The following was presented at a meeting of the Lacan Circle of Melbourne in July, 2013:
Marie-Helene Brousse (2013, p. 24) said of diagnosis that it was considered by Lacan ‘as an act, implying a decision requiring logical argumentation and clinical confirmation’. Alas, this is not the modus operandi for mainstream psychiatry and psychology.
To begin, the ICD system of collating and classifying medical disorders was probably the first attempt to systematise psychiatric diagnosis that found widespread acceptance. With its origins in the late 19th Century, it remains the most used diagnostic system around the world. However, it is the DSM system which has attracted more attention recently, with the release, earlier this year, of the DSM-V. Whilst some may be tempted to contrast the ‘good’ ICD with the ‘bad’ DSM, both systems are very similar, and the ICD-11 is expected to be brought into line with the DSM-5 in any case.
The development of the DSM arose in the US following the Second World War. So many of the dominant ideas of psychiatric diagnosis and treatment derived from this time and place, in a situation where there was mas demand for psychiatric and psychological interventions. The first edition was published in 1952; the second in 1968, with a revision of the latter arriving in 1974. The DSM-III was published in 1980, and the DSM-IV in 1994. The most recent edition, like its predecessors, spent several years in development. Unlike previous DSMs, however, the fifth version is the first to be published in the internet age, and has been the subject of criticism for years before its actual arrival. This is the main reason that I can think of for the controversy, since the latest DSM is, in every respect, a continuation of its predecessors, rather than a departure. I should add that this crisis of confidence in the DSM is accompanied by controversy in other areas of my discipline, clinical psychology. The practice of ‘burying’ negative findings is extensive, to the point of systematically distorting the empirical bases of many theories. The battle over what treatments are ‘evidence based’ continues, and regulators in Australia, at least, are raising the regulatory requirements of practitioners, and have announced crackdowns on those who deviate from official doctrine, even though this latter remains contested, where it is even defined at all.
There have been numerous criticisms of the DSM, and I won’t attempt to summarise them all here. Some, it should be said, are criticisms made by sympathisers, on purely technical, statistical grounds. For instance, some have argued that the reliability and validity of certain diagnoses are poor, particularly inter-rater reliability. Some objections have their origins in the anti-psychiatry movement of the 1950s and 60s, especially the notions that the vast expansion of disorders in the DSM constitutes an attempt at social control, by way of the medicalisation of ‘normal’ distress. Allen Frances, who formerly worked on the DSM, has spoken at length about the flaws of the DSM, including on the Lateline program, where he called for a restoration of faith in psychiatry. This struck me as unwittingly paradoxical, since the authority of psychiatry and psychology, and the justification for coercive practices, lies precisely in its assertions not being mere matters of faith.
When terms like the psychiatric ‘Bible’ are thrown around, the DSM’s authors may be tempted to believe their document was carved from stone tablets on Mount Sinai. Nonetheless, historians of the document know it to be thoroughly political. Homosexuality, for instance, was deemed a pathology in the first two editions. PTSD was added to the third edition after extensive campaigning by Vietnam veterans.
Aside from the ethical and technical objections to the latest DSM, there are a couple of others I’d like to discuss. Firstly, the raison d’etre of the DSM is to provide descriptions that will allow symptoms to be universally observed and classified. It is explicitly a matter of eliding subjectivity, in this case, for both patient and clinician. The patient’s symptoms are only registered insofar as they are transposed into the discourse of the DSM. The clinician is supposed to make a diagnosis with only a minimum of clinical judgement, which is to say, with minimum subjectivity. (In some jurisdictions, actuarial methods are coming gradually to replace clinical logic altogether). I should emphasise that, unlike in psychoanalysis diagnosis, assessment in mainstream clinical practice is generally a very quick affair, and in emergency settings is often completed in half an hour. Even court-mandated assessments seldom involve more than about 2-3 hours of contact time with the patient.
How do we determine what is a symptom? For both the DSM, and for psychoanalysis, it is a matter of naming, of nomination, but with the DSM, this nomination is never singular, but always aims at bringing the particular into the general, and only then, with a view to abolishing it. The consequences of naming and abolishing of symptoms are not considered by the authors of the DSM.
