Pharmaceutical reasoning
Tom Strong
As became clear in this context, the movement of standards not only carries technical implications, but also poses new ethical and political dilemmas.
(Lakoff, 2008, p. 14)
In a book titled Pharmaceutical Reason: Knowledge and Value in Global Psychiatry (2008),
Andrew Lakoff examines the controversial intersection of political, cultural, professional, and biomedical developments related to mental health practice in contemporary Argentina. A medical anthropologist with a Foucaultian perspective, Lakoff analyses tensions accompanying the increasing biomedicalization of mental health. With the Argentine experience as backdrop, he critically traces a commercial and clinical trend (and resistance to it) toward “pharmaceutical reasoning”. This developing practice, bolstered by genetic research, sees biomedicine and psychiatrists increasingly focused on the responsiveness of particular symptoms and patient
DNA combinations to pharmaceutical interventions.
Pharmaceutical Reason is a fascinating and scary book. Andrew Lakoff conducted his medical anthropology PhD research in a public psychiatric hospital in Buenos Aires. This context afforded an intriguing vantage point on a confluence of controversial issues shaping present and future mental health. Argentine mental health lags a bit behind Europe and North
America, with many Buenos Aires’ psychoanalysts (the world’s greatest concentration) still strong supporters of RD Laing’s 1960s radical psychiatry movement. Argentine politics have also seen huge pendulum swings between socialism and neo-liberalism and these swings extend

Pharmaceutical reasoning to mental health where tensions were playing out between analysts and pharmaceutically inclined practitioners. Lakoff’s riveting and Foucaultian-inspired account captures mental health professionals grappling with important issues fraught with ethical and practical implications for the future.
A modern/postmodern digression
For readers unfamiliar with Foucault’s concerns about mental health (e.g., 1988), I offer this digression. Foucault’s historical research, along with that of other cultural historians (e.g.,
Elias, 2000; Taylor, 1989), shows how arbitrary cultural definitions of problems, such as mental health concerns, and cultural responses to them, have been. This arbitrariness extends to science where historians and sociologists of science have identified conflicting paradigms of thought and practice (e.g., Daston & Galison, 2007; Kuhn, 1996; Latour, 2005). Such scholarship has sparked a contentious modern/postmodern debate over modern science’s capacity for representing reality
‘as it can be correctly known’. The scare quotes of the previous sentence bring us to the heart of the debate. Those who line up with Foucault see all knowledge and its use (such as psychiatric knowledge and its associated interventions) as bound to dominant values and politics particular to cultural groups and eras. The scare quotes of a Foucaultian ‘poststructural’ approach contextualize understandings and practices of any kind as socially constructed. Those holding that modern science can discover and ascertain universal objective truths, as fundamental to evidence-based practice, see postmodernists and poststructuralists as talking hogwash.
Where this debate gets particularly testy is when humans try to turn science back on to the study of themselves; as they might if studying rocks or other members of the animal kingdom. This testiness makes psychiatry and mental health a fascinating context to study for a medical anthropologist, particularly one adopting a Foucaultian stance like Lakoff.

Pharmaceutical reasoning
Developments in Argentine mental health – for being divided along political lines by its practitioners – offer a highly charged arena in which to make sense of a particular emerging scientific trend in mental health: pharmaceutical reasoning.
Tensions over biomedical diagnoses in mental health
Lakoff begins his analysis by recounting the efforts of a multinational biotech company to secure blood samples from the hospital’s bipolar disordered patients, for its DNA testing program back in Paris. Thus, readers are brought to a clash between Argentine psychiatric traditions and globalized commercial initiatives shaping the future of mental health treatment.
Part of the clash stems from a ‘failure’ by Argentine psychiatrists to properly use the
Diagnostic and Statistical Manual of Mental Disorders (IV edition revised; hereafter, DSM-IV-TR ) classification of bipolar disorder. While the rest of the world’s psychiatrists diagnose bipolar disorders as frequently as schizophrenia in the general population, in Argentina the ratio of schizophrenia diagnoses to bipolar diagnoses was 15: 1. Lakoff shows that there is quite a story to be told around this ‘discrepancy’, for what it portends for mental health practice.
Argentine mental health, as Lakoff presents it, can evoke a déjà vu-like familiarity for debates and concerns that never lost their currency for many mental health practitioners elsewhere. The increasing use of DSM-IV-TR diagnoses, and the associated use of diagnosisspecific interventions, sets off a number of conflicts. A few of the conflicts raised are, for example, over whether mental illness is best understood and treated as a social concern or a biomedical concern; over the replacement of local pharmaceutical products and industries with global companies who hold internationally recognized patents; over the recruitment practices used by international pharmaceutical companies to encourage psychiatrists to prescribe their medications (paid conferences, sophisticated statistically-monitored prescription ‘management’

