world of moral standards
and personal responsibility.
But the communication between the therapist and the insurance
company is intelligible only in the other, scientific language, the lan-
guage of the science of medicine. The diagnosis names a naturally oc-
curring event for which, like a flood or an epidemic, no one is
responsible.
The issue is not whether these two frameworks can be mixed or
that life can be understood as so mixed. Both mixes are the stuff of
our lives. The issue rather is whether such mixing can take place
without confusion and incoherence. If there were clear labels on the
events or on the compartments of life, such labels could tell us which
language is the relevant one for each event or compartment. Each
language would then be understood to be partial, and neither would
claim to understand everything.
Prescientific natural language absorbed and accommodated sci-
entific language as a modification of earlier fatalisms. Even so, it did
not claim to understand everything. We have given up believing that
the gods punish us with the weather. Science, however, is increas-
ingly aggressive in such ambitions—or perhaps it would be more ac-
curate to say that medical professions, bureaucracies, and
corporations are pushing science into that arrogance, from motives
(respectively) of professional prestige, bureaucratic convenience,
and corporate profit. Such a use of science generates prestige for pro-
fessions, convenience for bureaucracies, and profits for corporations,
but it does not serve science well or aid the coherence of our under-
standing.
As in the case of the insanity plea, we psychologists, but also the

culture at large (which is under our direction at this point), fail to
comprehend life’s problems coherently; further, we fail to know that
we fail to comprehend, so accustomed have we become to sloppy in-
tellectual constructions, such as diagnostic categories.2
THE PROBLEM OF BEING A CITIZEN

Any incoherence as central as the one discussed here must affect
our experience of life in nearly every way. I bring up the example of
citizenship simply to verify that fact and to protest again that we do
not grasp our own incoherence. In the case of citizenship, particularly
in our understanding of global politics, clichés abound instead of in-
formed concern. We might attribute this to mere lack of interest, but
our lack of interest itself may be a product of our inability to grasp co-
herently what it means that, say, the wealthiest fifth of the world’s
population (that is us, of course) receives 82.7 percent of the income of
the world, leaving the other four-fifths of the world to scramble over
17.3 percent (Korton, 1995).
What does this mean? Is it a moral outrage or an accident of na-
ture? Are we supposed to care about this fact? Feel guilty? Try to “do
something” about it? We find no answer, because we are confused
about the meaning of the fact. The encroachment of the scientific
world into the traditional world, construed as a moral universe, has
left us unable to respond. The encroachment of scientific discourse
into the natural language, in the hands of some advocates, promises
a single language and a coherence. But even if we can see outrageous
facts like the maldistribution of this 82.7 percent of available income
as inevitable outcomes of forces that we have no control over, and
even if we can call such circumstances “caused” instead of “chosen,”
we can never take away our discomfort with such facts of citizenship.
Even if we are led to feel fatalistic about these facts, such fatalism
does not solve the problem of the incoherence that paralyzes appro-
priate action.
Let us briefly recall how we arrived at our paralyzed civil life, by
briefly recounting the history whereby our privilege came about.
That privilege is enabled by what Wallerstein (1974) has called “the
modern world system,” the only world system, as far as we know, to
be truly global. In this global system, all Earthlings, regardless of na-
tionality or ethnicity, are party to the system. Many facets of contem-
porary life are global in their origins and destinations. What we
produce and what we consume depend on this system in ways too
elaborate to specify.
The modern world-system emerged gradually from European ef-

forts beginning in the late fifteenth century. Columbus began the oc-
cupation of the Caribbean on Spain’s behalf; Vasco da Gama sailed
into the Indian Ocean to promote Portuguese confiscation of Asian
commerce in spices. There followed a century and a half of land sei-
zures in the Americas, global exploration, forced production via chat-
tel slaves, piracy on the high seas, the rise of capitalism, and
technological revolutions in weaponry and production.
Even if our forefathers felt the bite of their guilt for the many
kinds of exploitation and expropriation, it was much later that there
arose “liberal” democratic ideals assesting values of individual dig-
nity, liberty, equality and responsible (constitutional) government.
Such a history would be an embarrassment except for our ability to
construe the situation as not our history.
It is very hard to take the moral importance of these facts seri-
ously if we believe that when “we” (our forefathers) did these things,
we (they) were just behaving naturally. If “nature” explains it, moral-
ity is relevant only as an afterthought having nothing to do with
“why” it was done. We quite understandably tell ourselves that we
are behaving according to “nature,” particularly “human nature,”
which includes motives such as greed and causes such a history to
have happened.
Thus we produce ideas that enable us to experience neither the
bite of guilt nor the embarrassment of confusion, by insisting that
our ideals of justice and our practice, then and now, do not contradict
one another. Science is a great help in importing “nature,” our nature
or human nature, into our world—recasting it, in effect, from a vol-
untary into a deterministic place. Nevertheless, our ideas and values
of human freedom are propagated worldwide, for we eagerly estab-
lish authorities like the World Bank, NAFTA, GATT, and the IMF,
whose policies maximize the profits of established (usually Western)
corporations.
The language and values of human freedom must condemn ex-
travagant corporate profits when they come at the price of crushing
poverty to indigenous populations. But our other, scientific, language
justifies such excesses in the social Darwinist theory of social
change. According to this theory, the fittest among us are the hardest
working, thriftiest, most individualistic and greedy. Once profits for
the rich at the expense of the poor are explained by a natural selec-
tion among human beings, the entire phenomenon ceases being a
moral matter at all. As with all inevitabilities, moral judgment is as
irrelevant as protesting gravity.
THE PROBLEM BEHIND THE PROBLEMS

There are no perfect circles, no perfectly straight lines. Conceptual
clarity, simplicity, elegance, and rigor are all ideals not contained in
real life. Science is mathematical, and, in principle, it is like perfect
circles. It describes the patterns we see, but such patterns are not in
reality; they are in our minds. They are the patterns in terms of
which we see reality. Meanwhile, the actual reality we see is always
less perfect, less regular, less understood than what we see through
these ideal lenses.
Refinement of scientific language never describes reality, because
it is a refinement of mental abstractions. This origin determines the
character of scientific language and its debt to these beginnings in
abstraction rather than in experienced reality. No matter how many
scales we apply to an IQ test, no matter how many gradations of
achievement, measured intelligence for a concrete person remains
abstract. IQ does not define a person or even a part of a person; it is
nothing more than a measurement. That actual person is a walking,
talking, breathing, feeling, creating, scrambling mortal who is terri-
fied of death and dedicated to being her- or himself. That person is a
particularity, a concrete reality, with whom I may have an acquain-
tance. It really doesn’t take long in any relationship for the knowing
of one person by another to go far beyond what any number and com-
bination of measurements can describe.
In fact, the refinement of scientific language, such as increasingly
refined subtypes of diagnostic categories, follows less from acquain-
tance with persons than from dictates of logic and meanings already
embedded in the abstractions. We do, of course, decide that
Cyclothymia is a different diagnosis from Major Depressive Disor-
der on the basis of empirical reality. But that empirical reality is not
one of concrete persons as much as it is one of numbers of concrete
persons who are similar to “Major Depressive Disorder” but not as
serious. The particularities of Jim, who is Cyclothymic, and Mary,
who is MDD, are not captured in this or any distinction.
In one sense, this is not a new thought. We always knew that “dis-
ease entities” are fictional (although human suffering is not), as are
categories of “criminals” (although unjust behavior is not). If one
commits a murder, he or she is indeed “a murderer,” and this de-
scribes what we need to know to punish the right people in order to
inform the rest as to what behavior is not tolerated. But most human
killings of other humans occur in warfare and thus are conveniently
excluded from the category “murder.”
Furthermore, the abstraction “murderer” is, of course, far from

everything such a person is, and to ignore the rest and reify his or her
having killed someone as her or his essence is an invitation to misun-
derstand who and what he or she is.
Both natural and scientific language operate in these ways. But
natural language allows retreat into particularity more naturally
than does scientific language. In the natural language of a narrative,
a context is created for every human act, and that context adds to our
understanding of the person by understanding the act. In diagnostic
language, the categories scientifically name diseases, in terms of
symptoms present or absent. This is a reification of abstractions, and
it carries with it the authority of the most successful intellectual ad-
venture of the modern age: science.
Current scientific opinion clearly tends toward reduction of expe-
riential language to scientific language. We are in danger of believ-
ing that science can homogenize the world. No one wants to
eliminate science, and yet science does not and cannot speak for our
particularity. No one wants to eliminate natural language and re-
place it with scientific language, and yet natural language does not
offer us the intellectual advantages of scientific language.
I have no quick solution. But it is clear that the absurdities will
continue to multiply until we begin taking this conundrum clearly
into account. Intellectual rigor must take the social construction of
meaningful reality seriously, and it must recognize not only the so-
cial construction of knowledge but also the way that our reifications,
again and again, prevent us from being aware of the problem of our
own incoherence. Indeed, awareness of the problem, which is histori-
cal and to which we are condemned by our position in history, is our
only recourse if we are to take seriously the fraudulence and absurd-
ity of modern mental science.
NOTES
1. Although diagnosis is a scientific procedure, no less a scientist than
Healy (1997) argues that diagnoses have been “marketed” by pharmaceu-
tical corporations for years, with the full complicity of the psychiatric pro-
fession. He points out that for over thirty years, since the work published
by Schildkraut (1965), the “catacholamine hypothesis of depression” has
been enormously popular, even though there are many things wrong with
it. One of the keys is that doctors, who are not research experts but are
nevertheless popular authorities, pick up phrases like “the catacholamine
hypothesis” and use it with patients who are unfamiliar with the difficul-
ties of interpreting the actual findings. The presence of pharmaceutical in-
terests in markets thus leads to the “marketing of diagnoses” to doctors, as

well as the marketing of slogans to patients. Both are inevitable parts of
the marketing of drugs. His best example is how the idea of low amines
came to be public knowledge. Beginning in the early 1970s, newspaper ar-
ticles spoke of the lowering of brain amines as a part of depression. People
came to expect, according to Healy (1997), that something might be wrong
with their amines or with some other brain chemical (p. 161).
Schildkraut’s (1965) catacholamine hypothesis was joined in 1987 by
Coppen’s (1987) serotonin hypothesis, which led to the marketing of a
group of drugs, including Prozac, called “selective serotonin reuptake in-
hibitors” (SSRIs), a sloganized name with all the pseudo-precision of the
way psychopharmacology is exploited by marketeers. Another similar slo-
gan appeared soon after Coppen’s work: a theory of the cell’s management
of its own receptors from its headquarters in the DNA in the nucleus. This
is popularly called “down regulation” (see Hyman and Nestler, 1996, for an
example of current research). This theory of, “down regulation” of recep-
tors refers to the neuron’s ability to decrease the number of receptors when
there is little activity, which in turn may be caused by blocking the recep-
tor, or by the presence of monoamine oxidase, or by the reuptake of
monoamines or serotonin. This popular theory also explained why it takes
a couple of weeks for the relatively quick phenomenon of down regulation
to translate into clinical change. At this time, the 1970s, major psychiatric
disorders came to be known as disorders of single neurotransmitter sys-
tems and their receptors. Not only was depression known as an amine dis-
order, but schizophrenia as a dopamine disorder, and so on. Evidence
supporting these idea was lacking, but
this language powerfully supported psychiatry’s transition of a discipline that un-

derstood itself in dimensional terms to one that concerned itself with categorical
ones. This legitimized the rise of biological psychiatry, which in turn fostered a neo-
Kraepelinian approach to diagnosis and classification, as embodied in DSM III.
(Healy, 1997, p.163)
A page later, Healy suggests that these biological investigations did less to
further the science than to “have provided biological justification for the
new approaches that were taken up by psychiatry during the 1970s and
1980s.” Healy’s conclusion may be obvious in light of his argument, but it
is, in fact, shocking to most people.
As a sociological phenomenon, the power of such ideas in disciplines such as psychia-

try to command brand-name loyalty and the reassurance that such brand-name loy-
alty provides should not be underestimated. (p. 164).
2. I would wager that there is not a psychotherapist in the country who

has not adopted a cynical attitude toward the role of diagnosis in getting
paid for her or his work. Such cynicism, to the extent it exists, makes a
mockery of science, or at least of the extent to which science has been pros-
tituted by bureaucracy and corporate interests.
PART II

Preface to Part II
The implications of our work so far are far-reaching and complex. At

one level, reality is, as Sartre (1943) said, of two kinds, en soi and
pour soi (“in-itself ” and “for-itself ”). Human life, in its freedom, is
for-itself, but our lives and thoughts are more than that. Human be-
ings do not simply leave in-itself reality behind. We are nature and
matter as well as thought and ideals. The incoherence is inevitable.
Yet a life—yours, mine—can be made more coherent by embracing
human freedom more consciously. Coherence is never complete. We
are nature, and we die. But unless we grasp life in the spirit of free-
dom, life has an ugly note of absurdity. To the extent that we see our-
selves as mechanical and determined reality in-itself, we trivialize
human possibilities by reducing them to necessities. Sartre called
this psychological strategy “bad faith.” It leaves us in doubt about
everything; we stumble and lose direction; we give ourselves over to
causality beyond our control.
In a sense, of course, such bad faith is inevitable. When that is all
we are, however, life becomes tragic. Reducing human being to inhu-
man mechanics trivializes us; when we do it to ourselves, that trivial-
ity is tragic. Such inevitability reduces life to tragedy—unless we
can realize human freedom. That isn’t simple. One interpretation of
psychotherapy is that it transforms triviality into human opportu-
nity, by engaging our freedom, by broaching and by living the ulti-
mate human question: Who am I to become?
CHAPTER 5
Narrative, Coherence, and

Ultimacy
The incoherence described in part I above has consequences, for the

profession and for the rest of us. The inevitable incoherence of our
understanding of ourselves and our patients follows from what has
been said. Psychotherapy can create coherence, for both groups. It
does so by forcing the recognition of our duplicity, and by invoking
that natural supraordinate category of self-consciousness, the nar-
rative (Sarbin, 1986). To say that my life is a narrative is to affirm a
coherence, which is also an inherent tendency in our self-experience.
Whether we want to or not, we inevitably construe our lives in the
form of a story. Indeed, my life is my self, so my self too is a story. It
usually coheres. It may seem to become incoherent, but unless I lose
my memory or become disoriented with respect to time, I can order
the major events of my life, from childhood to the present, and they
will constitute a sensible sequence. Like most stories, it will be re-
membered by a few people, and eventually it will be forgotten. But as
long as I live, it is not forgotten, and “how it comes out” is mostly up to
me. Ultimacy is inherent in experiencing myself as a narrative, as
fully as narrative is inevitable in experiencing myself at all.
We do, in the mean time, find ourselves in the grip of feelings that
are not always sensible in the usual terms. Psychology and psychia-
try have called some of these experiences “symptoms” of “illness.”
They may also come from the quarter of ultimacy—that dimension of
human experience beyond the ordinary. “Who am I to be?” is uncom-
monly explicit, but it is an inevitable question for most of us. We usu-
ally can classify it as not of immediate urgency. Our living answer is
66 ULTIMACY AND TRIVIALITY
always ambiguous—an ambiguity we always live with but can usu-

ally ignore. Sometimes we can ignore this question because it is an
ultimate question, and sometimes we cannot ignore it—because it is
an ultimate question.
Ultimacy does not always maintain its distance; it draws close and
contextualizes the ordinary, as a lake contextualizes the boat we are
in. Indeed, when symptoms terrify us, it is because non-sense sug-
gests loss of sense; loss of sense is madness, and madness, like other
disease, suggests death. When ultimacy draws close, it throws into
question our current narrative.
A narrative is a natural part of human cognition. In every culture,
children are told stories that portray the world as a meaningful and
coherent place. By the time one is in grade school, one has stories of
one’s own; one borrows themes from stories heard and creates a story
line by remembering events in a coherent way. This is not to say that
it is impossible to become confused, for our patients are exactly con-
fused, if not about the story so far then about its future. Very likely
something does not fit and cannot be made to fit.
Clinical experience does not tell us that people founder on the in-
coherence of scientific determinism versus moral free will—the du-
ality documented above in how we formulate the sense of events. We
know that some things were chosen and that some are beyond our
control, and we assume every day that our freedom is real but lim-
ited. We premise our lives on these two orders: choices we make and
things that are caused. The technological impulse, so vivid in the
modern world, attempts to bring the latter under the control of the
former, to reduce as far as possible the range of things that are out of
our control, to bring them under our control.1
If each of us had a technology that could, finally, make all life’s
events into choices we make, we would have only moral prob-
lems—about what choices to make. If we had no such power at all, we
would have only problems of endurance and acceptance. As it is, we
experience both aspects of life; we control some things, and we must
accept other things. Life comes to us as a combination of possibilities
and necessities. These features are represented exactly in narra-
tives.
To develop, or re-vision,2 my experience of my life as a narrative
and myself as its author, if a mortal and contingent one, is to begin to
recover from whatever has driven me to a therapist or a psychia-
trist—or a fortune teller. The conflicting discursive formats of free
will and scientific determinism, or morality and fatalism, date back
at least to the Renaissance, if not to the most ancient of traditions.
NARRATIVE, COHERENCE, AND ULTIMACY 67
Stories of human beings living life heroically are inspiring for their
coherence in the face of threats that would destroy the coherence
they depended on. Such human beings met with resistance from
causal relations or paralysis from indecision, yet they found ways to
write willfully their own narratives within the unmoveable frame-
work of determinate reality.
This is what we want from life; and it is what our clients want from
life, and as therapists it is our job to help them get it. Obviously, that
therapeutic work is complex; it demands our most thoughtful theo-
rizing.
POWER AND PSYCHOTHERAPY