In an extraordinary paper from 1992, an author of the DSM, then and now (Wakefield, 1992), actually argued that there is no coherent definition of psychiatric disorder. It is not, he said, a ‘pure’ scientific construct. Nor is it simply ‘whatever professionals treat’, since many ‘disordered’ individuals never seek treatment. Nor can it be understood in terms of distress, since not all disorders (such as sociopathy, for instance) are associated with subjective distress. Statistical aberration is likewise an unsuitable criteria, since this would make the particularly gifted, for instance, disordered. Having comprehensively refuted the basis for his own document, Wakefield attempted (unsuccessfully, I would argue) to resurrect it through the notion of ‘harmful dysfunction’, based on evolutionary psychology. Notwithstanding Wakefield’s speculative attempts to resolve the problem, there seems to be no coherent definition of a symptom within the DSM’s own framework.
One presumption behind the DSM is that the disorders it describes have some biological cause or correlate, yet this presumption has been insufficient for the US-based NIMH, who rejected the latest DSM, and wants instead to replace it with a diagnostic system based on biomarkers and brain scans. This approach seems to me to betray a fundamental misunderstanding about subjectivity, namely, the bizarre assumption that disorders of subjectivity are essentially non-existent unless localised to some part of the brain or genome. It’s a bit like turning to a physics textbook in order to learn how to cook a soufflé. It’s an extraordinarily basic, and naive conceptual error – to attempt to look at brain cells in an attempt to discern subjective complaints. Moreover, far from bringing the clinical disciplines into the 21st Century, the NIMH method is actually a regression to 19th Century phrenology, in which diagnosticians attempt to reduce human subjectivity to mere image.
The principal objection to the DSM, and the main reason for it being derided, is the massive increase in new diagnostic categories. There are now hundreds of diagnoses, many of which are based on splitting old categories into multiples. This expansion of the DSM is what I would like to discuss now, and I see at least three key reasons for it. The first is the political economy of health care; the second relates to what I will call, after Lacan, academic discourse; and the third and final relates to the epistemology of psychology and psychiatry.
1 Political Economy
The political economy of psychiatry and psychology has received extensive critique in recent years. The APA itself makes about $5 million a year through the DSM. The role of the pharmaceutical industry in manufacturing diagnoses, tampering with data, and marketing supposed cures is well-documented. Whilst Big Pharma played no direct role in supporting the development of the DSM, the overall research context is inconceivable without it. This is particularly the case with certain diagnoses, such as ADHD, or Bipolar, as outlined in a recent book by Darian Leader (2013). Nevertheless, whilst Big Pharma has the most to gain by, for instance, hiding negative findings of outcome studies, this sort of distortion is hardly limited to the corporate world.
The state of healthcare in the US is also a major factor in the push to proliferate diagnoses. A good deal of non-urgent psychiatric treatment is paid for by third-party insurers, who in turn require a diagnosis in order to fund treatment. (Whilst diagnosis is sometimes necessary for treatment in Australia, this is less universally true, and not so tied to the DSM specifically). There is, therefore, in the US at least, a perverse incentive to create ever more diagnoses, and to expand the domain of the pathological, as this may make it more likely that patients receive treatment.
As an aside, it should be said that corporations are far from being the only ones who want more diagnoses. Patients themselves, and mental health advocacy groups in particular want suffering to be inscribed into a disease model. On online forums, patients with chronic fatigue syndrome, or eating disorders, for instance, protest when researchers psychologise their complaint, and reject any implication of subjectivity in their malaise. This is one of the subtle but corrosive effects of those advocating more ‘rights’ and less stigma for psychiatric patients – the decrease in stigma is directly conditional on the patient’s woes being reducible to biological disease, even though this latter is almost entirely without any scientific basis. Psychiatric illness can be made ‘respectable’ only at the expense of doing great conceptual violence to the illness itself (to say nothing of the patient, who is submitted to reductionist ‘cures’). A similar trend is afoot in recent attempts to respectabilise sex work, for both workers, and clients. Some liberal feminists and disability advocates want sex work respected as a ‘right’, because it is a useful health service, for instance. Sexual enjoyment as ‘health service’ – aside from being a woeful misunderstanding of things – one can read Freud on love for a reminder of this – it makes supposed ‘respect’ conditional on fabrication and distortion. This may be indicative of a broader social trend, analogous to attempts to reduce sexuality (and, in particular, homosexuality) to genes, hormones, or brain anatomy. It is as if my jouissance, whether from my symptom, or my sexuality, is not only nothing to be ashamed of, it has nothing to do with my subjectivity at all. We should not imagine that all of those ensnared by the labels of the DSM necessarily want a different system. Even the crudest biopolitics exercises its power most insidiously precisely when its subjects act ‘voluntarily’.