Pharmaceutical reasoning of psychiatrists by sales reps); over whether mental health diagnoses are social and cultural constructions or like other diagnosable biomedical concerns; over what ethical treatment of diagnosed patients should constitute. What defines this as great ethnographic research is Lakoff’s astute yet critical eye for reporting striking details that convey a well-grounded sense of the tensions evident in this Argentine psychiatric hospital.
Lakoff’s research raises as many unresolved dilemmas and questions as it does answers.
Differences in mental health practice at the Buenos Aires hospital in the early years of the new millennium can be traced to old Argentine political lines: “ biomedical psychiatry was associated with the political right, and with the 1976-1983 political dictatorship, which persecuted psychoanalysts and social psychiatrists as subversive to the traditional moral order
” (p. 150).
Lakoff’s writing captures the dynamics of ‘lacanismos’ (à la Jacques Lacan) pitted against biomedicine’s more pharmaceutically oriented ‘neural activists’. But psychoanalysis,
Argentina’s primary psychotherapy, isn’t let off the hook either. Host to many of its own tensions, such as failures to address patients’ psychotic conditions, overuse by Buenos Aires’ cultural elite, and an overabundance of analysts, psychoanalysis is depicted as another less than successful human effort to pit language and interventions against suffering that won’t go away.
Readers can feel similarly when reading Foucault’s (1988) classic Madness and civilization; that
- regardless of the most well-intended and rigorous humane, artistic, scientific or administrative efforts - mental ‘illness’ won’t find a surefire response that overcomes it once and for all.
Research locally, contemplate globally
It is where such efforts seem to be heading on the global stage, and how these efforts become evident in the Buenos Aires’ hospital, that is of topmost interest to Lakoff. Drawing from the ‘psy-complex’ writings and research of Nikolas Rose (e.g., 1990), readers are shown

Pharmaceutical reasoning how mental health knowledge and practice takes on an administrative form as governments and experts using such research aim to further particular psychiatric conceptions of self and society.
In Lakoff’s research, readers are taken into similar administrative considerations – for and by multinational corporations. The earlier mentioned blood samples sought from Argentine
‘bipolar’ patients were for an ambitious project modeled on other recent developments in genetically oriented biomedicine (e.g., Wailoo & Pemberton, 2006). The DNA derived from such samples would serve the latest effort to overcome mental illness: genetically targeted pharmaceutical interventions for addressing specific DSM diagnostic conditions. This is where we are brought to the heart of the controversies so well accounted for in Lakoff’s ethnography.
Argentines had been late, or reluctant, to embrace the DSM-IV-TR as the language for mental health practice. This diagnostic classification system, as Lakoff points out, enables ways of commodifying the objects of health interventions — diagnosed conditions. Such commodified objects equate with those the financial world sees as possessing “liquidity”; assets having commercial value across international and commercial contexts. The liquidity values of diagnoses find their currency when matched with the assets of multinational pharmaceutical companies: psychiatric medications. The upside, if one sees things this way, is that the DSM-IV-
TR offers the potential of a globally common language for understanding mental health concerns.
When coupled with interventions scientifically shown to address the diagnosed concerns, rational scientific order and treatment is brought to a range of human concerns understood as disorders .
For therapists and others concerned about the world’s increasing corporatization, the downside is that standardizing mental illness and its treatment, using DSM-IV-TR diagnoses and
‘corresponding’ psychiatric medications, enables a kind of liquidity that is “ transferable between the domains of industry, government, and biomedicine
.” (p. 35). Said another way, the language

Pharmaceutical reasoning of DSM-IV-TR and its related biomedical interventions have liquidity that serves corporate and government interests as much as it meets the needs of medical specialists and their patients. For postmoderns concerned with promoting (or retaining) a diversity of therapeutic practices (e.g.,
Gergen, 1994), such a biomedical ‘triumph’ can appear as a movement toward foreclosure on what is deemed acceptable mental health practice. For snooty, biomedically oriented Argentine psychiatrists, however, the ‘triumph’ reduces psychoanalysts to “ clerics in a secular age
”
(Lakoff, p. 106). In the corporate world, the same triumph teems with lucrative possibilities.
Compared to these big scaled controversies, more mundane things were also occurring in the Buenos Aires psychiatric hospital. Considerable debate persisted over whether – or if – bipolar disorder was a diagnosable condition distinct from schizophrenia. Readers are immersed in case conferences about patients where Argentine mental health practitioners debate such differential diagnoses, while psychoanalysts debate whether such conditions could be better understood as a Lacanian failure by patients to acquire a suitable language for emotional mastery and personal agency. Such debates between the biomedically and psychoanalytically oriented psychiatrists had cleaved into a subjective/objective binary, with psychoanalysts championing human desires and meanings, while in the language of one biomedically oriented psychiatrist,
“ discarding subjectivity is not discarding the person ” (p.126). Meanwhile, back at the Parisian laboratory, the intention was to relate the DNA found in diagnosed patients’ blood samples to responsiveness to particular drugs also under development by the company owning the lab.
Niche reasoning
A new kind of reasoning animates this lab-setting, reasoning that can be related to the insights of the philosopher of science, Ian Hacking. Hacking’s recent historical research (e.g.,
1999) suggests that particular mental health concerns require and thrive in “niches” where