The psychotherapeutic situation differs from the rest of the medi-
cal situation in a crucial way: the distribution of power. The therapist
may be an expert, but she is not responsible for the outcome of the
therapy anything like as directly as other doctors are, even if they
are pharmacotherapists. Generally, doctors are accountable for the
success or failure of their treatment, within the constraints of profes-
sional expectations worked out, more or less, in decision trees and
medical protocols. Should a doctor deviate from a widely drawn but
nonetheless discernible path of treatment, failure of treatment
opens up the threat of suit.
The psychotherapeutic situation differs on exactly this point. Psy-
chotherapy is a conversation. It is dialectical; what either party does
depends on what the other does, and vice versa. The outcome is en-
tirely unpredictable from either point of view. More explicitly, in psy-
chotherapy patients should understand from the beginning that it is
they who must make the changes, decide the hard issues, steer the
course of their lives into a future that they are accountable for.
The point of the psychotherapy is not to introduce into the pati-
ent’s life a cause, such as a chemical whose effect is more or less
known. The point of therapy by conversation is to clarify the options.
Such options have meanings within the patient’s repertoire of mean-
ings, beginning with a “presenting problem.” But to clarify options in
the face of a problem is to expand our understanding of the origin
and destiny of that problem, and of one’s life.
Every therapist has his or her own way of performing this service.
The one presented here is only one way of talking about it. It depends
heavily on the notion of narrative. The initial questions in the life of
any patient are “Who have I been?” and “Who am I to become?” Both
questions are sufficiently complex that their exploration is not a
brief matter. The present is seen here as a point that emerges from a
history and aims for a future. Specifications of this history and this
future are bound to be moments of personal revelation for anyone,
but the crucial point of therapy engages the now, within which re-
side both remembering and anticipating.
What happens in the always advancing “present” of therapy is a
clarification of a history that defines constraints. This clarification
leads to some decisions about the future. Am I committed to those
constraints, to the particular future they entail? Both history and fu-
ture can be redefined; personal freedom is real. It cannot change the
past, but it can change its meaning. Different narratives can explain
any group of facts. Personal freedom does not completely control the
future, but it can certainly determine much of it.
Of course, no person exists outside a network of relationships, and
everyone has several ways of seeing him- or herself as a part of sev-
eral groups of “we.” Who are we, and who are we to become? This
sense of oneself as a part of a relationship, family, profession, or
group of any kind must be taken seriously in psychotherapy as well.
Hence we might envision the following table, which names areas of
therapeutic work:
Table 1
Questions within Therapeutic Work
Past Future
Personal Who have I been? Who am I to become?
Collective Who have we been? Who are we to become?
Each of the cells of this matrix names an occasion for reflective

work, which is the stuff of psychotherapy. Starting at the top and
moving from the past to the future, one engages important moral is-
sues about who to be. Proceeding clockwise, moving from the per-
sonal to the collective, other important issues surface. Moral issues
emerge from collective interpretations of the past, which constrain
us somewhat but always can be reinterpreted. Such decisions as
how to interpret the past and how to interpret one’s relation to col-
lective contexts in the real world are the work of psychotherapy (see
Table 2).
The therapist is not an authority. The patient is the authority in
these interpretations, but the therapist does have the obligation to
question interpretations he or she does not understand or agree
with. In the end, the final decisions all belong to the patient.
Table 2
Issues within Therapeutic Work
Past Future
Personal identity goals
Collective tradition relationships
This conversation moves from where the patient begins, through

the past, one’s “identity,” “goals,” “relationships,” and “traditions,”
which are made up of values and options in an order impossible to
predict. No one can tell therefore, except in very general terms,
whether the therapy is a success—no one, that is, except the patient,
who takes full responsibility for the outcome of therapy. It is really
not a medical procedure at all.
Any hour of therapy can begin anywhere. We may begin to explore
my “identity” with an intention of making a decision about my goals
for the future. Ultimate issues—about why, and so on—are drawn
closer with these reflections. One’s intention to be someone is always
open to revision; this is the question of who I am to become. But the
answer does not exist apart from its effect on people who matter to
me. My personal goals inevitably engage my relationships. Becom-
ing one or another person may or may not be good for some other or
others who care about me and whose opinion I care about, but I can
chose not to care about them in the future.
Relationships have a history. Writ large, such a history is a set of
shared values, a common narrative, a sense of common purpose. The
move, then, from relationships to tradition is inevitable. But tradi-
tion engages me in the past in certain ways that I may want to
change, once I understand what happened in my history. This line re-
peats the issue of my identity once again.
Psychotherapy is never neatly sequential in any simple way, but
these touchstones of the process demonstrate that psychotherapy is
not like the rest of medicine, not like the most medical part of psy-
chiatry, pharmacotherapy. A pharmacotherapist is truly unlikely to
ask you to deal with ultimate issues; a psychotherapist is obliged to
do so.
Note that human free will is taken seriously in psychotherapy.
Free will remains in vestigial form in other branches of medicine as
well, insofar as the patient is free (unless declared incompetent) to
follow or not to follow the doctor’s orders. But in most medicine, and
particularly in psychopharmacology, the theory is a theory of neuro-
chemistry, thoroughly scientific and deterministic in its format and
language. The practice nevertheless must sometimes engage theo-

ries and strategies to engage human freedom, as when I ask what pa-
tients want or who they want to become.
THE CASE OF ROB

The title of this chapter is intended to suggest that a self is a nar-
rative. So also is therapy, and so also science.3 This thought still re-
mains new in much psychological thinking. I would like to begin with
a description of a person with a problem, a description that I hope
will demonstrate how the problem came from his particular world
design and from the narrative of himself within that world. What is
important about this story of therapy is the client’s way of posing
problems. The therapy was oriented to narrative and coherence, and
later to ultimacy. Its effectiveness was not in supplying answers but
in posing questions.
In the center of one’s narrative is self; thus, we refer to a “narrative
self.” The narrative self has storylike properties that make it cohere,
that thematize it around a center or around a cluster of centers that
themselves make a pattern. Narratives make events intelligible by
placing events into a context where they have meaning, thus making
one’s everyday personal experience coherent and confirming the co-
herence of the background with which it fits. We turn now to a man, a
self, a narrative, and a therapy.
Rob was a confident man, but he was in a bind. He thought he
loved Ali, and yet he couldn’t quite stop “flying off the handle” at her,
frustrating himself and frightening her. He identified his temper as
his worst enemy, which made the problem his and not hers. This was
a promising beginning, but it soon became clear that Rob did not see
himself very clearly at all, nor did he know what was wrong. Much
more than his “temper” was at stake in his relation with Ali.
My first conversation with Rob was an opening session of marital
therapy. The two of them were just beginning to agree that their mar-
riage was in trouble. Rob was eager to talk, so I began by inviting him
to tell me “the story.” Although Rob and Ali were both nervous about
seeing me, this invitation put Rob and me into a kind of partnership,
where we both could look at “the story,” an object we examined to-
gether (see Freedman and Combs, 1996). With Ali listening pa-
tiently, he told me of recent conflicts with her, of her parents’
intervening on her side, and his resulting feeling that people were
ganging up on him. The atmosphere of this opening conversation
was intentionally collaborative, and it seemed to help him to relax.
He was glad that his version of the story was not being challenged by
other versions of the story—which is what he had experienced when

he and Ali talked to their minister.
When I asked Rob what his goals were, what he wanted out of life,
I could see that he was not attuned to ultimate issues. His reflections
were limited to his marriage and its problems. He clearly demanded
Ali’s attention and affection, and he could not seem to accept her re-
luctance to give them. Later, I also learned, from talking with them
together, that she had originally enjoyed giving herself to him but
that in recent years giving affection had become a rather grim duty.
She persevered for a while, even though her efforts lacked warmth,
which eventually dawned on him and then infuriated him. That did
not, however, lessen his demand for affection, and he wanted it of-
fered “with feeling.”
In the course of their not-always-calm discussions during therapy,
he at one point described or implied that these obligations were her
payment for his providing for her financially. She was insulted by his
understanding of their relationship as at best a financial transac-
tion; whenever she confronted him with this idea, he would become
even more sullen and explosive. My first hypothesis was that Rob’s
sense of his own life’s story was coherent, even though he was deaf to
ultimacy, as could be seen from how it followed a tit-for-tat, or com-
mercial, format.
Ali was not present for most of the therapy with Rob, for he agreed
with Ali after a few sessions that he was the one who needed to
change. After getting to know Rob somewhat better, it became clear
to me that the financial format of their relationship was a recent in-
vention by him, an attempt to mobilize her obligation to him, and
that it had little to do with how he really felt or how the relationship
developed. His narrative of their relationship was cast in those
terms only after an earlier narrative collapsed—a crisis in narrative
coherence (Holma & Aaltonen, 1995).
The earlier narrative had been with him for many years, and he
had constructed his marriage within it, although without explicit ar-
ticulation to either himself or to Ali. This collapsed marital narrative
was an incongruent part of his larger narrative self, which had been
a success story and still was, with respect to his employment and
other social contexts. Its collapse in his marriage had been the occa-
sion of considerable feelings of incoherence and, certainly, failure, ex-
periences he had rarely had before.
His earlier and more stable narrative had cast him in the role of an
attractive, in fact irresistible, person, whose charm and cleverness
could open any door. Grades in school, sexual successes as an adoles-
cent, admission to college and to his fraternity, his job and promo-
tions, all were understood by him as evidence of his extraordinary
attractiveness and (well-deserved) privilege. His whirlwind ro-
mance with Ali had seemed another chapter in his coherent life, with
the same theme. So also had their marriage, which he saw as proof of
his generous willingness to favor Ali, even though, he thought, he
could have had any woman he wanted. Without ever telling her so,
but nonetheless assuming that she agreed, Rob had begun adult-
hood and marriage believing that this was the story of his life.
THEORY
In therapy we could have talked about his childhood, where much
of this narrative had been learned; or about his marriage, where it
proved so ineffective; or about the self-concept that informed his be-
havior. None of these were irrelevant, but the center of Rob’s experi-
enced coherence was the narrative itself. Rob’s narrative self was
adept at overcoming obstacles through his unusual charm, talent,
and energy. His marital problems were an anomaly.
If there were traumas against which this narrative was a defense,
or losses for which it was a compensation, these origins were not as
central as the story itself, of his life itself, as he himself understood it.
It was possible to work at that story without spending much time
with these losses and traumas. When they came up, they did so not as
insight into the origins of his narrative but as testimonies to its lon-
gevity, ultimately going back to before he could remember. They were
also testimonies to the success of the narrative in helping him to re-
gain a coherent sense of self in the face of such traumas and losses.
In our early conversations, but after Ali left the therapy, we articu-
lated the narrative and examined it as an object, or, as Freedman &
Combs (1996) have it, we “objectified the narrative.”4 In the process,
he discovered that his narrative themes of charm and success were
now irrelevant to his life. This was a major incoherence. Now that it
was an object for our examination, his coherent narrative ceased be-
ing merely a set of assumptions about life that guided his decisions.
We began to see that the coherence of his life depended on maintain-
ing this narrative. Other narratives simply were not as important.
As Rob began to see this, Ali became more independent, contradict-
ing this theme. His anxiety became more marked.
We might think theoretically at this point about his main “symp-
tom,” which was what we might call his “puzzlement” about what to
do with his sense of incoherence. He was free, as humans all are, to
behave with Ali as he wanted, to relate to her in his own terms. This
freedom, like all human freedom, had limits—what she expected

from him. Initially, she had seemed to receive what she ex-
pected—much attention, passionate intensity, and ardor. But com-
plicating this fact was another—that she also wanted to have her
wishes respected. Rob was, she had finally concluded, absolutely
deaf to them. Ali presented a reality that simply could not be assimi-
lated into Rob’s enactment of this narrative self. She needed him to
be someone else; he could not do so; the relationship faltered.
Sometimes people’s desires run into the stubbornness of “reality”
like this. Their sense of their freedom disappears in the face of what
seems an overwhelming reality. Like death and other existential
frustrations, the stubbornness of reality can leech away our sense of
ourselves as agents and authors of our own lives. Rob did not have
this problem: his sense of his own agency continued, side by side with
the stubborn resistance posed by Ali’s own sense of her life. On one
level, he saw this clearly. But he blamed her more than himself, so she
was the one who was “out of control.”
Blaming Ali, because she was out of his control, again threw into
question the soundness of his narrative self. For if he considered the
possibility that Ali was not to blame, more than his marriage would
be at stake; his narrative self would be at stake. Rob drew on his
pride to overcome obstacles to seeing what his narrative self really
was. He was also able to see that his narrative self, always successful
by virtue of its inherent cleverness and energy, was now faced with a
very vivid failure. This incoherence interested him as an adversary
to overcome. I would say, looking back at this therapy, that Rob was
arrogantly approaching the limits of arrogance. That might be a first
step in seeing the virtue of humility.
My approach to the therapy at the level of his self-narrative was
not the only possibility.5 We could have worked through the feelings
that were left over from his traumatic relation to his father, who had
punished him often and made rewards therefore seem so much more
powerful. He came to idealize his father’s wisdom, consistency, and
strength—all of which had been lost, in Rob’s eyes, when his father
had left his mother; or we could have explored the sense of entitle-
ment that had emerged from his mother’s always promising him that
the world would love him; or how much he resented the birth of his
baby sister when he was four; and so on.
Each of these led to a part of the puzzle of contemporary Rob, with
his longing, his intolerance of being denied, his presumption of being
among the best and brightest on earth. In time we would have been
able to add together all of these feelings from the past, how they
played into the coherence of his current life, one by one. We might
have been able to shine the light of rational assessment on his sense
of entitlement, which he experienced as a justified reaction in the
face of a world that is unyielding and stingy.
But the narrative self summarized all these and had an immedi-
ate, if not explicit or consciously realized, guiding role in the destruc-
tion of his own marriage. The fact that Ali was not as generous as his
mother was not irrelevant, but we didn’t dwell on his mother. His
mother’s relevance manifested itself in his relationship to Ali, which
in turn was controlled by the narrative self that justified even his
temper outbursts. Mother loomed large in the history, but Ali loomed
large in his life now. His current narrative self had ceased being co-
herent, but he could change that narrative self, and he could do much
of this work without exploring his relation to his mother. In fact, the
focus on the present was the only reason why mother mattered at all.
If that focus on the present could change without dealing with
mother, and if that change could affect something as central as his
self-narrative, we could design our therapy to do just that.
THERAPY
In fact, mother and father did come up in the therapy, and consid-
erable progress was made in thinking about them. Their role, how-
ever, was not as perpetrators of trauma or deprivers of something
crucial. It was instead as coauthors of the narrative self that had
made him who he had been all those years before his crisis in the
marriage. That crisis was initially seen by him as a matter of unrea-
sonable demands by Ali. Once it became clear to both of us that he
had made unreasonable demands in the marriage, we were able to
deal with why he expected what he did from her. We explored several
earlier relationships, first as his examples of expectations that were
not unreasonable, and later as examples of relationships with a re-
petitive pattern that suggested they were, exactly, unreasonable.
Before Ali, Sandra had been important as a kind of confirmation of
his narrative self, for she had seemed to appreciate all that he did for
her. Not surprisingly, Sandra was enormously insecure and his at-
tention alone, regardless of his demands, was enough to make her
love him. But “love” itself came to be ambiguous to both of them when
she had the audacity to get pregnant. At his urging she received an
abortion, only to face his change of heart. The now-lost child was now
to him what he was to his father and mother, an irreplaceable treas-
ure, infinitely valuable, and so on. He found it more and more diffi-
cult to blame Sandra for the pregnancy, but he now came to blame
her for the abortion.
Confronted with this contradiction, Rob had had an opportunity
in this relationship to turn his attention to his narrative self and to
explore what, ultimately, was important. His evasion of ultimacy,
however, was hardly surprising; Sandra had not really been the
woman for him anyway. It was fairly easy, in this case, to lose her and
blame her for having bothered him in the first place.
Rob had never quite told this story before but rather had avoided
talking about what, to him, was simply “one of those mistakes.” His
telling me the story became a matter of considerable discomfort for
him when I asked simple questions about how she had felt. He came
to realize that he had never really understood her except as a minor
character in the master plot of his life. This was indeed the coherent
story he settled for as he began his relationship with Ali.
Ali certainly knew enough early on not to discuss in detail Sandra
and her story, but later, as they were negotiating their divorce, she did
tell him of her thoughts about Sandra and how unjustly Sandra had
been treated. Were it not for the therapy, Rob would have seen this as
merely additional misunderstanding by Ali. In light of what he had
discovered in the therapy (that he had never taken Sandra’s experi-
ence seriously), Rob had to consider the possibility that he was the
cause of the failure of his relationship with Sandra. He tried to con-
sider the possibility that he had also treated Ali in this way, but his an-
ger at her and his defensiveness in protecting his self-narrative
prevented him from saving the relationship with Ali, which may have
been too badly damaged anyway.
THE CREATION OF COHERENCE