2 University Discourse
For my second hypothesis on the proliferation of diagnoses, I would like to go back to Lacan’s matheme of academic discourse, which I take to be, among other things, a kind of psychoanalytic equivalent to Foucault’s theories of power and knowledge. If we recall, the signifier of science, knowledge and so forth masks a will to mastery, and produces barred subjects, which is to say, more alienation, and evermore insidious species of symptom. (See hysteria for instance, and its splintering into the neurological realm). In Anglophone clinical psychology, neither Foucault nor Lacan are generally heard of, much less read. Those researchers who wish to proliferate diagnoses are able to do so with untroubled consciences. Many protestors, from supporters of Wikileaks, to the US Tea Party, are quick to condemn state intrusion regarding privacy, taxation, and so forth, but intrusions from the field of psychiatry, psychology and the many bureaus of rehabilitation seem somehow to be ignored.
Nevertheless, just as Clausewitz said that war is the continuation of politics by other means, so we can say, after Foucault, that public health, in the broadest sense, is the continuation of policing by other means. Thus, a senior police official recently argued that drug addiction be treated as a ‘health issue’, rather than a legal one. Determination is negation; if we determine that addiction is a matter for doctors, a disease, then we also implicitly assert that it is not an ethical or political issue, that it is not a matter of a subjective position vis-à-vis enjoyment, desire, and the Other. At the very least, these other elements are likely to fade into the background. A good deal of the DSM is dedicated to the diagnosis of past or present criminality, and it is not difficult to see how ‘science’ is here called upon to launder ideology. Many of the psychological treatments endorsed by the profession are frankly conformist and managerial. And the mockery and criticism of the DSM has not stopped those in power from doubling down and supporting it, both here in Australia, and in the US. Where science fails, as it so obviously has, in this case, naked power makes up the difference, and renegade practitioners who oppose the DSM risk sanction from their professional organisations.
And to reiterate my point earlier, it is not only bureaus and policy-makers who want to expand the realm of ‘health’, but patients themselves. There is a double-movement here; on the one hand, an ‘external’ push by authorities to colonise subjects with ever more scrutiny and regulation, and on the other, an ‘internalisation’ of these demands and expectations by subjects themselves. This can be understood in Foucauldian terms as subjectification, and it stands in inverse relation to subjectivisation, as Lacanians understand it. Consider the growing trend to quantify the self, not merely with pencil and paper tests, but through apps. It is as if Freud’s famous maxim in favour of subjectivity had been directly reversed into a slogan for intensified alienation – ‘Where I was, there shall it be.’
3 The epistemology of psychology
The final factor that I would like to discuss is that of epistemology in psychology. (Some of what I say applies equally to psychiatry) In Australian psychology, as elsewhere in the Anglophone world, the psychologist is conceived as a ‘scientist practitioner’, and psychology itself is construed as a science, if not as rigorous as physics and chemistry, then certainly on a continuum with something like biology. The DSM researcher seems to see his findings as akin to the zoologist observing a new species, and does not stop to think that he has invented what he has purported to discover. No doubt anxiety is at the heart of psychology’s assertions of scientificity, but in any case, these practices have a number of consequences. Firstly, scientific method in psychology is reduced to certain conventions of form and writing, with extreme, fetishistic emphasis placed on statistical analysis The mathematical formalisations of chemistry, for instance, are aped in psychology through the use of correlational statistics (linear regression, structural equation modelling, etc). Meanwhile, psychology does not want any part in social sciences, like sociology, and does not see itself as having much to do with philosophy or history. Over time, this has led to an intellectual culture of virtual illiteracy, with poor textual analysis commonplace, and contempt for a priori reasoning, and for the critique and historicising of concepts. On the other hand, the vocabulary and conceptual framework of psychology is an inheritance of psychiatry, metaphysics, and various other bric-a-brac. I am exaggerating a caricaturing here, but only a little.
