Escaping the behavioural ‘spin’ of evidence-based psychiatry: Merleau-Ponty’s ontology of truth

Naturalizing phenomenology – A philosophical imperative

The Beagle record: By R. D. Keynes. Pp. 409. Cambridge University Press, London. 1979. £30.00

An important contribution to the field of communication is François Cooren's critique of the assumption that the social and the material are entangled because this assumption reproduces the divide it claims to reject. Rather, Cooren proposes that the social and the material are properties, or (im-)properties, of one another because their relational differences bring organizations into existence. Cooren's three conclusions on this matter argue that the sociomateriality of an organization is a relational ontology. In this article, I problematize those three conclusions and suggest Maurice Merleau-Ponty's ontology of flesh as an alternative to overcome the problematics of each conclusion. Conclusion 1 lacks a conceptual groundwork explaining where social and material matter comes from, and I suggest flesh as the element to categorize matter. Conclusion 2 denigrates human existence to a matter of degree. I reframe this through the notion of alterity. Conclusion 3 suggests that relations and relata are the same yet theoretical support for that proposition is missing. As such, I offer the missing theoretical support through Merleau-Ponty's ontology of flesh. Taken together, Merleau-Ponty's ontology of flesh provides one coherent system and better affirms each of Cooren's conclusions of what a relational/communicative ontology of organization consists of.

Just as the perceived world endures only through the reflections, shadows, levels and horizons between things ... so the works and thought of a philosopher a re also made of certain articulations between things said. Maurice Merleau-Ponty, Philosopher and His Shadow What other mode of reading or writing, of interpretation and affirmation, may be mine inasmuch as I am a woman, with respect to you, a man? Is it possible that the difference might not be reduced once again to a process of hierarchization? Of subordinating the other to the same? Luce Irigaray, This Sex Which Is Not One Irigaray has stated that her readings of philosophical texts are not intended to reproduce a point-by-point interpretation of philosophers' utterances.' Still, one is startled to find that her reading2 of Merleau-Ponty's influential chapter, Intertwining-the Chiasm from The Visible and The Invisible? skips over its entire middle portion, focusing only on its first and last few pages. Along with this glaring omission, Irigara'sy characterization of Merleau-Ponty's work as oculocentric, solipsistic, and male-biased is another puzzling and controversial aspect of her commentary. For one thing, touch is critical to Merleau-Ponty's understanding of perception. His notion of reversible flesh is based on a model of touched and touching hands. Moreover, he calls solipsism an illusion and even says, in the chapter under discussion, that the visible is to visions other than our (VI 143). Finally, his philosophy has influenced feminist theorizing, Irigaray's included, in a remarkably positive way.4 So perhaps it is not surprising that her critique, entitled Invisible of the Flesh, has itself become the focus of commentary explaining or cross-examining her objections to MerleauPonty.5 Ethical and ontological issues at stake in her reading account for some of this critical attention and lead to questions concerning the viability of both philosophical projects. Is there room in Merleau-Ponty's ontology for a sexually and subjectively differentiated other or is this possibility precluded, as Irigaray suggests, by his positing a structure of reversibility? Can Irigaray open up some sexually-differentiated, respectful space between her reading and his writing or does her use of a controversial mimetic strategy simply reproduce or reintroduce unethical gestures of silencing and exclusion? In questioning Merleau-Ponty, does she take her own ethics seriously or is her apparent disregard of so much of what he says a scandalous suppression of his own (sexually-differentiated) speech? This essay argues that Irigaray's interpretative re-reading should not be dismissed as a simple mis-reading, an uncharitable account or irresponsible caricature of Merleau-Ponty's philosophy.6 While skipping so audaciously over the middle part of Merleau-Ponty's text may complicate her critique and make it appear uninformed, evasive or unbalanced, I show how this obvious omission can also be read as a critical aspect of her argument, a strategy of resisting his notion of one universal Flesh and ultimate truth of its reversibility (VI 155). As we shall see, the lapse in Irigaray's reading mimes what she discursively depicts as the neglect of a sensible medium in his Flesh ontology and is a (fittingly) silent indication of her own sense of this medium. What she leaves unspoken in her text is intimately connected and meaningfully fleshed out by what is. My interpretation of Irigaray's critique approaches it through the twin lenses of narcissism and nostalgia. Through Irigaray's selective reading, idiosyncratic questioning and unconventional interpretative strategies, we see her ontology diverge from MerleauPonty's at the point where they seem most enmeshed: in the notion of a pre-reflective, prediscursive formative medium-that of (maternal) flesh. While her notion of sexual difference appears to be influenced by an ontological matrix of non-coincidence original to Merleau-Ponty, she achieves a critical distance from it by exposing its reliance on a patriarchal or polarized understanding of sexual difference, where the sexes are modeled after a mother/son relationship or regarded as reversed reflections of each other. …