The most central moment in Rob’s therapy was his creation of a
new coherence in the therapy. That is, who Rob has been, is, and aims
to be all changed during this therapy. The self-narrative that had
made coherent to him his success on the job and in his studies did not
explain his failure in relationships. In order to live with his failures
in relationships, he would have to change the story of his life—a
story of talent, energy, and success. I have to admit that I was not par-
ticularly fond of Rob; I could easily see how both Sandra and Ali, af-
ter their initial attraction, had been disillusioned. He could not. He
saw coherence where I saw incoherence. The maintenance of his co-
herence required that he simply dismiss their views; I saw that he
needed to give up this maintenance in order to change.
One question that occurred to me early in the therapy was his

sense of others’ perception of him, and how it was filtered, indeed
shaped and changed, by what he thought of himself. What to them
was egocentric and cold was to him strong and admirable. This was
not simply a case of not understanding women, as he liked to put it. It
was a case of dismissing, instead of understanding, people, particu-
larly women, and above all their view of him.
The therapeutic task became, first, to get him to experience the
lack of fit between his view and that of others. This would require a
breakup of the coherence of his self-narrative, and it would motivate
him in his second task, to reconstruct that coherence, not by dismiss-
ing others but by (1) taking them seriously, (2) experiencing the inco-
herence of his narrative and theirs, and (3) working on how to
recreate his narrative self in a way that required neither dismissing
them nor staying the same.
In a word, Rob needed to reinvent himself; he needed to see that
the narrative self he had lived caused trouble, for others and for him.
He needed to change his narrative self, from the one who knows how
to be a man to one who does not, so that it was no longer dissonant
with others’ view of him. From there, it would become necessary for
him to change who he was as a man.
I therefore engaged Rob in an extended fantasy, one that bridged
several of our sessions in the third month of therapy. “Imagine that
you are your secretary, Carla. Tell me what she sees when she sees
you; tell me how you feel about what she sees; support your conclu-
sions with actual evidence from your life in the office where you
work.” Rob began this game with great confidence, for he really had
no doubt that his secretary was full of admiration for him, and he
even believed that he knew why. However, once this game began,
Carla changed in his estimation. She became much more important;
he thought of her when he was not in the office, which was quite un-
heard of. He began to wonder what she did with her husband, whom
he had met only briefly and had not known, or cared to know, at all.
How did he stack up in her estimation? Was he a “better man” than
her husband? His early efforts to carry out this line of fantasy put
him into a competition with Melvin, Carla’s husband; he even imag-
ined himself as this man’s boss as well as Carla’s. I did not appreciate
how important his secretary’s husband had become until he shared
with me a dream that he was in a boxing ring; there was a big crowd,
cheering, and his opponent was this very man. Dreams sometimes
seem random, of course, but in this case his reluctance to explain
why he imagined such a vivid competition with Melvin persuaded
me that his desire to avoid the topic was out of step with his usual co-
operative attitude in therapy.
Although it did not appear in the therapy, I would not have been
surprised to hear of such a dream about me. In fact, my first thought
about this particular dream was that it really was about me, not
about Melvin. But in fact, I had (for the time being) escaped the ad-
versary role, partly because, I suppose, I had unwittingly put his sec-
retary’s husband so inevitably into that role. Rob was also
surprised—and then not surprised, and then surprised again—that
he was not faring well in the ring.
The initial surprise was because he was sure he was stronger than
Melvin. On second thought, Melvin may have seemed a threat in
terms of the fantasy he was authoring about his secretary’s view of
him. But later this dream shifted its scene to a gunfight, and, Rob re-
ported, in the dream he felt real fear that he would be killed. Why
was an imagined competition for the admiration of his secretary so
important to him as to feel like a threat of death?
Meanwhile, at the office, Rob became much more considerate of
Carla’s feelings, her convenience, and so on. Since he had treated her
very much like a servant, even a little human concern would have
been noticeable to her—and to him. He was, he insisted, the first to
notice it—again dismissing her point of view and assuming his domi-
nance.
Why was seeing Carla and Melvin so provocative for the therapy?
His narrative self defined what he saw, thought, felt, and understood.
Thus Rob and I created an intentional fantasy of a competition with
Melvin for Carla’s love. It became an exercise. How would she feel?
How could he control this? What would Melvin feel? And so on. Dur-
ing this period Rob also saw Carla and her husband at a nightclub,
and they seemed to be having a nice time dancing. He reported in-
tense jealousy—rage, in fact—at Melvin, without mentioning
(again) his secretary.
He was proud of the fact that he rarely learned from anyone else. I
had originally thought of this fantasy as a way for Rob to place him-
self into a life space somewhat different from his usual one. Typically,
he assumed himself to be the center of everyone’s perception. He
learned from his experience, but not from anyone else’s. I wanted him
to change the structure of his world from a single-centered one to a
multicentered one, and I wanted him to see that his self-narrative
failed to give anyone else, especially women, any credit for teaching
him anything or for having a point of view worth attending to. Before
the dream I had not heard much about Carla; I had learned of her
only because he had been annoyed at her missing a day of work.
The fantasy exercise was easy at first for Rob. It mirrored earlier
fantasies of women, whose obvious consciousness was one of admira-
tion of him. The extended nature of this fantasy, however, forced him
to think of Carla differently from how he usually perceived women.
She had married Melvin, and she may even have loved him. How
would that affect her view of himself? He had to make Carla into a
person with a life of her own; she seemed to prefer her husband to
himself. The boxing match and the gunfight both gained meaning
in the fantasy. Rob himself was surprised at how complicated life
really is.
His narrative of himself, however, did not easily become, in this ex-
ercise, a story with more than one point of view. As a narrator of his
life, he was of course the main character, but for the first time I was in
a position to force him to include other voices in his narrative. That
Carla thought he was terrific as a boss suddenly came into question.
Did he really know what she thought? No, nor had he really cared.
Was this the same problem that appeared in his relationships with
Sandra and Ali? Again, Rob resisted admitting these things. The
only safe question for him was why it became a life-and-death matter
in his dream. Rob’s answer: he was proud of not being afraid of dying.
There may have been some sense in which his life was unreward-
ing enough that he would not have minded dying, but I didn’t believe
that he did not fear death. I believed instead that the boxing match
had become a potentially lethal gunfight because he sensed that the
stakes here were very high indeed. Rob himself gave me the opportu-
nity to explore this issue, or rather a friend of his did. His friend died.
Rob went to the funeral. He realized he was not afraid of dying: so he
told himself, and me. I asked him to walk me through his attendance
at the funeral, the sights, smells, sounds, thoughts, feelings, seeing
the strangers cry, seeing his friend’s dead body—everything. He did
so. I then asked him to tell me what it was like from his dead friend’s
point of view.
I had never before produced a panic attack in my office as a rou-
tine part of psychotherapy. Rob looked at me, then stared past me,
then had trouble catching his breath, then gripped his chair, knuck-
les white, every muscle tense; he found himself terrified of dying. I
waited him out. It took some minutes for him to relax enough to
speak. His sentences were interrupted by sobs that surprised me as
much as him. I asked him if it was his friend he was crying for, and he
managed to blurt out, “No!” I continued to wait. He never told me out-
right that it was his own death that frightened him, but he knew that
I knew, and I knew that he knew that I knew. It was enough.
One incoherence in Rob’s narrative self and daily experience came
from his inability to recognize the point of view of other people.
Whatever particular slant they might have was always unavailable
to him, because he never asked about others’ experiences of any-
thing. His own experience was, for him, definitive. This style continu-
ally produced surprises; Rob did not understand others’ comments
and behavior, and he therefore had to dismiss or denigrate them as
inferior to his own. As Rob began to come into an understanding of
these facts about his own life, it became apparent that his defense of
them was limited to the fact that they had always been so.
A second incoherence, a less obvious but more decisive one, came
from his panic at his reflection about death. I had not intended for
Rob to panic, or to confront so suddenly and dramatically his ulti-
mate vulnerability, but the reflection about death, combined with his
realization that he had forever failed to take others seriously, seemed
to make something in his narrative self collapse all at once. To be
sure, he recovered from the panic attack, but he could not recover the
arrogance that had protected him from taking seriously confronta-
tions with other people, and from confrontation with himself.
Rob’s none-too-rational dismissal of others and his failure to see
himself clearly were related. Most of us see ourselves through others’
eyes, thus confirming, little by little but continuously, a narrative
self. Rob’s experience had to select carefully from what others fed
back to him, a dogmatic style that was shaken loose only when Ali
created a vivid incoherence in his narrative self, and when he suf-
fered a kind of collapse upon confronting death. Neither alone could
have precipitated such a crisis, but together they forced him to
change.
The ultimacy that attacked his narrative self was sparked by the
funeral. Death is a common event on television and in newspapers,
and we are right to suspect a certain popular taste for the topic, a
taste that sells tabloids, murder stories, and war movies. That taste
is, I believe, counterphobic, by which I mean that its appearance in
these media rehearses our dismissal of ultimacy, thus making life
less profound, perhaps, but certainly less risky. The “safety” of my
narrative self after seeing an admired war hero die in a movie helps
me to recover, and to protect myself, from a realization of my mortal-
ity.6
Rob’s parents had been, in their mutual conflict, careful to outdo
one another in praising him for everything. His father particularly
led him to believe that he, like all the men in the family, was destined
for great things. He recalled that he had been important in the fifth
grade to his female classmates, acting as their counselor as they
struggled through the tribulations of fifth-grade romance. Only
later did his wisdom (in his own eyes) turn into confidence in the face
of girls and eventually into trust in his own charm.
Rob remembered wondering if the battling between his parents
had been a bad sign; their battles had sometimes frightened him. His
consolation: he had been why they stayed together, for he had been
too valuable to inflict with a broken family. Inside every bad feeling
was a silver lining, which Rob learned to find—and to live on.
His narrative self remained coherent as long as he was able to in-
terpret events in terms of how good he was, and he learned to dismiss
information that would have corrected what was becoming a very
presumptuous self-assurance. Maintaining coherence became the
basis for selecting information from others, and eventually he proc-
essed only that which confirmed his extravagant self-image. He
learned to reject readily opinions that were not consistent with his
sense of himself. He became his own authority on all matters having
to do with what sort of person he was. Coherence was rarely chal-
lenged, until Ali proved intractable, at which point she too was dis-
missed.
In a way, therapy did not do what he wanted it to do. It did not con-
firm all this history that informed him who he was. In the course of
our work, I sometimes focused on particular words that populated
his self-description. For example, as a “winner” he found the loss of
his marriage very painful. He could, of course, dismiss it and Ali and
all she said, except that he came to see that her view, while different
from his, had nevertheless won.
“I really see now that she is right to be so mad at me.” That led me
to point out that this must be a new experience for “a winner.” The
“story” of his life was full of such terms (“the best,” “trend setter,”
“natural leader”); so we listed them, thought about their origins,
why he had adopted them, why other people generally did not, and
so on. The very language of his narrative self contained the content
of his bias—in fact, his gross error—in his self-concept. There is a
way in which the analysis of the language of his self-narrative re-
sembled a postmodern critique of language that contains a bias
(even though unrecognized) and manipulates others (even though
unconsciously) in the pursuit of self-serving goals (even though un-
acknowledged).
NOTES
1. This commonsense orientation has been pulled into vivid focus in a
book by Martin Seligman, president of the American Psychological Asso-
ciation. See Seligman (1994).
2. James Hillman (1975) uses this term to describe the process of revi-
sion in its more ultimate sense of the “vision,” or envisionment, we have of
life as a whole.
3. Science is sometimes taken to be a collection of facts. The best com-
mentators on science, however, such as Sacks (1970), Hughes (1964), and
Kuhn (1972), insist that science is a narrative of human scientific work,
never really completed, always indebted to its history, and always enlarg-
ing its story.
4. Self-objectification was central to my earliest theoretical work
(Keen, 1970). It led me to an entire psychology. I have in the three decades
since then seen many versions. Certainly one of the best is the absolutely
stunning vision of the self as spectator and the body as specimen, in Roma-
nyshyn (1989). It is from reading that book that I have come to see the fol-
lowing: The heart is a pump; it can break down. I have experienced broken
pumps. I can also experience a broken heart in unrequited love. The two
hearts refer to one another, but from within separate universes. In the dif-
ference and the distance between these two universes lies a space of hu-
man confusion. Between them lies the seeming impossibilities (1) of it
being both, and (2) of being either without the other. What is the human
heart? In our experience, from which this difference comes, we experience
our bodies, of course, as both, but never simultaneously.
5. Sources for narrative explorations in psychology are numerous, be-
ginning with Sarbin (1986), Kleinman (1988b), Polkinghorne (1988), and
extending to Omer and Alon (1997), among many others.
6. I recall reading Sartre’s short stories as a college student, and later
the reflections of R. D. Laing (1967). I was terrified by these books, but I
also felt enormously attracted to them, and eventually more confident for
having taken death seriously. Such novels and films attract and repel in a
way more complex than “ambivalence”—feeling two ways at once about
the same thing. The experience of surviving the fear of death leads us to a
kind of distancing from both. This “strengthens” us in the sense of increas-
ing our tolerance, even as it “weakens” us in the sense of closing off from us
the reality of human mortality.
CHAPTER 6
Discourse, Therapy, and

Science
DISCOURSE ANALYSIS AS PSYCHOTHERAPY

The analysis of discourse, which we see as a “postmodern” critique of
knowledge, explores ways in which power corrupts knowledge.1 The
corruption of knowledge has always been an issue. During the last two
or three centuries, often called “the modern era,” we have assigned sci-
ence the task of solving that problem. It is only now, after a couple of
centuries, that the old issue of the corruption of knowledge has again
become current for nonphilosophers. We now have a “postmodern” cri-
tique of knowledge, especially of its slogan of “objectivity.”
The critique of the myth of “objective truth” is, of course, a very dif-
ferent project from the critique of the coherent narrative in Rob’s ex-
perience and life. Yet our understanding of Rob and his story can be
elaborated by what postmodern theorists call “discourse analysis.”
The point of discourse analysis is to bring into focus the historical
forces that shape how we ask and how we state things, and how these
particular uses of language serve social interests and forces. Rob, like
all of us, is a “culture of one” (embedded, as all cultures are, in a larger
context) who has a particular way of casting facts and ideas into dis-
course. Like a culture’s ethnocentric bias, this way amounts to a subtle
but powerful means of self- aggrandizement and self-justification.
A COMPARISON
In light of this kind of analysis, we may scrutinize the mispercep-
tions and discursive slant (these go together) in Rob’s style and com-
pare it to the issue of whether objective truth can be known by

methods of science. Is there a scientific subculture that benefits from
the supposed power of science to define mental health? We won’t
elaborate an answer to this question, but others have, most notably
Szasz (1961, 1970, 1987). The subculture in question is the science,
ideology, and profession of psychiatry. Of course, it is important that
science can combat personal biases. However, equally importantly,
science is less effective with collective and institutional biases—for
it is one. This postmodern critique points to the fact that individual
observers can follow exactly the rules of science and still be biased,
because science itself is a bias. But we can see this only by pointing
out peculiarities in scientific language.
Scientific language, for example, is always impersonal. Rob’s self-
description, in contrast, is always personal. Yet what he says may, in
important ways, be true. It is certainly true to his experience; at no
point does Rob lie. If he is wrong, it will have to be shown to him in
some way.
The point of psychotherapy is about an individual’s mental con-
structions, in the same way that science represents the world in
mental constructions. In Rob’s case, we wish to expose, as science ex-
poses, a slant that creates a limitation or error in knowledge. The
parallel slant to be exposed in treating Rob resides in his self-
narrative. Exposing such slants appears by science of common sense,
in the critique of science by postmodern writers, in Rob’s self-
narrative, and in the therapeutic treatment of that narrative.
In fact, the self-critical project of individual psychotherapy preceded
discourse analysis, and in some measure perhaps inspired it. We must,
however, note that the history of philosophy is a history of criticism, of
self, of tradition, of tradition in self and of self in tradition. So the so-
called “postmodern” project isn’t as new as it sometimes seems. Never-
theless, reflective self-criticism, at either the personal or cultural level,
is always a worthy struggle, an impulse toward truth, however vaguely
sensed or intuited. This commonality between psychotherapy and a cri-
tique of objectivity suggests commonality between psychotherapy and
postmodern discourse analysis.
Our cultural faith in science produces socially shared arrogance,
and also error that becomes invisible. That faith suggests that the
scientific method guarantees objective truth. There was, of course,
even early in the establishment of modern science, a reflective
awareness of the possibility of error in science. The elaborate meth-
ods of science are designed exactly to prevent bias and error. This
DISCOURSE, THERAPY, AND SCIENCE 85
was an attempt to institutionalize self-correction in science. Post-

modern critiques continue that effort. Psychotherapy is analogous.
WHAT CAN SCIENCE OFFER PSYCHOTHERAPY?