What happens when the contemporary methods are applied to the old concepts? In the first instance, one can take virtually any category from classical psychiatry, and start running statistical analyses on those who fit that category. Quantitative methods, used in this way, need no clinical logic of any sort; all kinds of variables will eventually be sufficient to produce heterogeneity in the sample. Used in this fashion, quantitative methods become a kind of filter, or sieve. Having found heterogeneity, irrespective of its basis, it is but a small step to construct a new subset or diagnosis, and hence one can see contemporary psychology as particularly sympathetic to the pleasures of the nosologist. This is one of the reasons why we can end up with multiple depressions, bipolars and so forth, and why we end up with ‘spectrums’ for many other things, such as psychosis, and the so-called personality disorders. (Autism is, or course, a notable exception, with the spectrum having been truncated in the latest DSM).
Of course, the scientific status of psychology is not as clear as its proponents aver, and by many definitions, it is not a science at all. Like the other dismal ‘science’, it is responsible for much mischief. Even to the extent that it engages in Popperian falsificationism, for instance, it is only ever the most limited hypotheses that are falsified, and not entire doctrines, or paradigms. The most rudimentary tenets of CBT, for example, have been comprehensively refuted by the neuroscientific work of Damasio and LeDoux well over a decade ago (i.e. there is no functional or neuroanatomical basis for the infamous affect-intellect distinction), but this does not stop official psychology from proclaiming CBT as ‘evidence based’, or from regulatory bodies enforcing this doctrine. With no recourse to the tools of the humanities – conceptualising, critiquing, historicising – there is little way out for psychology as a discipline other than to continue as it is, short of a veritable scientific revolution. Any alternative to the DSM would, if it conformed to the dictates of mainstream psychology, fall prey to much the same problems. Attempts in the UK to replace diagnosis with an ill-defined notion of psychosocial ‘formulation’ shift the problems rather than solve them. Instead of subjectivity being evaded through bioreductionism (as per the NIMH, for instance), there is an emphasis on social determinism, as if the facts of one’s environment and history required no questioning, and could be regarded as perfectly self-evident data.
What does this mean in an Australian context? Not so much, in my view, as least, not in the short-term. The courts will continue to require a lingua franca for diagnosis, and the DSM will likely continue in this role. It remains to be seen whether the recent controversy will see the DSM itself contested in court. Most third-party funders of treatment require some kind of diagnosis, but not specifically from the DSM. (Where a formal diagnosis is required, assessors can and do easily ‘game the system’ in any case, by diagnosing personality disorders as depression, for instance, in order to secure funding). The classical categories are still in use, even though different interlocutors use them to discuss discernibly different things. To the extent that one needs to peruse the DSM at all, there is Wikipedia, where its contents are freely available, and nobody need pay $200 for the new one. The way the DSM is structured, a neurotic patient (in psychoanalytic terms) with no severe psychiatric problems could easily end up with 4 or 5 diagnoses; say, a mood disorder, anxiety disorder, substance use disorder, personality disorder, and problems with workplace, relationship, bereavement, etc. Australian insurers say that with the new DSM, between 60—80% of Australians will now likely qualify for diagnosis. We are in a situation of near-universal disorder. Psychoanalytic diagnosis of the structural, Lacanian variety may be the only adequate means out of this problem.
Brousse, M-H. (2013). Ordinary psychosis in the light of Lacan’s theory of discourse. (Trans. A.Price). Psychoanalytical Notebooks, 26, 23-31.
Leader, D. (2013). Strictly bipolar. London: Penguin.
Wakefield, J. C. (1992). The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist, 47, 373-388.