In a fourteenth-century copy of Henri de Mondeville's Chirurgia (Cambridge, Trinity College, MS 0.2.44), a flayed human body carries its skin on a staff, displaying the underlying fleshy tissues. The unpainted drawing illustrates Mondeville's discussion of flesh and fat. Taking this image as its main focus, this article is concerned with the fleshiness of the medieval image. It considers medieval understanding of flesh to examine the relationship between flesh and the figure in the Chirurgia. I explore closely the relationship between parchment, a support made of skin, and the pen-drawing on its surface. Moreover, I draw on Maurice Merleau-Ponty's ontology of flesh, which postulates an association between visuality and flesh. Overall, the article argues that the drawing formulates a discourse on flesh. It is not merely a depiction of flesh but rather, I contend, becomes fleshy in the interaction with the viewer.

In our philosophical, medical, and everyday discourse we are often forgetful of the creative subjectivity of the pregnant and birthing woman. Traditionally, woman is more easily associated with the body, but she is thought to become even fleshier in pregnancy and less able to think. The ever more expansive materiality of her body will impede her movement and cloud her mind. I find this emphasis on the passivity of the pregnant body problematic. It assumes that pregnancy and birthing could not possibly be creative processes. The artist creates; the pregnant woman merely lets procreation happen. In opposition to this negative view and with help of Simone de Beauvoir's description of a “strange creativity” and Maurice Merleau-Ponty's ontology of the flesh, in this essay I contend that the pregnant woman's body is more than an instrument of passivity; it is a lived-body of an engaged and strangely creative subject and this “strange creativity” she has indeed in common with the artist.

A new materialism in literary and cultural criticism has regrounded much scholarly debate in the archive as a corrective to ahistorical theorizing. Often, in granting archival discoveries the evidentiary status of fact,historical criticism fails to attend to the difficulties surrounding the mediation of historical understanding by material things. In order to get at the thorny issues surrounding the material as an authorizing category in cultural analysis, I focus on Shakespeare's well-known literary meditation on visual proof (and visual perception) in Othellogy. Reemphasizing the problems that nag materialist epistemologies, I examine the role of material(ocular) proof in Othellogy, in the form of the much discussed handkerchief. Drawing on Maurice Merleau-Ponty's ontology of perception, I argue that Othellogy provides a parable about the disaster of confusing the objecthood of things with the stories we tell about them. I conclude that as cultural history moves into its next phase—beyond the return to the archive—it must respond to the phenomenological challenge and avoid the temptation to stop with either thing or theory, always working to occupy the space between.