In psychotherapy, the provoking of such reflective awareness may
be entirely new in the experience of the patient. One’s personal style
may well lead one to rush to interpret in one’s usual ways whatever
happens. Often, we see events as confirming what we simply assume
to be true, to have always been true, and to be more or less beyond
question. In Rob’s case, in a way strikingly similar to the phenomena
of scientific discovery, only symptoms of incoherence provoked such
questioning. The first contribution science makes to psychotherapy
is thus the sense that our picture of the world, in its various compart-
ments, can tolerate only so much inconsistency.
In its effort to be self-critical and self-correcting, science depends
on skepticism, which appears also in psychotherapy, but in much at-
tenuated form. But both can fail to process self-correcting data. Both
can come to take their respective successes too much for granted. Sci-
entific knowledge, its self-critical tradition notwithstanding, has
sometimes come to be as confident as Rob was arrogant. Just as Rob
clearly worked hard to sustain the self-narrative to which he had be-
come accustomed, science tends sometimes to ward off critical reflec-
tion. The defense in Rob’s case is very personal; his self-narrative
confirms itself; his arrogance confirms his arrogance. The defense in
the case of objective science is less personal than social and institu-
tional. Scientists need one another’s support when under attack; en-
tire institutions can be mobilized in defense of science, at least
among scientists. When L. Ron Hubbard (whom I have no desire to
support, but whom I mention as a case in point) attacked Prozac as a
fraud, entire corporations and much of the medical profession
rushed to defend science.
Again, somewhat like science might approach it, in psychotherapy
with Rob I was able to undermine his arrogance by engaging his
pride in his ability to solve the incoherence that his destroyed mar-
riage confronted him with. This is a second striking similarity be-
tween science and psychotherapy. I was also able to do so without
mobilizing his usual blaming reaction, because I could engage his in-
terest in his own incoherence. I could, in other words, not only appeal
to notions of “objectivity” in helping him to get distance on himself
but could in fact ask him to “be scientific.” That is, I could lead him to
look at the data and ask himself what it meant that Ali had left him,
bypassing the clearly unscientific assumption that it was somehow

all her fault.
Therefore, we see at least two similarities between psychotherapy
and science: first, the crucial role of incoherence as a signal of error;
and second, the proud intolerance of such error, which in turn moti-
vates reflective rethinking of what is thought to be true. This con-
firms that psychotherapy and science share a crucial meta-
theoretical impulse.
Science has a prior commitment to mastering incongruities, re-
solving unresolved questions, and restoring the coherence of the tra-
ditional scientific framework. Like Rob, science sometimes falsifies
its own history, attributing perspicacity to earlier views and over-
looking the limits of its perspective. But coming to see earlier views
as wrong is nonetheless commonplace in science; scientists are
proud to claim that they face the incoherence of knowledge rather
than deny its relevance.
HOW DOES PSYCHOTHERAPY WORK?

When faced with someone like Rob, what must the therapist do,
and not do? As his therapist, I certainly had my opinions of him early
on. I could see his arrogance and how it had poisoned most of his rela-
tionships and much else in his life. I really had little doubt I was right
about these things. But I did not behave as if I knew the truth. Here I
have to admit to a bit of bad faith; I pretended to withhold judgment
about something I was, in my own mind, making plenty of judgments
about. I did not, however, tell him everything I thought. (Nor did he,
of course, tell me everything he thought.)
I knew that he had heard such judgments before, and I knew it
was much better for him to come to see for himself what I could
clearly see. All I could do, and all I needed to do, was to pose ques-
tions. Any pretense of knowing the truth would certainly provoke
him to resist proudly or to ask me to tell him the solution to his prob-
lems. Were I to do either, I would be doing bad therapy. He needed to
speak the truth, from the vantage point of his own struggles, not hear
it from the quarter of my presumed wisdom and authority.
Of course, no therapist is merely passive. I did have authority, or
he would hardly have trusted me with his story. The crucial achieve-
ment in psychotherapy is to engage the client in the task of trying to
improve the story he tells himself about who he is. I therefore fur-
thered the cause of therapy by sharing, and telling him that I was
sharing, authority with him—we were in this together. I couldn’t do
my work without trusting his authority. He was the one whose expe-
rience had to be pulled into focus, and only he knew what that experi-
ence was.
Of course I had my experience of him, and he was not uninterested
in what it was, but if he was to know my experience, it had to be di-
vorced from my authority. My view was not right because of author-
ity; if it was right, he had to say so. If it was different from his view,
then we had to see that difference not as one wrong view and one
right view but rather merely as a consequence of the fact that per-
spectives, visions, interpretations always vary between different ob-
servers. Also we had to discuss the difference.
This does not mean that he couldn’t learn from me, or that we
couldn’t learn from one another. It means only that in such a case
there are two teachers and two learners, and that they pool their
knowledge to come up with a view of the truth that is an improve-
ment on either perspective alone. This implicit or explicit agreement
is a necessary agreement in psychotherapy. I can honestly say that
everything I know about Rob I learned from him. To be sure, I have
listened to many people, and that listening is more or less present to
me as I listen to him, but he too has listened to others, who are part of
his way of listening to me. The fact is that neither of us had a privi-
leged position from which truth can be claimed. Each of us knew
something the other did not. Together, we could both learn. Therapy
must be such a two-way street, or it could be done by listening to lec-
tures.
All this learning has to do with what the person is like and how he
would like to be. These are questions of possibilities and actualities,
and in coming to explore them he acquires a new sense of who to be
and to become. These are the main issues in therapy, and as in sci-
ence, they focus on questions of what the person is. Both science and
psychotherapy explore this “what,” against a backdrop that usually
remains unexplored.
What I am and who I am to become are dwarfed by the prior but in-
tellectually neglected fact that I am. That I am is a different kind of
issue. It cuts beneath questions of what I am (so-called questions of
“essence,” to use the philosophical term) to approach the prior fact
that I am, an existential (rather than essential) issue (see, for more
discussion, Keen, 1970).
The most important, and most neglected, common feature of na-
ture explored by science, and of our patients explored in therapy, is
that we are. In the face of this fact, our attitude usually retreats to
the interrogative (What is my life?), as it does in science (What is na-
ture?). But more crucial than this interrogation is an appreciation
that nature is and that we are. This appreciation is rare among scien-
tists, therapists, and patients. It humbles us. It dwarfs us. It leads us
from curiosity and manipulative hopes and plans to a kind of re-
spect, if not reverence, in the face of there being anything, or anyone,
at all. This attitude signals the dimension of ultimacy.
I was able to help Rob to see the ultimacy in these issues. I was
able to pose the problem so that his pride, including the actual truth
of his own self-judgments, was at stake; he had to take it up. I was
able to provoke his sense of his own mortality, in the face of which his
defense of his arrogance was trivial. Once these things happen, a
therapist need do little more than watch the process unfold of its own
momentum.
WHAT CAN PSYCHOTHERAPY OFFER SCIENCE?

In order to explore further the spirit of science and of psychother-
apy, let us cast the issue in the following way. Let us suppose that the
therapist stands in relation to her client the way the scientist stands
in relation to nature. If we follow through this line of thought, suc-
cessful psychotherapy is a mutual listening, and successful science
may also require such a mutually respectful interaction.
If science could adopt that kind of mutual relationship with na-
ture, what and how would a scientist think? It goes perhaps without
saying that the dialogical situation of therapy is quite incongruent
with the scientific exploration of nature. In therapy I talk, the pati-
ent listens; the patient talks, and I listen. Therapy can be reciprocal,
balanced, dialogical. This seems to be an impossibility in science,
where only the scientist takes the initiative. The scientist wants to
know about nature, and he sets out to find out what he wants to
know. It is reasonably presumed by us all that nature is rather unin-
terested in knowing about us.
Certainly one of the cardinal errors of animism is to assume a re-
ciprocal relation to nature instead of a one-sided relationship. To
think otherwise is to read into nature versions of ourselves, to imag-
ine spirits who try to trick us, who tell us lies, or perhaps the truth.
Nature has no such personages. To see them is to be exactly prescien-
tific. Animism posits souls in trees and flowers, dogs and people,
which no scientist believes in, and rightly so insofar as he is thinking
scientifically. In what sense, then, can we continue this analogy with-
out positing what we now call the errors of animism?
I would suggest, however, that to imagine in nature intentionali-
ties analogous to our own is to stretch credulity no further than cur-
rent psychiatric theory does by claiming to understand the human
mind by understanding the chemicals in the brain. Intentionalities

can be imported into our perception of nature from the realm of hu-
man consciousness. This importing is a projecting of our properties
onto nature. Similarly, the causal mechanics of brain chemistry are
imported into human psychology from the realm of nature. Both are
justified heuristic strategies that explore possibilities heretofore not
obvious, although seeing the human organism (and even the human
mind) as nature is the more traditional projection.2
On the other hand, few psychiatrists are so clumsy as to neglect
the person who possesses the brain he is treating. If the literature of
psychopharmacology reduces mind to brain in this way (and it does),
it does not follow that psychiatric practice is so crude as to under-
stand my human experience solely the way science understands
forces in machines or chemicals in test tubes. Even the most
pressed-for-time general practitioner or primary-care physician
knows, when she prescribes medicine to reverse a chemical anomaly,
that she is treating a person and not a thing—even if she knows
rather more about what chemical events are thought to cause anxi-
ety than she does about the exigencies of her patient’s life.
Indeed, it is not clear that using the terms of mechanics and
chemical reactions to state what we understand in psychology or
psychiatry is entirely an error. Such language has been useful, to a
significant degree, even though it is reductionist (from mind to brain,
from dialogue to mechanics).
Therefore, let us try a thought experiment. Let us turn the tables
now and ask: Why do we reject an understanding of science as a dia-
logue with nature? If I tell myself a serotonin reuptake inhibitor in-
creases serotonergic activity and that this cures depression, am I not
reducing what was human experience to chemicals? Why not turn it
around? It could be said, with as much justification as a mechanistic
psychologist pronounces neuropsychological knowledge, that we
should “listen” to nature “speaking to us” in reading the data of our
own experiments.
As a scientist, I vary an independent variable in an experiment
and watch what happens. Nature responds to my initiative. Once I
believe that I understand that response, I do the next experiment,
the results of which will further confirm or disconfirm my growing
conviction that I understand nature. This much of the parallel is ob-
vious, and perhaps that is as far as it goes. Nature takes no initiative
to experiment with me; nature has no curiosity to see what I will
do—no consciousness (in the human sense) at all. Nature may be
“alive,” but it surely does not share human curiosity or our pride in
mastery and control. We see none of these things in nature, which we

conceptualize as mechanical, or at most organic, but not as mental.
Nature intends nothing with respect to us.
The inability to see analogues of our own mental life in nature has
been taken, for the three of four centuries of modern thought, as veri-
fying that we are different from nature. We know it; it does not know
us. When we treat it well, as in crop rotation or calculated harvest-
ing, it may “treat us well,” but that phrase is clearly metaphoric. Na-
ture doesn’t treat us at all. It simply responds as it does. It is always
the same; it has no moods, no feelings, no intentions. To see it as
merely mechanical may be an exaggeration of its nonhumanness,
but that does not signal that nature has anything like human inten-
tions. It did not intend to create us.
As we review our attitudes toward nature, we must be struck by
human arrogance. Since nature is not like us, we are “above” it. In the
worst case, we scoff at its inability to know us. But is our (human)
knowledge the only knowledge there is? When we make nature into
the object of our calculation, we do something to it that it cannot do to
us. But do we know what it “does” to us? Is nature’s relevance to our
lives limited to whether it can “do” to us what we “do” to it? Is that the
test of nature’s importance?3
When we catch ourselves believing that nature does not know us
and that this proves nature’s subordinate place in our calculations,
we catch ourselves in a most amazing blindness, a blindness to what
we do not, in fact, understand. What we call “nature” vastly outstrips
our understanding. We may be (finally) coming to see how vital it is
to “preserve” its “integrity” in order that our children will be able to
breathe and eat. But that, generally speaking, is as much respect as
we grant to nature.
The way we reduce nature to our own terms (knowing it without
its knowing us) pretends that human knowing is all the knowing
there is. Maybe nature “knows” in ways we don’t recognize. We do not
“know” (in human terms) very much about death, which is the point
at which nature reduces us to its terms. It is the nature in us that
makes us die, but we can make only very thin sense out of the inevi-
tability of our own death. To the extent that we make any sense of it
at all, it is the sense of nature, not the sense of the supposedly
“higher” being of which we are so proud, human consciousness. Lis-
ten to these not uncommon thoughts: “Had I my way, I would not die”;
or—“Well, I wouldn’t die young, but I wouldn’t want to get too old ei-
ther.” Human reckoning of the natural event of death is uncertain,
inconsistent, trivial, and stupid. It is scant evidence indeed for the

“higher” status of human knowledge and human existence.
What can psychotherapy offer science? I suggest two notable
items—first a little humility, and second an attunement to ultimacy.
In therapy, Rob’s, attunement with ultimacy cast an entirely differ-
ent light on our work together. He knew that I, like him, was mortal
but that it somehow did not affect me as it did him. This neglected
context of his life, his being subject to the contingencies of nature,
brought to his presenting self-aggrandizement a new realization of
its triviality.
SCIENCE AND DISCOURSE

Natural science speaks a scientific language, which is understood
to be a specialized version of natural language. Scientists have
rightly pointed to slants and prejudices embedded in natural lan-
guage; they are the slants and prejudices of a human community. As
a correction, scientific language is considerably more circumspect
about the terms it uses, and in fact it has created a discourse that has
some of the properties of natural language but does not have other of
its properties.
We might describe the difference in the discourses in the following
terms. Natural language mediates the experience of you and me as
we converse. It is oriented to understanding whatever we are talking
about, but natural language is also oriented to the larger rhetorical
situation in which two persons may have different points of
view—may exchange them, perhaps argue, perhaps learn, but at any
rate understand not only the object they are talking about but the
various subjective grasps of that object from which we might gather
and formulate some consensual knowledge.
The scientific situation differs from this “natural language” con-
versation. Ambiguity about different theories is temporary; its reso-
lution will come not from a conversation or from a negotiation
between subjects, nor will it allow two apparently incompatible
views to be equally right. Rather, a resolution will be dictated by the
data of the “objective world.” Conversations between scientists may
indeed be fruitful, but for exchanging data and ideas, not negotiating
differences. Someone may prevail in a scientific disagreement, but
not because he or she rhetorically overcomes the other. It will happen
when in the long term the data bear the winner out. It is the data
that decide who the winner is and what the consensus shall be.
At this point we see a feature of science that makes it fundamen-
tally different from a human conversation. Scientists have agreed
ahead of time that the data have the final word. But of course, “the
data” do not come to us in words and does not give us “objective
truth.” Data gives us knowledge, but only in our own terms. Our
knowledge is real knowledge, but we must remember that our ques-
tion frames for us what the data are telling us. Thus the listening by
science is totally one-sided. As long as it stays that way—as long as
the data are not allowed to determine “the question,” then “the an-
swer” by nature’s data is not nature’s answer at all. It is merely our
own answer to our own question. We are not listening to nature, in
its own terms, at all.4
SOCIAL ARRANGEMENTS
If a doctor tells a patient that his headaches come from a brain tu-
mor rather than from his anxieties and he can prove it with good sci-
ence, his authority serves the truth of science. If the doctor then
moves from that truth to the more general issue of what should be
done, he is quite rightly obliged to proceed with invasive treatment
only upon the agreement of the patient. This agreement serves not
the scientific truth but the structure of the larger political situation
that grants a physician authority over a patient’s body. To perform
such an operation without this agreement is violence.
We do not grant to nature what we grant to surgery patients.
Think of scientific explorations: final authority over the investiga-
tion and the treatment is not granted to nature. Such rights of the in-
vestigated and the treated are extended to our patients but not
generally to nature. We think more of humans than we do of nature;
we accord humans rights and privileges that we cheerfully deny to
nature. There are reasons for this. When we approach nature as a
scientist, we have no way of asking its permission for us to explore it
or to know it. It has no way to tell us what it permits. Permission is
political, as is a conversation; science is not political, insofar as it de-
personalizes its object of study. Our study of nature is science only in-
sofar as it depersonalizes nature.
We have, therefore, arranged the social facts surrounding a con-
versation very differently than the way we arrange the social facts
surrounding science. Therapy is dialogical; science is not. Yet this
lack in science may arise not only from the fact that nature does not
take the initiative to know us; it may also come from the fact that we
do not look for it to do so.5 We simply assume that we are subject and
it is mere object. Our social and legal constraints can apply only to
how subjects (ourselves) are treated, not to how objects (nature) are
treated.
When we realize that our warrant for this lack of respect is our as-
sumption that we are above nature, not the other way around (in
spite of the fact of death)—when we realize that this is scientific ar-
rogance, we feel more modest about nature. That modesty realizes
that nature precedes us, owns us, feeds us, contextualizes us. That
diffidence accepts the priority of nature as surely as we must accept
the fact of human mortality. We cease to feel superior to nature, as in-
deed a therapist should cease to feel so about his patient.
Nature’s way of being differs in many ways from human objectifi-
cations and investigations. When we objectify and investigate, we
place ourselves quite actively above nature. The other side of the dia-
logue is quite different from us. It does not place itself. It simply (in
human terms, passively) is what it is. Human terms (like “passive”)
are inappropriate. The most inescapable feature of nature is not
what, in human terms, it is but rather, in its own terms, that it is.
That too is important for psychotherapy. It is perhaps even more im-
portant for science.6
NOTES
1. For a congenial sample of the literature of “postmodernity,” I recom-
mend Calvin Schrag’s The Self after Postmodernity (1997).
2. The formulation of brain processes as causal is seen by neuroscien-
tists as more than a “projection.” That is because their language of the
brain is the language of science. If they take seriously mental life and the
rather different language in terms of which we understand it (see Keen,
2000a), and if they agree that our understanding of the brain must eventu-
ally make sense within that language too, then the two discourses,
physical-causal and mental-moral, eventually have to be equally descrip-
tive of both mental life and brain processes. If neuroscientists don’t agree
with this conclusion, then they cheerfully approve of dualism.
3. Of course, to take this argument seriously one must ask whether we
grant to all of nature the friendly respect that we feel obliged to grant to
our patients. We surely do not feel that way about cancer, which is a part
of nature. Generally, any condition we put into the category “disease” is a
condition that requires of us only to destroy it. We do not merely permit
ourselves to destroy it; we feel it is a duty to do so. The ground of that duty
is our identification with humankind. Disease is our enemy; we have no
higher calling than to destroy it.
This cultural truth sounds natural. It isn’t; it is cultural. But that does
not mean it can be dismissed. The move from suffering a disease into a
campaign to destroy that disease does not sound especially remarkable. Of
course, the extension of “disease,” the concept, and its accompanying
rights and obligations from physical ailments, the struggle with which is
one of life or death, to mental states, styles, and differences has been ques-
tioned many times (e.g., Szasz, 1970), but it seems to me an even more
questionable intellectual extension in light of the argument of this chap-
ter.
Disease is nature, and we make it as different from us as death. In our
irrational coping with anxiety, in our vague but frightened grasp of our
own incoherence, we categorize all three—nature, disease, and death—as
like one another and utterly unlike ourselves (Gilman, 1985).
4. It is not, of course, clear what might be an exemplar of “listening to
nature in its own terms.” However, in pursuit of that topic, I recommend
Thich Nhat Hanh (1991).
5. “If we cannot feel the rivers, the mountains, the air, the animals, and
other people from within their own perspective, the rivers will die and we
will lose our chance for peace” (Thich Nhat Hanh, 1991, p. 105).
6. I am sure I know scientists who already have the sense of ultimacy
about the nature that they explore with their science. In general, such sci-
entists are likely to be academic, as opposed to (for example) industrial. It
is in the rapacious destruction of nature by industry that we see the great-
est need for that sense of ultimacy that appreciates the existential dimen-
sion of nature. Technology’s official task of “exploring nature” can be
contextualized and conditioned by either an (existential) appreciation that
it is, or by a much less reflective curiosity about what it (essentially) is.
The latter, but not the former, is compatible with the more self-centered
hope to exploit nature for human profit, or in the case of capitalist indus-
tries, not even human profit but mere corporate advantage.
CHAPTER 7
Trivialization, Ultimacy, and