Pharmaceutical reasoning cultural assumptions, concerns and practices converge as forms of cultural and scientific reasoning brought to bear on specific historico-cultural concerns. His examination of converging factors in such a niche, at the end of the 19 th
century, when fugue states in “mad travelers” were scientifically and culturally reasoned to be an ‘epidemic’, serves as a case in point. Lakoff’s concern is that pharmaceutical reasoning is becoming our era’s niche, and it has already escaped from the lab and made its way into clinical (and possibly cultural) reasoning.
“Pharmaceutical reason” speaks to an entirely new way of considering mental illness and its treatment. The reasoning goes as follows. DSM-IV-TR is a language that is both imprecise in description and imprecise in diagnostic use. Such imprecision can be overcome by turning to pharmaceutical science. Specifically, if a medication therapeutically addresses a patient’s complaints, it is the medication, backed up by research that shows what it has been effective in treating in the past that indicates the ‘actual’ diagnosable condition. In other words, patients’ conditions are best diagnosed according to the medications their conditions are responsive to.
When a patient’s DNA profile is thrown in as added information (along with the symptom complaints), choice of medication, based on prior research with similar complaints and genetic make-ups, becomes more targetable. Stressors are seen as activating pre-existing genetic predispositions or risks for conditions for which one can prescribe a tailor-made, geneticallycompatible medication. Clinically, there would be no reason to talk to patients at all as historical, genetic, and other details furnish the evidence required for the needed biomedical intervention.
What can remain, however, is a need for “diagnostically truing” medications according to the responses they elicit, until the proper biochemical balance is restored with the right medication.
Undergirding this pharmaceutical reasoning is the structural assumption that causal factors and

Pharmaceutical reasoning diagnosable conditions are materially identifiable; and best through chemical responsiveness (or lack thereof) rather than from diagnostic data produced in practitioner-patient interviews.
Conclusion
Lakoff has a knack for conveying the understandable and palpable tensions that were playing out in the exotic but not unfamiliar Buenos Aires’ psychiatric hospital. The stakes for mental health were high both there, and in how they feature in mental health practice across the globe. The blood samples of ‘bipolar disorder’ patients in Buenos Aires could bring mental health closer to the kind of humanity envisioned in his chilling novel Brave New World by
Aldous Huxley (2006, original published in 1932) back when the world slumped into its last economic depression. Lakoff shows that the increasing corporatization of mental health, twinned with developments in genetic research and biopsychiatry, was a battle Buenos Aires psychoanalysts felt they had to fight, despite the then diverse practices in mental health in
Argentina. However, Lakoff’s research on “pharmaceutical reasoning” points to converging developments shaping mental health worth better understanding and of concern to us all.
References
Daston, L., & Galison, P. (2007). Objectivity.
New York: Zone Books.
Elias, N. (2000). The Civilizing Process (revised edition). Oxford, UK: Basil Blackwell
(original edition published in German, 1939).
Foucault, M. (1988). Madness and Civilization: A History of Insanity in the Age of
Reason.
New York: Vintage.
Gergen, K. (1994). Realities and Relationships: Soundings in Social Construction.
Cambridge, MA: Harvard University Press.

Pharmaceutical reasoning
Hacking, I. (1999). Mad Travelers: Reflections on the Reality of Transient Mental
Illnesses. Cambridge, MA: Harvard University Press.
Huxley, A. (2006). Brave New World . New York: Harper Collins (originally published in
1932).
Kuhn, T. (1996). The Structure of Scientific Revolutions . Chicago: University of Chicago
Press.
Lakoff, A. (2008) Pharmaceutical Reason: Knowledge and Value in Global Psychiatry .
New York: Cambridge University Press, 2008)
Latour, B. (2005). Reassembling the Social: An Introduction to Actor-Network Theory .
Oxford, UK: Oxford University Press.
Rose, N. (1990). Governing the Soul . New York: Routledge.
Taylor, C. (1989). Sources of the Self: The Making of the Modern Identity . Cambridge,
MA: Harvard University Press.
Wailoo, K., & Pemberton, S. (2006). The Troubled Dream of Genetic Medicine: Ethnicity and Innovation in Tay-Sachs, Cystic Fibrosis and Sickle Cell Disease.
Baltimore,
MD: The Johns Hopkins University Press.
Tom Strong PhD works in the Division of Applied Psychology at the University of
Calgary. E-mail: strongt@ucalgary.ca