Aesthetic surgery is commonly framed as a technical modification of anatomic structures. Yet patients rarely seek surgery for tissue alone; they seek transformation within a visual and social field. Drawing on the philosophy of Maurice Merleau-Ponty, particularly his concepts of "flesh" and the reciprocity of seer and seen, this paper reinterprets aesthetic surgery as an intervention within the relational space between body and gaze. Merleau-Ponty's ontology of flesh describes the body not as an object but as a visible-sensible field embedded in mutual perception. The surgical patient inhabits a body that is simultaneously lived and seen. In aesthetic practice, the surgeon operates at the intersection of anatomic modification and perceptual recalibration. Procedures such as rhinoplasty, blepharoplasty, or facial contouring alter structural form; however, their clinical success depends on shifts in self-perception, social gaze, and embodied confidence. Thus, aesthetic surgery functions as a recalibration of the reciprocity between flesh and gaze rather than a mere correction of tissue. This relational perspective reframes surgical ethics: the surgeon intervenes not simply in morphology but in a perceptual ecology. Understanding aesthetic surgery as an intervention into the reciprocity of flesh and gaze expands the conceptual horizon of craniofacial practice. It situates technical skill within an embodied, phenomenological framework and encourages surgeons to acknowledge the lived body as central to operative decision-making.

The aim of the present survey is to discuss Merleau-Ponty's description of our experience of the world in terms of nature (section 1) and its development in relation to a particular expression of nature, namely that of the living being (Section 2). This survey, which strictly refers to Merleau-Ponty's Nature lectures, will allow us to retrace the way in which Merleau-Ponty, addressing certain specific natural phenomena, carries out a description of our experience of the real. Particularly, we will discuss Merleau-Ponty's analysis of nature and the living being with the aim of eventually focusing on the results of his phenomenology of nature (Section 3) as the outline and anticipation of an ontology of reality which, although never completed because of Merleau-Ponty's premature death, finds in his projected work of The Visible and the Invisible the challenging expression of a 'negative philosophy.

Jean Laplanche (b. 1924–d. 2012) was a French psychoanalyst and vintner. Among the most innovative and theoretically rigorous thinkers of his generation, his work is characterized by a return to the letter of Freud’s text, a method of reading Freud according to Freudian principles, and a complete rethinking of the foundations of psychoanalytic theory and practice. Under the Vichy regime, he joined the French Resistance in 1943. The following year, he entered the École Normale Supérieure where he studied philosophy with Jean Hyppolite, Maurice Merleau-Ponty, Gaston Bachelard, and Ferdinand Alquié. In the years 1946–1947, he received a scholarship to Harvard University where he developed an interest in psychoanalysis through the interdisciplinary Department of Social Relations. Upon returning to Paris, he became a founding member of the revolutionary group Socialisme ou Barbarie. In this same period, he entered into analysis with Jacques Lacan, who remained his mentor until 1963. Laplanche signaled his formal break with Lacan in 1964. However, his intellectual break was well underway when, at the historic Bonneval conference of 1960, in a paper with Serge Leclaire, he directly opposed Lacan’s theory of the unconscious “structured like a language.” In 1967, with J.-B. Pontalis, he published The Language of Psychoanalysis, today the definitive encyclopedia of Freudian thought. The fruits of this project were distilled in Life and Death in Psychoanalysis (1970). A book of extraordinary insight, Laplanche showed how Freud’s thought is structured by the rhetorical figure of chiasmus, wherein the repression of the sexual unconscious is itself the object of repression. This critical return to Freud was intensified through a series of lectures published as Problématiques. Lessons from the first five volumes are condensed in New Foundations for Psychoanalysis (1987). Whereas Life and Death showed how the sexual drive “leans on” vital instinct, thus restoring the rightful place of sexuality in the psychoanalytic understanding of the human being, New Foundations presents nothing less than a refounding of the entire psychoanalytic enterprise. From a recovery of Freud’s famously abandoned seduction theory, Laplanche developed a “general theory of seduction,” which explains how the situation of primal seduction, the primacy of the other in the transmission of enigmatic messages from adult to infant, is simultaneously the irreducible foundation of psychoanalysis and human subjectivity. With career achievements as co-founder of the Association Psychanalytique de France, professor of psychoanalysis and founder of the Center for Psychoanalytic Research at the Université de Paris VII, founder of the journal Psychanalyse à l’université, and scientific director of the translation of Freud’s complete works into French, the magnitude of his thought is only now starting to penetrate Anglophone audiences.