Discourse
A TRIVIALIZATION OF ULTIMACY
Controversy between a patient and her psychiatrist is an interaction
between unequals. At stake is the question of whose discourse will
define her experience. It is hardly surprising when the doctor per-
suades the patient. What if she resisted? The doctor would draw, in
carefully phrased ways, upon larger echoes of medical discourse.
Even the most confident and well educated party to such a discus-
sion with a doctor must cope with a medical discourse of disease and
death, one that echoes fears as real to us as the burning fires of hell
were to those who, in desperation to avoid them, admitted to witch-
craft.
The specters of disease, suffering, and death provide an inevitable
backdrop to any discussion of medicine. This backdrop raises the
stakes to a point of ultimacy; since nothing matters to the dead, liv-
ing takes priority over everything else. A cloud of seriousness thus
envelops the discussion, dulling the edge of our critical reflection,
none of which seems to matter in the face of death. In our everyday
interaction with and about medicine, assumptions slip by unnoticed,
as if to interrogate them were to tempt a frightening apocalypse.
A recent advertisement by a pharmaceutical firm states that
sleeplessness and fatigue may be signs of depression, that you
“should see your doctor today.” “Depression” is a code-word link to
concepts like insanity and suicide. This thought was planned in a
very central place, a corporate office that blankets our nation with
discursive persuasions. But our analysis must go beyond the interac-
tion between a power center and a population. That message de-

pends on plausibility at the local level, that of the person reading the
text.
Such ads are carefully calculated. I could write one that says that
postmodern discourse analysis will enable you to understand why
you think, feel, and behave as you do, but it would fail at the local
level. The meanings of pain and death are much more elementary;
they have been co-opted by medical discourse. The psychological
field of medicine, psychiatry, spreads medical caution into two every-
day experiences, anxiety and depression, that may be no more medi-
cal than everyday struggle and tragedy.
It is a telling fact that death lies at the root of medical, and even
psychiatric and psychological, authority. Death is, as we noted in the
previous chapter, a visible presence of nature within us. Our claim,
as medical authorities, to having a say in society depends on this su-
perior power of nature. This is true even though we professionals
speak rarely of death. The taboo in medical circles against dealing
with death (as noted by Kubler-Ross, 1969) is not merely to protect
us all against unpleasantness. It is a taboo because medicine must
deny its technical limit, must deny nature’s superior power, must
maintain a pretense of being in charge. This is not in order to keep
business booming; it is because we are all, human beings every-
where, afraid of death. Our faith in medicine, however temporary
and partial it must be, needs to be reassuring in our face-to-face
meeting with the possibility of death.
One might ask, of this line of criticism, what exactly a medical pro-
fessional can do to avoid parlaying the inevitable ultimacy of her pro-
fession into a trivial achievement of prestige. This question is
important. Individual medical professionals can do little to correct
what is a cultural process. Doctors and psychologists, and even their
professions and traditions, are not alone in trivializing this ultimacy.
Medical and professional power and prestige are granted without re-
luctance by the population. As a culture, our fear of ultimacies leads
us to create not only a profession of experts but also to exalt its social
position to a status congruent with the magnitude of our discomfort
with ultimacy.
In addition to human frailty, from which denial protects us, there
is human meanness, which is also protected by such denial. Plague
returned in Africa in 1998; we tend to understand it as an “epidemic,”
a natural phenomenon practically as capricious as an act of God. Hu-
man participation in the malnutrition created by political events
there is easily lost beneath the medical discourse of disease. The con-
TRIVIALIZATION, ULTIMACY, AND DISCOURSE 97
cealment of the role of political power in this example is like the con-
cealment of political interest once medical discourse takes over. It is
as if the centers of power control the meaning of events in careful cal-
culation about the specific and local discursive possibilities—how we
name things.
When the discursive possibilities of the population are under con-
trol by professions or corporations, so also is our purchase of self-help
aids, such as tranquilizers and antidepressants. These expenditures
($1.83 billion in 1997 for Prozac alone) affect the distribution of
wealth. Thus, much of this country’s resources and wealth goes to
pharmaceutical corporations (for example) instead of going to sup-
ply food, improve infrastructure, or renovate educational systems.
In other words, we may say that the quiet domination of medical
discourse is partly because of the raising of the stakes; death is an ul-
timate stake. The silent but powerful presence of this stake, in turn,
hypnotizes our critical faculties into submission. Further, it en-
croaches on politics, on local and international relations, expanding
rapidly through our moral lives. But this backdrop of ultimacy is the
basic condition for creating the hegemony that finally leads us to
analyze the interaction between power and truth.
Another example is military discourse, which may help us grasp
how our awe-inspired forgetfulness leads to such hegemony. Military
discourse, like medical discourse, is premised on the threat of death
made salient in the slaughters of humanity in this century—vivid in
the media coverage of them. If writers like Illich (1976) and Breggin
(1991) have helped unmask the pretenses of medicine, writers like
Chomsky (1987) and McCarthy (1994) have unmasked the pretenses
of the military.1 In both cases, the “succeed or else” format of the im-
plicit argument lays groundwork for the rest of the discourse, which
thereby becomes so powerful.
A metonymic transformation substitutes one word for another
that it suggests, such as “the kettle boils” (substituting the container
for what is contained) or “schizophrenia causes fear” (substituting
cause for effect and effect for cause)—as Szasz (1987), among others,
points out. The metonymic transformations that result in medical
ultimacy and its death-referencing implications follow many paths.
These transformations are concealed both because medicine often
avoids the explicit reference to death and because death is often
trivialized by being listed among the side-effects of typically bland
medicines.
Doctors who appeal to issues of health often are appealing to is-
sues of death. The very unlikelihood of their trying to deceive us
about such things makes any such concealment more effective, even
to themselves. No one has more confidence that they will be taken se-
riously than people who offer, even implicitly, a plausible way to
postpone death.2
The crucial upshot is that the power of medical discourse rests
heavily on the ultimacy of death, which operates as a silent refer-
ence, thus discouraging a critical attitude toward the medical estab-
lishment. In psychiatry, the baseline alternative is less frequently
death and more frequently insanity, or social disgrace. However, one
senses a deathlike ultimacy in our current image of the helpless
schizophrenic, which has had its roots in “madmen” and “mad-
women” since the seventeenth century (Foucault, 1965).
THE DISCOURSE OF PSYCHIATRY AND

PSYCHOLOGY
This ultimacy3 may be usefully compared to an alternative dis-
course, also grounded in scientific explorations of human misery, but
that does not depend on such ultimacy. It also commands a much
smaller audience, lacking as it does the constant backdrop of either
death or insanity. Mirowsky and Ross (1989) engage in what might
be called “problem-solving discourse,” which defines problems
within social conditions like poverty, explores their causes, and envi-
sions ways to solve them. Their focus, human misery and distress, is
distinctly nonmedical, and intentionally so, for they see many pit-
falls in medical discourse. Nevertheless, they very reasonably be-
lieve that their knowledge is as relevant and as urgent as that of
medicine.
Knowing the social conditions that cause severe distress (poverty,
racial and gender inequalities, and others that can well be life
threatening) allows us to compare people most favorably situated
with those least favorably. “In fact, if we split society into two halves,
better situated and worse, the worse half of society has 83.8% of all
severe distress. The better half has only 16.2% of the severe distress”
(p. 176).
Their analyses make it all too plausible that social class is not only
a correlate of mental distress and misery but also a cause. Further-
more, their research offers concepts that enable us to understand the
complex relationship between social class and what we (but not they)
call “psychopathology.” For example, bad events, such as losing one’s
job, being battered, or getting physically sick, inevitably cause dis-
tress, but they cause more distress for those with less “cognitive
flexibility” (problem-solving skills) and less “instrumentalism” (mo-

tivating sense of efficacy)—not to mention, of course, financial and
social resources. Poverty creates misery both by issuing more bad
events to poor people and by preventing the development of those
psychological skills and traits—or the social contacts—that can
buffer the effect of bad events in the production of misery.
It is a short step to arguing that a greater reduction in misery than
at present would come from (1) focusing our efforts on those most
miserable instead of on those who can afford psychotherapy or phar-
macotherapy, and (2) improving our teaching of skills and traits for
coping with life instead of struggling to refine further the mental ef-
fects of treating various aspects of depression. Better grade-schools
and high schools are a better investment than more clinical psy-
chologists and psychiatrists. The class bias in who gets the benefits
of medicalized professional care is enormous. Common sense would
dictate that we oil the squeaky hinge instead of polishing the lock on
the gate.
This is not a well-known line of thought. It fails to capture the
imagination of the general public. It is not eye catching for many rea-
sons, but one of the reasons is that the argument gives up one of psy-
chology’s and psychiatry’s greatest rhetorical advantages, the
ultimacy of medical discourse. The analysis by Mirowsky and Ross
tries to look behind the scenes to see some of the origins of human
suffering in modern societies. It suggests that official pronounce-
ments, such as those that medicalize and thus implicitly use more ul-
timate language, are sometimes misleading. Why else would such
official pronouncements exist? Why do “professional” views rule the
day? Do we see here irrelevant ideas springing into view instead of
relevant ones?
It is very much to the point to ask, “Cui bono?” Who benefits? The
answer involves professions, medicine but certainly also others, that
benefit not only in terms of expanding their legitimacy and access to
public funds4 but also in terms of the recognition of their expertise by
the population—in the United States, a population impressed by
professional expertise.
It is also important to see the role of science here, especially since
science has been interrogated in chapter 6. Individual scientists
make decisions about what to investigate, but they never make those
decisions alone. Every scientist knows that she makes such decisions
in an institutional context of finance and facilities. That context is de-
cisive for the scientific decision, and like all social organization, the
scientific context seems to justify itself in our casual acceptance of its
authority. At the same time, of course, science is hardly trivial;

market-driven products, however, frequently are.
In what follows, let us look behind the scenes—that is, at dis-
course, such as that of scientific and professional expertise, and not
only at how it manipulates images of death and insanity but at how
the exercise of that power interacts with what we, the common-sense
population, understand to be knowledge and truth.
POWER AND KNOWLEDGE IN POSTMODERN

THEORY
Knowledge must be seen as a kind of power. This idea is not new,
for the knowledge that comes from having played lots of contract
bridge becomes power at the bridge table. A postmodern critique
goes further, to say that power corrupts knowledge. Our analysis
says even more, however. It proposes that in the inevitable interac-
tion between knowledge and power, power comes first. Inevitably,
power is active, and knowledge is passive—until enlivened by power.
Knowledge becomes a factor in already-active power relationships.
Active power may play a role in the acquisition of knowledge, but
knowledge itself is not active, not transitive in itself.
Hence, knowledge serves power more than power serves knowl-
edge. This abstract statement will become concrete below, but its im-
portance is that we have tended in the modern period to see
knowledge as free standing and independent of power, politics, and
profits. We have not always appreciated the place of power in strug-
gles between contenders with different values.
In everyday life, knowledge sometimes serves power, such as when
scientists help the police. Power serves knowledge sometimes, such
as when police help scientists. As we begin the twenty-first century,
calling ourselves “postmodern,” we more frequently see how knowl-
edge serves power more than the other way around. We more often
see (to continue the example) scientists working to increase police
power than police working to help scientists find more knowledge. In
fact, we have knowledge of power in order to have more power, not in
order to have more knowledge.
The power of science to cure disease is irrelevant when solutions
to disease and starvation would come with political change. Often
the science is available but it is in the wrong hands. In such cases, it
is politics, not science, whose power counts. Again, politicians use
and need science more than scientists use and need politicians. Thus,
science is for hire.
Modern Expertise as Power

Powerful people seem to make discourse powerful, but actually
the reverse is also true; discourse makes them powerful. A discourse
is how to “put things” verbally. Stated in the right discursive form,
even inconsequential knowledge becomes consequential. How does
discourse do that? How do the experts do that? They know some-
thing that they do not know they know; they know it inarticulately,
implicitly, at a level of assumption.
For example, the ability to solve a problem is important and im-
pressive, but it fades in comparison to the ability to pose a problem
for which knowledge will be needed. Posing the problem defines the
range of possible outcomes; it lays out—silently and secretly, per-
haps unconsciously—the map of possibilities and necessities, with-
out which the future cannot be imagined. To pose a problem, experts
use simple, understandable, unremarkable, seemingly power-
neutral and unsurprising words. Once we understand this, we un-
derstand that even unimpressive knowledge becomes powerful—by
controlling the vocabulary, determining the discourse, confirming
the map and casting the possibilities, envisioning and naming the
problem.
For example, suppose I, a clinical psychologist, call your experi-
ence of fatigue and worthlessness “depression.” Suppose further that
you know that depressed people sometimes even commit suicide and
that this thought immediately awakens you to the possibility that
you too could escape all these aversions by that route. The result of
my clinical comment leaves me in charge of what the question is. Are
you really depressed? You may dispute my implicit answer, but it is
much harder to dispute the question—and it is the question, not the
answer, that gives me power over you.
I have posed “the problem” in a discourse that takes place in lan-
guage, which expresses presences—factors to reckon with. “Depres-
sion” becomes “the problem.” Not mentioned (especially with the
increasing use of drugs) are all the things you may be depressed
about. These may include very nonpsychiatric issues, like poverty,
debt, or unemployment.
Meanwhile, within the profession, the question “What causes de-
pression?” is much less popular than “What brain processes control
depression?” The former opens up a look at one’s life; the latter con-
strains the view drastically. Especially when pharmacological
agents are prescribed, the constraint limits how we think about
treatment, and it obscures questions about one’s life, feelings, and re-
lationships.
What is not mentioned remains invisible. The visible, present fac-

tors become our focus. Presences not mentioned seem nonexistent to
us. However, beyond this power of discourse, we are led by a discur-
sive slant and by how we pose a question and select a vantage point,
which we do not even know we are selecting. The vantage point in
this case is that of curing a disease. The terms I lay out in talking
about your depression increasingly call up notions of disease, medi-
cation, and cure, and they direct us away from asking what in your
life is depressing. Such a vantage point is obscured; this obfuscation
is discursive; it is in the discourse itself. It is a kind of power. It is a
kind of power that corrupts knowledge.
To have control over this kind of verbal “laying out” is to have
much more, and more basic and less visible, power than to have, say,
the power to frighten you. When the rest of us understand this, then
the power holders will have to negotiate the terms of the laying
out—that is, the question, not just the answer, the discourse and not
just the content. Getting to this point is the goal of the discourse
analysis of postmodern thought.
This opens up the radical project of analyzing the discourse of a so-
cial institution, such as the mental health industry (the professions
of psychiatry, psychology, and pharmacology). Such an analysis
(Breggin, 1991; Ross & Pam, 1995) does not simply show how power-
ful this knowledge is, in the sense of how our modern knowledge of
the brain and its chemistry enables us to make livable formerly un-
livable lives. It also reveals a project well under way in the second
half of the twentieth century: bringing people into the care, and
teaching them the vocabulary, of the treatment professions.
Critique of Psychiatry
For three decades, Szasz (1961, 1987) showed us vividly how the
concept of “mental illness” facilitated the development of profes-
sions, institutions, and industries. It has done so in this country by
creating an unlikely alliance. The alliance is between, first, our con-
tempt for the incomprehensibility of people struggling with, say, hal-
lucinations, and second, our compassionate attempt to cure disease.
Psychiatry and psychology apply our contempt to those behaviors we
want to eliminate. We have medicalized hallucinations—and thus
also all incomprehensibility.
Incomprehensibility needn’t be a medical problem; it might be
moral confusion or ambivalent indecisiveness. But by medicalizing
incomprehensibility, our society has found a new way to deal with for-
merly vague popular anxieties, provoked by madmen and geniuses
whom we knew only at a distance. In turn, the professions found a

new way to make people into patients. But beyond that, we have
found a new way to express our intolerance, not by locking people up
in the horrible conditions of Bedlam but by nullifying the mental life
of those we don’t understand, and of that part of ourselves we don’t
understand. My fears and suspicions are no longer, in this discourse,
mental life; they are disease. Their content can be ignored; it needn’t
be interpreted or even listened to. It can simply be eliminated—by
administering drugs that operate to convince us that experts of men-
tal life are hereby producing healthy minds.
This sort of critique seems to contest the very premises of psychia-
try, certainly to beg the question of the truth of psychiatric knowl-
edge. Is that knowledge fraudulent? Are mental patients truly ill?
How do we know they are not?
Concern for truth as the touchstone of the Enlightenment was de-
mocratizing, so much so that the powerful had to yield to the truth of
physics and astronomy. Old myths, ecclesiastical and royal, fell.
Truth, with this incredible power, thus came to be confused with
knowledge, some of which is much more circumstantial than truth-
ful, especially in its relevance. (“You have a chemical imbalance in
your brain” is circumstantial knowledge that neglects the truth of
the relevant problem, “What in your life made that happen?”)
Some knowledge is neither true nor false in itself; it depends on
the context and how it is used. Psychiatric knowledge is like this. In
our society, it has become a powerful kind of knowledge. It knows, for
example, about the power that makes other truths irrelevant, such
as the power that defines what is sane and what is not. Psychiatric
knowledge assumes that everyone’s commonsense truth will be
measured against that criterion. But psychiatric knowledge dis-
claims an interest in power. Meanwhile, power has much to do with
psychiatry, for the powerful psychiatrist says that the powerless pa-
tient is insane. The issue of the truth of that statement, which deter-
mines the truth of many others, is settled by power, by fiat, by role
and status, not by the rationality of the Enlightenment.
In many controversies, several conflicting propositions claim to
correspond to reality. At most, a partial winner may be named. The
establishment of this “truth” enacts a myth that “the winning”
proposition matters. But again, the content is hidden in the form,
and most especially in the vantage point. There is a psychiatric van-
tage point, and it is sometimes important. But to say that my theory
corresponds to reality as seen from a certain vantage point is to say
much less than to ask whose vantage point is to be the one used in de-
fining truth. It is never entirely true that a psychiatric vantage point

is the definitive one, but the ultimacy of madness, like the ultimacy
of death, continues to guarantee psychiatry’s power.
To move from the question of the truth of a psychiatric diagnosis to
the question of the relevance of a psychiatric vantage point is to
move to a more fundamental issue of truth. It is to deal with the
authority of the vantage point. It is to take into account other van-
tage points, which usually are omitted from psychiatry.
Coherence requires that we take into account the issue of vantage
point. We need to see multiple vantage points and to see that the is-
sue of which vantage point is privileged is the issue of what is to be
taken into account, and that this is answerable only by fiat, not by in-
vestigation. It is a matter of power, not simply a matter of truth. We
have now come full circle, to the primary role of power in what we
call, unreflectively, simply “knowledge.”
AN IRONY
It is ironic that this power of psychiatry is premised on the echoes
of ultimate issues, such as disease, insanity, and death, and yet that
at the same time, the power of psychiatry steers us vividly away from
the ultimacy that in fact resides in having a hallucination, or depres-
sion, or anxiety. Ultimacy is used by psychiatry for its own legitimacy,
but ultimacy is also a feature of human experience, and a decisive
one. The content of psychiatry itself, especially in its pharmaceutical
guise, insists that the content of the symptom, one’s fears, moods, or
fantastic perceptions, do not express ultimacies of any importance.
They are mere disease. They need not be interpreted or understood.
In the words of Laura Slater (1996), they are merely the pus of life.
They deserve only to be eliminated. They tell us nothing about the
sufferer, about life, or about psychiatry. They are there merely for
technological elimination.
In fact, drawing on pre-pharmacological psychiatry (Sullivan,
1940; Boison 1936, 1942, 1947; and others), the argument can be
made that ultimacy should be taken into account—not as a lever to
mobilize compliance but as a guide to understanding what it is that
people suffer from in their psychiatric symptoms. Sullivan (1940), for
example, deals with “love” and “grief,” two words whose experiential
trajectories move us from everyday labeling to issues whose appear-
ance and resolution involve nothing less than ultimacy. This kind of
language connects the phenomenal surface of a “symptom” to issues
whose immediate relevance to every life is only a brief event away.
For example, a death is the occasion of grief; a gift is the occasion of
love. Experienced fully, deaths and gifts are not just material events;
they take up residence in the realm of meaning, of the meaning of my
life.
Yet these terms, love and grief, are too raw for most everyday expe-
rience; we couch them in contexts or decorate them with images de-
signed to dilute their experiential potency. In that space of such
evasions, elaborations, and ambivalent acknowledgments, we create
symptoms, or patterns of meaning and its compromise, that eventu-
ally become exquisitely expressed in symptoms. Our tendency,
within the medical model, of making diseases out of unwelcome ex-
periences leads us to neutralize the emotional content of our lives be-
fore we have had a chance to try to approach it. Any effort to
interpret or understand such experiences is bypassed by our preoc-
cupation with symptom elimination.
In that way, our psychiatric treatments often collude with that
part of the person who would chose not to face life at a level of strenu-
ousness; we ally ourselves with the flight from life that the symptom
itself represents, by taking its announced presence as speaking for
itself. We do not listen to what it says, we merely pronounce ritualis-
tically that it is unwanted: it is a symptom; it is a disease; it can be
cured.5 Finally, should there be any doubt about the rightness of our
attitude, we implicitly remind our patients that diseases ruin lives
and kill people; the risks are high in letting a symptom go untreated.
Do not help the symptom undermine your life by dwelling on it; have
it eliminated, be done with it, go on to other more important aspects
of your life.
Go on to aspects more important than loving and grieving? Many
psychiatrists do not, surely, lead their clients to believe this explic-
itly. Instead, they pronounce the elaborated and disguised appear-
ance of these issues (i.e., “symptoms”) to be merely noise the diseased
system makes. “A little Prozac ought to clear that up nicely.” “Xanax
will get you through your panic attack sooner, or even prevent it, and
you can go on with your life.” “I am not alarmed with these symptoms
because I am a doctor, and my confidence that we can eliminate them
should be shared by you as long as you stay in my care. Of course, we
shall have to adjust the dose, perhaps augment or change the chemi-
cals used, but the elimination of what you understandably want not
to experience is close at hand.”
If sometimes grief, love, meaninglessness, and guilt present them-
selves in disguised form, and if their elimination constitutes bad
treatment, it is also true that the path from these symptoms to their
more profound (“ultimate”) meaning is hardly clear. I feel confident
that a number of persons I have seen in psychotherapy are moti-

vated to see me primarily because they are lonely. I am their paid
companion (Schofield, 1964). With them, much of the talk hovers be-
tween realizing that and indulging the fantasy, which they think I
share (and I have only rarely challenged), that we are enacting a
quasi-medical procedure designed to cure a disease.
The loneliness that does not surface in these cases, like the guilt
and the grief or the rage that clients cannot admit to, may be just as
ultimate as the fear of death. Even when we die with someone there,
we die alone, for the word “with” lacks meaning to the dead. Thus, ul-
timacy will be there, always, because we are human beings, and hu-
man beings can and inevitably do think beyond the present, beyond
the past, and beyond the future. We think ultimacy in spite of our-
selves; we live ultimately whether we like it or not.
SUMMARY
We began with the observation that medical discourse legitimates
itself by posing its problems and solutions within the context of one’s
confrontation with death. This became quite useful in the nine-
teenth century, and it is neither a mere intentional grab for power
nor an untrue version of what medicine is and does. However, such a
position, over historical time, has become a reservoir of authority,
upon which practitioners trade to bolster the prestige of their profes-
sion. By extension, psychiatry, trading on insanity, uses the same
kind of ultimacy in dealing with the legitimacy of its authority. This
amounts to an impressive acquisition of power, noted by Szasz but ig-
nored by most of the profession.
The power of psychiatry has, according to Szasz (1961, 1970, 1987)
and others, imposed the medical model on other institutions. But
less clearly noticed has been its power to undermine discursive de-
viations or to undermine controversy over the legitimacy of its lan-
guage. Current and historical controversies over the language of
diagnosis (e.g., Sarbin & Keen, 1998) offer specific examples of what
becomes postmodern discourse analysis, whose effect amounts to a
critique of traditionally unquestioned authorities.
Ironically, the view presented here does indeed take psychiatric
“symptoms” to express ultimate issues—sometimes death, some-
times love, grief, guilt, meaninglessness, and so on. These issues
present themselves disguised as psychiatric symptoms.
The role playing of sufferer/healer, or doctor/patient, is difficult to
ignore in our secularized society, but given the more trivial, and
power-driven, latent content of both “doctor” and “patient” today it
may not be a bad idea to reconsider the roles of priest and parish-
ioner. Such an analogy has the virtue of revealing the seriousness of
both the symptom and the therapy, without indulging the status op-
erations of scientific professions.
However, the roles of parishioner and priest also run the
risk—probably to a fatal degree—of manifesting a pretense as se-
vere as that of doctor and patient. Ultimacy provokes us too easily
into pose and pretense. It is hard to ignore this ultimacy without
trivializing our work, and it is hard to take it seriously without kid-
ding ourselves.
NOTES
1. The American bombing of the former Yugoslavia in 1999 expresses
the other side of the implicit presence of death, by making death too trivial
to consider. The capability of public discourse (and thus also public con-
sciousness) to have it both ways is astonishing. We appreciate death when
it is implicit (as in our respect for medical professions) and are unmoved by
its explicit presence (as in our killing of Yugoslavians). Of course, it also
matters that we don’t care about Yugoslavians.
2. In fact, the implicitness of medical relevance to death increases the
effect. Not mentioning death increases its mystique. I recommend, as an
antidote to this effect, Lifton and Olsen, Living and Dying (1975), a book
that brings death into vivid focus. Without trivializing death in the least, a
book such as this offers a frank and, I must say, revelatory discussion, and
it vastly decreases the negative side of the mystique of death.
3. The concept of ultimacy is not a theoretically driven concept, nor
does it name a particularly esoteric experience. In Morton Deutsch’s
(1999) commentary on hope and optimism, in the journal Peace and Con-
flict: Journal of Peace Psychology, he describes the “temptation to use the
most powerful weapon available against your adversary if you think the
other will strike you first with a powerful weapon” (p. 19). That temptation
not only points to the dangers of modern weapons but describes what he
calls “a new way of thinking about conflict,” namely that my temptation
and its extravagance often intimidate adversaries. Deutsch notes this also
in Einstein’s reaction to the detonation of the first atomic bomb. Such “a
new way” of thinking about conflict, was, in fact, also very old.
Human beings’ ability to anticipate their own death may rarely be ex-
plicit, but so also is it rarely very far from that range of meanings we draw
on to interpret the crises of everyday life. In psychiatry, every serious dis-
cussion of the sleeplessness or agitation of depression also discusses the
possibility of suicide. This is, in a way, rational, as is the role of much ulti-
macy in human reflection. What is remarkable is that it all remains un-
spoken—where it escapes critical reflection. In fact, its implicitness
enables the exploitation of ultimacy to enhance the status of concepts and

professions.
4. Is it accidental that funding for Mirowski and Ross’s research came
from the “research fund” of the university for which they work, not from a
federal agency? Federal funds have probably been spent on such research,
but they are certainly small in comparison to those that support, implicitly
or explicitly, powerful professions like medicine.
5. Note here that our pharmaceutical ability simply to eliminate symp-
toms, bypassing the necessity to listen to them, is an example of the scien-
tific attitude toward nature (see chapter 6). Scientists do not expect nature
to speak to us; it is merely passive, and we learn about it, how to control it,
ultimately to master it. The contempt (disguised as clinical patience) we
have for the content and meaning of the experiences of a schizophrenic
treats patients the way science treats nature. But in this case, the reduc-
tion of the patient to nature is a transparent violation of the patient’s
status as an individual person.
CHAPTER 8
Triviality and Ultimacy in

Therapy
People visit psychiatrists and psychologists because they have had

trouble making sense of their lives. Those troubles have as many
twists as there are personal narratives, selves with storied histories,
the end of which is one’s present state. What we call “symptoms” are
maladaptive ways to deal with what does not make sense. Hence ob-
sessions, phobias, nightmares, bouts of depression, chronic fatigue,
haunting guilt, and fantasies of exorbitant eroticism—each of these
are ways of dealing with something that cannot be integrated into
one’s life. That something, that latent incoherence, is a hidden mean-
ing of the symptom.
Two major categories of such hidden meaning have to do with two
facts of human development: first, our parents will not take care of
us forever, and second, we will eventually die. Each of these can move
us in profound ways, and when they do, we are often unable to deal
with them in their own terms. Hence our derailed coping becomes a
symptom.
As for our parents, we will have outgrown them, for the most part,
but they remain, even if they are deceased, active parts of our narra-
tive selves. These active parts become increasingly implicit as we get
older, but they are never in fact replaced as the basic format of rela-
tionships upon which we have built a life. In the present, instead of
realizing that I want my mother to take care of me or that I fear I can-
not match my father’s uncanny perseverance, I find these experi-
ences incongruent and irrelevant to who I reckon myself to be.
Insofar as their presence in my life continues to demand attention, I
am more likely to experience “a symptom,” the meaning of which is

quite obscure.
Many symptoms are ways to deal with the first of the two themes
about parents—to express, compensate for, protest against, or sym-
bolically correct whatever it is I feel I must do about my childhood.
The raw memories that would make this vivid are buried beneath
less painful aspects of my narrative self. Freudian theory is our most
profound method of exploring these issues and their way of leading
to what we call symptoms.
The other category of hidden meaning is the fact that I will not live
forever. Existential struggles with death were current in psychology
and psychiatry a quarter-century ago, as we in the West finally came
more fully to grips with the devastation of World War II. Hiroshima
and the Nazi holocaust stand as enormous facts of the twentieth cen-
tury, about which narratives are still being written in order to make
sense of them. It is, of course, the death and destruction—particu-
larly the death—that made existentialism flourish in the 1960s. In
Freud’s time, there was a similar wasteland following World War I,
but Freud had already targeted the primary family, not human fini-
tude (or the human propensity to kill one another), as the major con-
tent that lies behind what we call “symptoms.”
Freud (1920, 1950) did, as we know, deal with death by assimilat-
ing the issue to his already developed theory of instinct. Hence, the
“death instinct” emerged, one of Freud’s most ingenious conceptual
inventions, in the midst of a career of ingenious conceptual inven-
tions. But the Nazis overtook our attempt to understand the death in
“the Great War,” leading us to enact it all again. It is of interest to dis-
cover, incidentally, exactly what has deterred the third enactment
so that the last half of the twentieth century has mercifully not
produced that third war.1 The crucial point here is simply that
death—our frustration with it, fatalism about it, wavering denials
and theories of immortality, all of which predate this century and
these decades—remains, as fully as do our childhood and devel-
opmental struggles, in the background of every narrative self we
create.
ULTIMACY IN THERAPY
To see symptoms as expressions of this second question is not
“depth psychology,” where “depth” refers to distance from the pres-
ent, back into one’s personal history and childhood conflicts with
parents. As important as these conflicts are developmentally, for
adults there seems so often to be a different background, a shadow
TRIVIALITY AND ULTIMACY IN THERAPY 111
presence of a kind of seriousness, even gravity, certainly some oppo-

site of triviality or inconsequentiality. I characterize this back-
ground factor by its ultimate questions in human experience, which
give our lives a dimension of ultimacy.
The move from less to more ultimacy in Rob’s experience of his
own therapy occurred when he reflected on the funeral, with the ef-
fect of experiencing his own mortality. This changed not only the
therapy but made it possible for Rob to bypass agendas of self- exal-
tation that had trivialized his life and his relationships. For Rob, as
for most of us, the inevitable move from being to nonbeing was more
important than an opportunistic change in his status or power in re-
lation to others.
Triviality gives way to ultimacy; this happens in good therapy, but
it is not a technique or a goal. It must come from within the patient,
for therapeutic efforts to bring it about usually end up trivializing ul-
timacy. Nevertheless, symptoms do express this human ultimacy as
often as they have to do with one’s parents. Indeed, complaints about
one’s parents often mask more ultimate matters, although this may
more likely be true if the parents have died or are dying.
Ultimacy, insofar as it has been captured by religion and philoso-
phy, is familiar to us—as religion and philosophy. It is not familiar to
us as psychology. But it is in psychology that we enact these strug-
gles, at least insofar as our symptoms are late derivatives of them.
Some symptoms have to do with the fact that our parents have
stopped taking care of us, at which we protest. But some of us have
somehow accepted that fact, and we find it hard instead to deal with
the fact that we have just one life to live. The question of who one is
to be in that life, the moral content of one’s having been here, may
also remain untended and yet demanding.
COHERENCE AND ANXIETY