This paper analyzes Foucault’s early thinking (from 1954 to 1957) as it bears on psychology, anthropology and psychiatry. The author maintains that Foucault’s texts from that period can be mined for the origins of the Foucault methodology, early indications of its scope, and its first applications. Although Foucault opposed a phenomenology of epistemology and allied himself with the latter, a close reading of his early work reveals a paradoxical synthesis of phenomenological and epistemological views. The influences of Georges Canguilhem, Maurice Merleau-Ponty, and Ludwig Binswanger were decisive here.Foucault adopted the “practice-to-theory” vector from Canguilhem and grounded the history of psychology and psychiatry on the study of essential oppositions: normal - pathological, personality - environment, evolution - history. Merleau-Ponty’s theory allowed him to demonstrate that the ontological perspective of psychology and psychiatry does not match the subject of their research, which is the person and their experience. Foucault’s application of Binswanger and the idea of existence is to problematize the boundaries between psychology and psychiatry and their identity as sciences while formulating the problem of pathology and normality as crucial to their identification. He also considers mental illness as one of the forms of experience. Foucault thus goes beyond the boundaries of psychology and psychiatry to develop his archaeological method. In the Order of things and the Archaeology of Knowledge he makes two philosophical maneuvers: in the first, he rejects the subject; in the second he abandons the continuity of history. Foucault’s early psychological and psychiatric discourse is then the first harbinger of his trespassing the boundaries of disciplines and schools, combining perspectives, and scrutinizing the foundations of scientific practice. A critical dialogue with his own earlier thought is the source of Foucault’s birth as a philosopher.

As a way to make medical decisions, Evidence-Based Medicine (EBM) has failed. EBM's failure arises from not being founded on real-world decision-making. EBM aspires to a scientific standard for the best way to treat a disease and determine its cause, but it fails to recognise that the scientific method is inapplicable to medical and other real-world decision-making. EBM also wrongly assumes that evidence can be marshaled and applied according to an hierarchy that is determined in an argument by authority to the method by which it has been obtained. If EBM had valid theoretical, practical or empirical foundations, there would be no hierarchy of evidence. In all real-world decision-making, evidence stands or falls on its inherent reliability. This has to be and can only be assessed on a case-by-case basis applying understanding and wisdom against the background of all available facts—the “factual matrix.” EBM's failure is structural and was inevitable from its inception. EBM confuses the inherent reliability and probative value of evidence with the means by which it is obtained. EBM is therefore an ad hoc construct and is not a valid basis for medical decision-making. This is further demonstrated by its exclusion of relevant scientific and probative real-world decision-making evidence and processes. It draws upon a narrow evidence base that is itself inherently unreliable. It fails to take adequate account of the nature of causation, the full range of evidence relevant to its determination, and differing approaches to determining cause and effect in real-world decision-making. EBM also makes a muddled attempt to emulate the scientific method and it does not acknowledge the role of experience, understanding and wisdom in making medical decisions.

Arguments for and against evidence-based psychiatry have mostly centred on its value for clinical practice and teaching. Now, however, use of the same paradigm in evaluating health care has generated new problems. To outline the development of evidence-based health care; to summarise the main critiques of this approach; to review the evidence now being employed to evaluate mental health care; and to consider how the evidence base might be improved. The following sources were monitored: publications on evidence-based psychiatry and health care since 1990; reports of randomised trials and meta-analytic reviews to the end of 2002; and official British publications on mental health policy. Although evidence-based health care is now being promulgated as a rational basis for mental health planning in Britain, its contributions to service evaluation have been distinctly modest. Only 10% of clinical trials and meta-analyses have been focused on effectiveness of services, and many reviews proved inconclusive. The current evidence-based approach is overly reliant on meta-analytic reviews, and is more applicable to specific treatments than to the care agencies that control their delivery. A much broader evidence base is called for, extending to studies in primary health care and the evaluation of preventive techniques.