The ultimacy of mortality is related to what has been called “exis-
tential anxiety” (Keen, 1970; May, 1969). But such ultimacies are,
most of the time, experiences of incoherence. It is sometimes hard to
make sense of death. Anxiety lies there, and so does incoherence.
Even more generally, the experience of coherence and the experience
of anxiety are inversely related. To find one’s experience incoherent
is an occasion of anxiety, as if something were terribly wrong, out of
control, unpredictable, dangerous (Loeffler, 1999). To make it com-
prehensible is to reduce anxiety. To feel an intense need to make it
comprehensible is to experience a version of human ultimacy.
There is often a trade-off between internal coherence and a larger

coherence that takes account of not only my experience but also the
experience of others. Rob was able to maintain his internal coher-
ence by dismissing the experience of others. Beyond that, when oth-
ers’ views sufficiently contradicted his own, that incoherence forced
a more vehement rejection of others’ views rather than a modifica-
tion of his own. What Rob in fact had done for much of his earlier life
was forego the negotiation of his views with those of others; he sim-
ply dismissed those who disagreed with his conviction that he was a
splendid fellow.
At the time his wife left him, he vacillated between simply dis-
missing her and experiencing a loss of something that he not only
wanted but thought he should have: her loyalty and love, but most of
all, her admiration. To dismiss her was to pay a high price in terms of
external coherence—between his view and hers. But in order to pre-
serve his internal coherence, her view simply had to be dismissed.
Further, to admit that he missed her was to admit that he had failed
to keep her, a failure he coped with by blaming her, devaluing every-
thing she thought and did.
This last experience was, of course, highly emotional, expressing
his anger at her. There were other times when his solution to his own
anger was simply to turn feelings off. To the extent that the feelings
persevered, he felt not only anger at Ali but, behind and close by, a
feeling of loss, which was an incoherence between two conflicting
facts: he should have her—in fact, wanted her—and he couldn’t have
her. When he could stop wanting her, the incoherence of her view
with his mattered much less.
His surrender of this external coherence between the two of them
in order to the preserve his internal coherence continued a lifelong
pattern. At times when he did succeed in not wanting her, he per-
suaded himself that not having her didn’t matter, but this coherence
was bought at the price of internal incoherence incurred by denying
what he usually acknowledged—that he desired to have her. Blam-
ing her for everything was a gross, but efficient, if later unworkable,
way to preserve his internal coherence.
Sometimes one’s narrative coherence is a narrative that accounts
for what is, in fact, a conflicting and confused world. To have a narra-
tive that is about confusion is not necessarily to have a confused nar-
rative.2 A narrative that explains an incoherent world (say, where
death is rampant) does not have to be incoherent itself. Sometimes
life is simply chaotic; to narrate that coherently makes it seem less
so, but in fact the chaos remains. Narrating the chaos of rampant
death may not eliminate confusion but may offer a way to cope
within it.3 Sometimes we simply have to accept chaos, and that act
itself can be made coherent with a continuing sense of self.
Ultimate issues provoke incoherence. That I want but do not have
the undying protection of my parents, or of my wife as their substi-
tute, is an inevitable incoherence. So also is the inevitability of my
death. The best I can do in making these facts into a livable coher-
ence is to be a person I can respect. I can respect myself only within
some range of human possibilities. It is not necessary to be unafraid
of death, but I must be uncowed by its inevitability, so that every day
adds to a story that is not made futile by its eventual end. That is one
way to respect myself. Another is to find a way to accept my relative
good fortune. If I don’t suffer as Rob does, it is not because I am enjoy-
ing life at his expense. I can live with my easier inner life without
feeling guilty or unworthy of my good fortune, and without losing re-
spect for myself. In fact, being able to do this is necessary in order to
be able to help him.
SELF-RESPECT AND GUILT

“Who am I to be?” must be answered in terms of the world. There
are, therefore, limits to this self-respect. It is challenged, in my case,
for example, by my failure to understand why I have so much wealth.
I know that as an American I belong to a group that consumes a vast
portion of the world’s income and resources. That is not consistent
with calling myself a fair person. Should I be crushed by its injustice?
I can try at least to be on the side of change toward justice rather
than further the imbalance of worldwide wealth. Such trying does
not make chaos into order, but it can narrate my life amidst the chaos
in a way that is coherent.
There are people who must simply deny that their good life is
bought at the expense of the bulk of the world’s population. This de-
nial leaves an incoherence unattended, which may be a serviceable
strategy but is not altogether a safe existential place. For example, it
risks having to confront the facts and feeling guilty. We all know this
is not, for most Americans, a major problem. We typically do not nar-
rate the incoherence of our wealth side by side with their poverty. For
the most part, we simply do not deal with it at all.
Americans live with this psychological debt with surprising ease,
facilitated by ideological pride more than simple logic. At the very
least, a logical result would lead us to be less judgmental about other
nations, but to explore this aspect of our lives openly is to expose our-
selves to a degree of ultimacy that is psychologically difficult and so-

cially unacceptable in American polite society.4
Not to deal with it is to ignore or deny incoherence, which is stable
as long as one continues to ward off certain facts. That strategy de-
nies incoherence outside in order to feel coherent inside. It is similar
to, but less socially unacceptable than, Rob’s life. It must be true that
one need not explicitly deal with all the moral dilemmas of the world
in order to be mentally healthy. Even our best effort not to make in-
justice worse does not solve the problem of the incoherence of the
facts of wealth and poverty in the world. But it is possible to narrate
those facts and to live among them in such a way as to incorporate
them into ultimacy without sacrificing coherence. The price is not
necessarily trivialization.5
The fact that life is lived in something other than a “just world” is
an ultimate fact. Its ultimacy may also lie beneath a manifest symp-
tom, although as already noted, for most Americans this seems not to
be much of a problem. However, any symptom we see in the clinic can
be an expression, somehow, of an ultimate issue.
ULTIMACY IN PRACTICE
There is a great collusion between psychiatrists and their pa-
tients: Each evades the dimension of ultimacy and in doing so rein-
forces the other’s doing so. Patients, who are ultimately concerned
about ultimate questions—such as “Who am I to become?” “What am
I doing here anyway?”—present to the psychiatrist eating disorders
and anxiety attacks, obsessions and fits of sadness, whose meanings
are ultimate but whose presentations enlist popular symptoms as
their idiom.
Meanwhile, psychiatrists counter these stylish trivialities with
stylish trivialities of their own, by telling their patients that they
have a “chemical imbalance in their brain. . . . Take these pills; I’m
sure you will feel better.” The patient will take the pills, and will feel
better, and no one involved will suspect that some human existential
issue has announced itself and been summarily squashed by the col-
luding members of a culture of technology, a culture that proudly en-
acts its impatience with either human suffering or moral reflection.
On the other hand, we might rightly ask if there is any real dam-
age done here. In fact, we must consider the possibility that ultimacy
does not lie behind every symptom. In fact, a chemical imbalance
may exist in your brain that can be corrected pharmacologically; in
such a case, life can go on as if one had simply acquired a disease and
was cured; and one can cheerfully forget it. This is, after all, the atti-
tude most dearly sought by pharmaceutical corporations, which make
such handsome profits, and also by most prescribing practitioners. It
also perpetuates the premise of most psychiatry and psychology: That
symptoms can be understood scientifically and require nothing from
moral language or experience in order to be intelligible.
Notwithstanding the ubiquity of such practice, for which drug
therapy is a vivid symbol, there is an outrage here. It is not what is
done in the laboratories of the pharmaceutical industry, nor is it in
the offices of the National Institute of Mental Health, which ap-
proves drugs one by one as they are perfected by the industry. Nor is
it in patients’ demands for the quick fix, nor in medical schools and
psychiatric training programs, where prescribers are educated. Nor
is it in the offices of general practitioners (primary-care physicians),
who prescribe three-quarters of psychotropic drugs.
The Problem, the outrageous truth that lies at the core of psychi-
atric practice, can’t be located precisely within this network of mutu-
ally reinforcing organizations, economic interests, popular culture,
and professional training. The Problem pervades this constellation
of agents and agencies. It is in their collective belief that technology
can, finally, guarantee that any existential issues that lie behind
symptoms need never surface. All we have to do, as a culture, a pro-
fession, a science, a cluster of institutions, and as a population, is set-
tle for the comforts of a decent job, happy family, good sex, and hopes
for more of the same in the future. If a symptom can be fixed by a pill,
further inquiry is unnecessary.
All we have to do is to ward off ultimacy. Or, if we are ambitious in
exploring our own psychology, we can focus on why our parents did
what they did, which points to the origin of much current psychopa-
thology, and avoid asking the other kind of “deep” question, the kind
that omits the family history and solidly confronts us as adults with
the simple question: “Who am I to be?” But does it matter that I could
be different than I am? Who couldn’t? Where’s the beef? Snobs can al-
ways say I could be better; maybe the striving for perfection has al-
ready driven me into paroxysms of obsessive dead ends; or maybe
worrying about what I am supposed to be doing with my life (instead
of enjoying it) has driven me into a guilty depression; or perhaps try-
ing to make life better for others has engaged me in an exhausting ef-
fort to “be there” for people who need me, and I have never taken any
time for myself.
This problem has been with us forever, perhaps, but warding off
ultimacy seems particularly vivid in American psychological prac-
tices. Many false starts and dead ends follow the serious taking up of
the question, “Who am I to be?” Falling into one of the dead ends
(many of which are, in fact, symptomatic) has become nearly inevita-
ble. To deal with ultimacy is a high-stakes enterprise, and it cannot
be entered into without genuine consultation with those in my life. If
I trust them, and they trust me, we can talk about who I am to be-
come. If at first the question yields trivialities or clichés, these need
not be definitive.
Perhaps we must recognize that as Americans we are party to an
orgy of consumption of resources that comes easily to us because of
the exploitation of poor populations the world over. We pay twenty
dollars for a soccer shirt that was sewn in Puerto Rico by women who
make forty cents a day in a sweatshop. We do not know them, so we
cannot simply send them the money instead, the vast bulk of which
is in any case channeled into corporate profits or reinvested in fur-
ther development of the market and further exploitation of third-
world populations. I cannot solve this problem. In fact, it is not my
problem. I didn’t create it. You can say I perpetuate it by buying such
garments, but my sons need soccer shirts. They are on a team. Should
they go without?
We see here the enormous complexity of this injustice (and it is
like others) in the modern world. Simply feeling guilty won’t help.
Certainly, getting depressed, for which I will then take antidepres-
sant medication, will not help. Not buying the shirt might help, espe-
cially if our whole team decided to buy less flashy but just as
serviceable cotton T-shirts made in the mainland United States.
Such a move would not be aimed to support mainland U.S. rather
than Puerto Rican workers; it would be aimed at refusing to be a part
of the exploitation in Puerto Rico. If such a decision were made on a
national scale, it would lessen the market, undercut profits, discour-
age this kind of “development” in the third world—development that
does not serve the locals but exploits them shamelessly.
WHAT DO THE HELPING PROFESSIONS

HELP WITH?
Human beings have existed for thousands of years, with notable
variations in mood, style, activity level, and focus. In the last fifty
years, in the United States and a few other highly developed coun-
tries, industries and professions have developed as if they were dedi-
cated to reducing that variability. The helping professions might be
accused of simply homogenizing life.
The mission of an industry (like psychopharmacology) and of pro-

fessions (like psychology, psychiatry) is never simple. The primary
dedication in both cases is probably to make money, along with help-
ing people and advancing science. Reducing the variation among hu-
man beings is perhaps an effect rather than an intention of these
agents. Working through a system of market economics, patients fol-
low consumer desires, and it may be exactly here, where individuals
fear being different, that the homogenization originates. The indus-
tries and professions, however, are complicit with, if they did not
originate, this project.
The creation of greater homogeneity necessarily, if silently and
unconsciously, requires these industries and professions to select
from the range of personal styles the patterns they endorse, encour-
age, and create, and to urge the elimination of other patterns. This
project engages the language of “health” and “illness” in making
these selections and eliminations; the industry most engaged is
pharmacological, and the profession most engaged is medical.
Like other historical examples of human selection and elimina-
tion, the “mental health” effort implements values and preferences
whose origins are obscure but whose content generally fits into other
themes of the culture. In the case, for example, of defining scientifi-
cally those variations that we call versions of “depression,” human
unhappiness of all varieties—inconsistent moods, demoralization,
disruptions of eating and sleeping cycles, rhythms of energy and fa-
tigue, enthusiasm and discouragement—become caught up in the
processes of medical selection and elimination. This process of elimi-
nation is defined many ways, and the complexity defies analysis.6
The presence of science in this project is ambiguous. In a sense,
scientific methods are mere means, tools for implementing cultural
values. Thus diagnostic procedures and pharmaceutical prescrip-
tion are scientific ways to implement the cultural value judgments
about what to select and what to eliminate. But there is also a sec-
ond, vivid presence of science in this process. By implementing these
choices through medical routines, the value-laden character of the
whole enterprise is concealed behind scientific judgments about
what is disease and what is health.
Once the definitions of “unwell behavior” are in place, any positive
role of these experiences in the course of human life is lost from view.
For example, among those famous persons of the past who are now
diagnosed as “depressed” was Abraham Lincoln. It is quite possible
that what we now call pathological mood changes were an integral
part of Lincoln’s sensitivities and motivations. Maybe they were no
more disease than what was experienced as the struggle against the
state by Soviet dissonants who were imprisoned in the U.S.S.R. in
the 1950s.
To be sure, the overlap of various depressive experiences with
glandular and hormonal events, including diseases, offers testimony
to the fact that “depression” can very well express, or be expressed by,
physical disease. Such a connection is part of the tangled complexity
of human existence, on a par with, for example, the interweaving of
depressive and elated moods with one’s financial successes and fail-
ures, or with one’s romantic vicissitudes, or cycles of creativity, or re-
ligious meditation, or other variations of personal and cultural life.
Depression, as a scientific concept, fraudulently declares a value-
free status of scientific insight. Its origins in the cultural project of
homogenizing human experience masquerades as scientifically cre-
ating health. In our understanding of what we call “depression,” we
fail to see its embeddedness in human variability in general, or in the
multidimensional interweaving of the many aspects of any individ-
ual life. Thus a part of human variability is attributed to “disease”
because physical intervention by what we call “medication” can
eliminate it. An infusion of money into the life of one we call “de-
pressed,” or ecstatic sex, or high status and prestige, spiritual insight
and peace, or simply decent respect, may have the same “health-
enhancing” effect.
Of course, it also may not. For some people, these other changes
may be impossible to appreciate without, say, a change in brain
chemistry, which psychopharmacology can supply. For others, it is fi-
nancial security that is the crucial ingredient, or perhaps spiritual
peace or decent respect, without which even a change of brain chem-
istry fails.
Ironically, these other ways to eliminate what we call “depression”
may, as they change one’s brain chemistry, also change other condi-
tions of one’s experience. One’s brain is—unlike, say, one’s bank ac-
count—a central clearinghouse of life’s complexity. Yet some do find
the bank account central—or social success, or sexual ecstasy, or re-
ligious quest, or athletic achievement—more central than their
brain chemistry. Is it not likely that each of these is merely an indi-
rect route to one’s brain chemistry?
That possibility is far from obscure, since the centrality of the hu-
man brain is more universal than any other centrality. Thus our
technological control of brain chemistry—still, of course, enormously
incomplete—promises to succeed like no other manipulation in im-
plementing the cultural project of selecting and eliminating aspects
of human consciousness. The project of homogenizing human experi-

ence, if its success implies a project, may have found in psychophar-
macology its technique of choice.
The question now becomes whether that project is a good idea.
Perhaps eliminating those experiences we call “depression” is not a
good idea. Certainly in the face of financial, social, spiritual, and oc-
cupational success, depression may not be debilitating. In fact, it
may express a crucial sensitivity, the elimination of which may have
serious negative effects on other compartments of one’s life.
I have always been fascinated with the Great Depression of the
1930s, during which I was born but which I do not remember. It was
the economy, not one’s mood, that was “depressed,” although there
surely was human suffering, caused by the economic woes, that may
have looked like what we have so scientifically now specified as
“clinical depression.”
I also have often wondered whether “the American experience” of
the “great depression” would have been less “pathological,” or more
“healthy,” if there had been then the enormous network of psycho-
pharmacological services and agents that exist now. Had we been
able to cheer up the father whose job had disappeared, or the busi-
nessman whose life’s work of creating a business had disappeared, or
their children whose nutrition, restful sleep, and sense of safety had
disappeared—had we been able to treat their depression with medi-
cation, would the Great Depression have been different? Perhaps
less great?
It is possible to imagine that if the endogenous tendency to react
“depressively” were medicated away, the vastly reduced income of so
many people would have led to less contagious despair. The paralysis
of pessimism, the exacerbation of familial conflicts, and the blaming
and judging and retaliating at the familial, community, and national
levels may have been less. But this imagined improvement brought
about chemically can easily be matched by our recalling the heroism
also provoked by the financial crisis. Families shared more resources
and more concern. Communities pooled the efforts of unemployed la-
bor, sometimes organized at a local level, more famously at the na-
tional level in the WPA and the PWA. Churches organized food
banks. Fraternal organizations ran employment services. Hospitals
initiated nutrition programs. The government hired literate people
to staff a national literacy program. Thousands of such projects were
invented and developed to cope with the crisis.
It is impossible to know whether antidepressant and antianxiety
medicines would have made the heroism more marked or less. Cer-
tainly, our current experience of these drugs often frees people to fo-
cus more on such worldly tasks, but it also leads to an increase in
self-preoccupation, to an identity as “less independent,” if not a
“mental patient,” and other versions of self-doubt that provide ex-
cuses for withdrawal from collective efforts like those invented in the
1930s.
Perhaps the most central feature of the many heroisms of the
Great Depression was the sense that “We are all in this together.”
Such a slogan exists on the fringe of our personal and cultural con-
sciousness, side by side with “Every man [sic] for himself.” It is not
clear, but I suspect that “Every man for himself ” is the more robust
slogan. On the other hand, do we know how heroic we would or could
be if we experienced ourselves as having special psychological limi-
tations because we had been diagnosed and treated for “dysthymia”
or “major depressive disorder,” and if we had medicine that elimi-
nated the symptoms?
In addition to these speculations, which are totally absent from
the popular consciousness about psychopharmacology, the larger
project of homogenization is invisible. “Difference” becomes terrify-
ing under certain conditions—terrifying to the person who feels dif-
ferent as well as to the person who realizes that someone close by is
different. Psychiatry, psychology, and psychopharmacology do not in-
tend to make this situation worse. They intend to help individuals to
feel confident in their uniqueness and responsible for making their
contribution to our collective well-being. But these industries and
professions in American culture at the beginning of the millennium
thrive on more rather than less anxiety and hopelessness of those
who feel different. In spite of their intentions, these corporate and in-
stitutional players offer the population assurance that they needn’t
settle for being different, that certain differences are in fact diseases
that can be treated and made to go away.
If we try to characterize the nature of the diseases that can be
medicated away, the common denominator, besides being different
rather than like others, is the experience of distress. Depression and
anxiety are unpleasant, anhedonic, and yet the definition of such ex-
perience by the social context, more than one’s inner experience, is
decisive. We’ve known for half a century that feeling helpless, sad,
and ashamed will be defined by the person with feeling proportion-
ate to the authority of the social context (Asche, 1956). Distressed
people in the 1930s had an alternative explanation that led them
away from personalizing and pathologizing their experience. The
Great Depression may have hurt them, but it was not their personal
problem; it did not signal their inadequacy.
Two-thirds of a century later, feelings of helplessness, sadness,
and shame do not have the defining social context of the 1930s. In
fact, the last decade of the twentieth century has seen the most ro-
bust and continuous economic growth in many decades. The world’s
wars are far away from the West and seem to have little to do with
most Americans. There are no epidemics that threaten most Ameri-
cans, and people generally feel their prospects are promising in
every respect. Stressed like academic competition among students,
or failed dreams and marital disappointment among baby boomers
may “explain” much distress, but more salient than these is the con-
sciousness created by pharmaceutical advertising and a vastly ex-
panded psychological awareness propagated by television.
“Medicalization” (Sarbin & Mancuso, 1980) of such feelings is easy,
calculated, and successful (Szasz, 1970).
I am not arguing that psychopharamacology is simply an exploita-
tion of the population by techniques of marketing. The reality is
much more complex. The advancing technology of psychopharmacol-
ogy will continue to refine our treatments of schizophrenia, bipolar
disorder, and even depression and anxiety. But no one appears to be
asking what, among all these symptoms, is valuable and should be
appreciated, even encouraged. The answer proposed in this book is
that the concept of ultimacy names such experiences.
RETURN TO ULTIMACY
To see that personal experience sometimes addresses profound is-
sues, no less for ordinary people than for philosophers, is to question
the dismissal of anxiety and depression as mere symptoms of dis-
ease. When they should be treated is never reliably inferred by their
mere presence. Thus moving from a realization of such experiences
to a decision to medicate them away is hardly a simple matter. Ex-
perts should be able to help us. But most experts have failed to be
critical of the corporate meddling in defining “expertise” as congru-
ence with corporate interests (Healy, 1997). Pharmaceutical spon-
sorship of research in continuing medical education opportunities
does not always focus on the virtue of the particular drugs made by
that corporation. But it does include training in which questions to
ask, and these rarely have any moral dimension at all. Thus, by im-
plication, this is training in which questions not to ask.7
To reopen such questions should be the obligation of every treat-

ment professional.
NOTES
1. Of course the cold war and the threat of total annihilation are key
factors in the later-twentieth-century relative peace. This possibility not
only helped obviate World War III but lends a note of ultimacy that
reaches far beyond the more common ultimacy of one’s own death.
2. I am indebted to Loeffler (1999) for this insight.
3. See, for example, Lifton (1997), who describes how death-camp
guards managed.
4. The greatest challenge in my personal experience along these lines
has been to take seriously the life and actions of Mohandas Ghandhi and
his followers early in the twentieth century. I can take some comfort in the
fact that the cultural and historical context made their choices very differ-
ent from what would be the equally conscientious choices by Americans to-
day. But these contextual differences serve our psychological comfort more
than our moral logic, and we Americans should all acknowledge an ulti-
mate debt to the accident of our historical good fortune. The ambiguity of
that debt, however, makes many of us much more likely to trivialize ulti-
macy than we might in other circumstances.
5. I know people whose value commitments to justice have such a back-
ground.
6. Consider the dramatic increase of immigration into the United
States since Hiroshima ended the war in 1945. This demographic fact also
describes further diversification of American culture, especially for the
less privileged urban neighborhoods to which immigrants gravitate.
Meanwhile, wealthier Americans undergo much less of this diversification
of culture and more pharmacological homogenization of experience. While
diversity of experience and culture expand among the relatively poor, the
diversity of experience and culture shrinks among relatively well off, and
better insured, segments of the population. While it is entirely impossible
to see all this clearly, these trends might produce an increased intolerance
of diversity in well-established Americans, which might seem to justify ex-
aggerating the traditional contempt of the wealthy for the poor.
Once more, this possibility is far from certain. The point here is less a
matter of answering such questions than of asking them. Psychiatry, the
medical specialty, is hardly responsible for, say, an increase of intolerance
of the poor by the rich, but it may not be wise professionally to ignore such
undesirable by-products of a therapeutic technology that prefers pharma-
cological trivialization of symptoms to appreciating their many layers of
meaning.
7. In what way does ultimacy interact with the incoherence born of our
traditionally denied dualism, our traditionally divided discourses of scien-
tific dualism and human morality (see Keen, 2000a)? The question “Who
am I to be?” requires personal decision—clearly a moral matter. It is scien-

tific language of causal and mechanical (and diagnostic) matters that is
likely to trivialize issues and impede our access to ultimacy. Such scien-
tific language too often replaces the natural language, within which access
to personal and moral issues is available. To face ultimacy is to let the
question “Who am I to be?” guide one’s life. Such guidance, by such a ques-
tion, is not a matter of following a particular value. It is, rather, simply to
live the question, thus to be aware that our living is our answer.
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Name Index
Aaltonen, J., 71, 126 Feung, H. K., 125

Alazvaki, A., 125 Foucault, M., 49, 98, 126
Alon, N., 81, 128 Frank, A. W., 38, 126
Alpert, J. A., 44, 125 Freedman, J., 70, 72, 126
Asche, S., 120, 125 Freud, S., 24–25, 110, 126
Austin, G. A., 20, 126
Gendlin, E., 26, 30, 126
Baxter, L. T., 26, 30, 125 Gilman, S. L., 94, 126
Bergman, K. S., 125 Goodnow, J. J., 20, 126
Blakeslee, S., 16–17, 125 Greenblatt, D. J., 33, 126
Boison, A. T., 96, 104, 125 Greider, W., 126
Breggin, P. R., 10, 97, 102, 125
Grinker, R., 126
Brenneis, G. B., 44, 125
Gutfreund, M. J., 126
Bruner, J. S., 20, 126
Guze, B. H., 125
Capps, L., 43, 126
Castillo, P. J., 38, 126 Healy, D., xiv, 15, 49, 58, 121, 126
Chomsky, N., 97, 126 Heidbreder, E., 19, 126
Columbus, 56 Herman, J. L., xv, 23–25, 126
Combs G., 70, 72, 126 Hillman, J., 81, 126
Contratto, S., 126 Holma, J., 71, 126
Coppen, A., 59, 126 Hovestad, W. E., 43, 127
Hughes, H. S., 81, 127
Descartes, R., 29, 46, 47, Hyman, S. E., 59, 127
Deutsch, M., 126
Illich, I., 97, 127, 225
Engel, G. L., 25, 126
Ennis, B., 49, 126 James, W., 19, 20, 23, 127
132 NAME INDEX
Kardiner, A., 23, 127 Phelps, M. E., 125

Keen, E., xiv, 10, 15, 19, 29, 30, 35, Piaget, J., 20
44, 52, 81, 87, 97, 106, 122, 127, Pitman, R., 128
128 Polkinghorne, D. E., 81, 128
Kepler, J., 47, 72
Ketcham, K., 42, 44, 128 Robertson, J., 26, 30, 128
Kleinman, A., 38, 40, 81, 127 Ricoeur, P., 40, 128
Korton, D. C., 55, 127 Romanyshyn, R. D., 81, 128
Kramer, P. D., xv, 4, 7–12, 127 Ross, C. A., 102, 128
Kristiansen, C. M., 43, 127 Ross, C. E., 98, 99, 102, 108, 128
Kubler-Ross, E., 96, 127
Kuhn, T. S., 81, 127 Sacks, O., 28–29, 81, 128
Kurtz, R., 127 Sarbin, T. R., xiii, 30, 44, 52, 65, 81,
97, 106, 121, 128, 129
Laing, R. D., 81, 127 Sartre, J.-P., 61, 129
Leifer, R., xiii, 127 Schildkraut, J. J., 58, 129
Lifton, R. J., 107, 122, 127 Schofield, W., 106, 129
Loeffler, V., 111, 122, 128 Schrag, C. O., 29, 44, 93, 97, 129
Loftus, E., 42, 44, 128 Schwartz, J. M., 125
Seligman, M.E.P., 81, 129
Mancuso, J. C., xiii, 52, 121, 129 Selin, C. E., 125
Marriotta, J. C., 125 Shader, R. I., 33, 126
May, R., 111, 128 Skinner, B. F., 20
McCarthy, C., 97, 128 Slater, L., xiii, 96, 129
Meloy, J. R., 49, 128 Spiegel, H., 127
Mirowsky, J., 98, 99, 108, 128 Spiegel, J. P., 126
Morris, D., 38, 128 Sullivan, H. S., 96, 104, 129
Munford, P., 125 Szasz, T. S., xiii, 49, 84, 94, 102,
106, 129
Nestler, E. J., 59, 127 Szuba, M. P., 125
Norden, M. J., 26, 128
Thich Nhat Hanh, 94, 129
Ochs, E., 43, 126 Turpin, J., 127
Olson, E., 107, 127
Omer, H., 81, 128 Valenstein, E., xiv, 129
Osheroff, R., 14 von Bertalanffy, L., 25, 129
Pam, A., 102, 128 Wallerstein, E., 55, 129

Parsons, T., 37, 40, 128 Watson, J., 20
Subject Index
American Psychiatric Association, of psychiatry, 98

52 and science, 91–92
American Psychological Associa- and symptoms, 117
tion (APA), 50–51 and values, 117
anxiety and coherence, 111 disease, 93–94
drugs, theoretical vacuum, 34–35
behaviorism, 21 dualism, xiii, xiv, xix, 6, 19–31,
47–50
citizenship, 55–57
cognitive psychology, 21 effort, 35–37
coherence, xiii, xvi, xvii existential issues, 87–88, 110, 114
and anxiety, 111
creation of, 75 GATT, 56
external, 112, 114 Great Depression, 119–121
internal, 112, 114 guilt, 113
of narrative, 119, 120
of social injustice, 113 hidden meanings, 109, 114
culture and treatment, 17 Hiroshima, 122
historical versus scientific under-
Darwinian theory, 56 standing, 27
death, xviii, 73, 78, 79, 96, 110, 113 homogenizing people, 116–117
depression, 57, 95, 101, 117–119
depth psychology, 110–111 identity, 69
diagnosis, 51–52 illness as social fact, 37
dimensional versus categorical de- IMF, 56
scription, 15 incest, 41–43
discourse analysis, 91–98 insanity plea, 49–51
134 SUBJECT INDEX
insurance, coverage of psychologi- issues explored in, 68

cal conditions, 52–55 as narrative reconstruction, 75
I. Q., 57 passim
the point of, 84
just world, 114 the process of, 87
questions within, 67
knowledge as power, 100 passim and science, 85–86, 88–91
theory of, 72 passim
language, 46–49 power, 67–68
legal system, 41–43 as knowledge, 100 passim
listening, by medical practitioners,
38, 39 recovered memories, 41–43
relationships explored in therapy,
mastering nature, 38 69
meanings of symptoms, 109 religion, 32, 47, 110
medical education, 121
mental health, 117 science, 31–34
marriage (Rob’s), 74–75 as dialogue with nature, 89–91
moral reflection, 114 and discourse, 91–92
and psychotherapy, 85–86,
NAFTA, 56 88–91
narrative, xv, 27, 30, 40, 66, 73 and symptoms, 117
coherence of, 112 and values, 117
depth of, xviii symptoms, 109, 115
language of, 21
medical, 40 technology, xiii, 2, 114, 117
in therapy, 73 theoretical incoherence, 31–59
narrative self ,74 tradition, explored in therapy, 69
trauma therapy, 23–25
nature, attitudes toward, 92
triviality, xi, 111, 114
neglect of the personal, 39
ultimacy, ix, 3, 65 passim, 110–111
placebo, 16–17, 25–26
and anxiety, 111
postmodernism, xvi, 31, 43, 83–93,
and death, 109, 110
100
evasion of, 114–115
and critique of self-narrative, 80
and existentialism, 111
psychopharmacology, 25–27, 101
critique of, xiii, xiv, 3–17, 33, vantage point, 103–104
34–35
and homogenization, 116–121 war, xii, xviii, 97, 107
as provoking interpretation, Who am I to be?, 3, 36, 67, 68, 116
10–11 Who benefits?, 99
psychotherapy, 67–70, 84, 109–122 world bank, 56
and authority, 86 world-design, 77–78
About the Author
ERNEST KEEN is Professor Emeritus of Psychology, Bucknell Uni-

versity, a practicing psychotherapist, and the author or coauthor of
several books, including Drugs, Therapy, and Professional Power
(Praeger, 1998) and Chemicals for the Mind (Praeger, 2000).

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Ultimacy and Triviality

Keen, Ernest, 1937–

The paper used in this book complies with the

The Problem of the Insanity Plea 49

I have practiced and reflected on psychotherapy, and I have recog-

available, and when it is not explicit it is nonetheless close by. In the

events and medicalized diagnostic descriptions: it sometimes works

now as professionals, capable of indulging triviality as if it were an

tion brings us directly into contact with postmodern and narrative

How are we to understand the role of medication in the practice of

For some depressed or psychotic patients, therapy is barely possible without

We may, therefore, ask how we might understand the difference

his or her “psychology.” We do not know how to unravel the complex

THE PHYSICAL AND THE PSYCHOLOGICAL

I recently had occasion to do marriage counseling with a couple in which the

Kramer,2 who refers to this case as a “typical family therapy” issue,

will be as good if one partner simply changes to some less trouble-

Ignorance of physical causation is not a boon; in today’s world it is a form of

Kramer here is not denying a difference between physical disease

MEDICATION AS PROVOKING INTERPRETATION

and even educational themes like telling people something they

SUMMARY AND CONCLUSIONS

I fear we can count on this pattern to continue and to produce in-

does not prescribe antidepressant medicine. Healy (1997) describes the

2. I discuss this case also in Keen (1998), chap. 4.

circumstances. We might appreciate this variation of states by thinking

Our current scientific response to this phenomenon is quite variable.

It is possible, or necessary, in light of these considerations, to inquire

Neurons and Narratives

THE TWO DISCOURSES OF PSYCHOLOGY

lieved that reducing the subject matter of psychology to the object

central, rather than marginal, in American psychology. There had

FROM TRAUMA THERAPY

is mental events we must understand if we are to interpret what we

cation may be the same whether it is an active antidepressant or a

sider drugs magic: My fears of my incompetence don’t frighten me,

We have always two universes of discourse—call them “physical” and “phenomenal,”

pend on one or the other (psychological or physical) language. It is telling

“A professional disgrace”—strong language. It is, in fact, language

Such a commitment bears differences and similarities to a relig-

“Science,” and yet through these many satellites we all came to be

spite of exciting advances, neuroscientists know little more about

DRUGS: A THEORETICAL VACUUM

THE PSYCHOLOGY OF HUMAN EFFORT

“mental” problem. The mechanics of behavior are working, but the

BEING ILL AS A SOCIAL FACT

Not only is medical discourse partial and yet presumptuous about

of mastering nature. The human ability to control and cure disease

contributes to a social narrative of humanity that will ground psy-

PSYCHOLOGY STRUGGLES WITH RECOVERED

ceptive than the metaphorical language above. Experimental rigor

tique.” For a helpful discussion of the effect of postmodern thought on con-

Wider Echoes of the

Let me begin by stating some very general facts about language

The dualism of Descartes greatly advanced what became natural

problems often encountered in so-called mental sciences, such as

THE PROBLEM OF THE INSANITY PLEA

What is the APA saying here? Confusion continues to reign. Is the

THE PROBLEM OF DIAGNOSIS

world of responsibility and human morality, on the one hand, and

FINANCING PSYCHOLOGICAL TREATMENT

bound to produce bigger and better safeguards than is our concern

As in the case of the insanity plea, we psychologists, but also the