Le discours psychiatrique contemporain dominant repose principalement sur un paradigme médico-technologique où la souffrance mentale est conceptualisée comme un « mécanisme défectueux » qui nécessite une « réparation » grâce à l’arsenal médical. Dans ce contexte, l’evidence-based medicine(EBM) a donc été largement adopté par la psychiatrie à la fin des années 90. L’EBM est une proposition qui vise à influencer et même légiférer la prise de décisions cliniques en mettant de l’avant l’idée d’une hiérarchie des évidences, où le savoir tiré d’essais contrôlés randomisés (ECR) et de méta-analyses a préséance sur les informations tirées d’autres sources. Ainsi, comme l’EBM favorise ces outils de création de savoir (ECRs et méta-analyses) il en découle que le savoir qui compte véritablement dans le paradigme EBM est celui qui est mesurable et spécifique ; deux conditions préalables nécessaires pour l’utilisation même de ces outils. En conséquence, l’EBM diminue la valeur et va même jusqu’à ignorer d’autres formes d’évidences, de savoir et de justifications pour la prise de décisions cliniques. Du point de vue éthique, le concept EBM soutient que la « bonne chose à faire » est d’appliquer le savoir produit par l’EBM dans le contexte clinique. Les autres formes de savoir pouvant être impliquées dans la prise de décisions cliniques, mais qui ne peuvent pas être étudiées via l’EBM, sont dévalorisées d’un point de vue éthique. La littérature révisée et explorée ici considère donc que l’EBM est mal adapté à la réalité de la pratique psychiatrique. L’EBM ne peut pas, par définition, prendre en compte les spécificités de la discipline, notamment pour ce qui est des diagnostics psychiatriques ; leur complexité rend les évidences produites par l’EBM d’une validité questionnable. Le concept ne peut pas non plus tenir compte des spécificités des thérapeutiques psychiatriques. Les facteurs thérapeutiques non spécifiques, ceux discrédités par l’EBM, sont cruciaux pour les soins de santé mentale. Également, les observations portant sur des aspects de l’esprit, sur des expériences subjectives, ne sont que bien incorrectement traduites en résultats statistiques, mesurables et spécifiques. Ces observations amènent le présent essai à considérer qu’il serait peut-être préférable pour la psychiatrie, de rejeter la « hiérarchie des évidences » de l’EBM, et de développer son propre « système des savoirs ». Celui-ci devrait prendre en compte la position épistémologique unique de la psychiatrie, où subjectivité, contextes, et valeurs pourraient occuper de façon légitime la place qui leur revient dans la prise de décisions cliniques en psychiatrie. Bien qu’une alternative à l’EBM en psychiatrie n’ait pas encore été établie, la littérature, et ce papier pointent vers l’idée d’un « système des savoirs » plus flexible que ce qu’offre l’EBM en termes épistémologiques, où les aspects éthiques reliés à la discipline, incluant l’éthique du savoir, l’éthique de « ce qui compte comme évidence », revêtent une importance cruciale.

The current emphasis on Evidence Based Medicine (EBM) is both welcome as a bid to improve the empirical foundations of clinical practice and a cause for concern because it has the potential to distort the scientific approach that has underpinned the development of cognitive-behavioural approaches. It is suggested here that EBM needs to be seen in context; that is, as an approach that almost exclusively focuses on just one of the dimensions that have been and are crucial to the further development of Cognitive-Behavioural Treatments (CBT). EBM is particularly well suited to the development of Biological approaches to treatment, where treatments (and treatment development) are largely atheoretical. However, different considerations apply to CBT, where validated theory and linked research studies are key factors. It is suggested that relationship to evidence in CBT is best conceptualized in terms of Empirically Grounded Clinical Interventions. The parameters of such an approach are considered in relation to the Scientist Practitioner model that is prevalent in the field.