The British Psychological Society has released a major report on psychosis, which pushes the debate on this topic further than anywhere else in mainstream psychology in the Anglophone world. The report calls for, among other things, listening to psychotics themselves; seeing psychotic experiences as ‘understandable’ responses to distress, on a continuum with ‘normal’ phenomena; a rethink of bioreductionism and the medical model more generally; advocacy of ‘formulation’ rather than diagnosis, and advocacy of patient rights more generally; and finally, the provision of psychotherapeutic treatments alongside pharmaceutical approaches. There are numerous online responses to this report already, some supportive, some hostile. I would like to offer a few words from a critical, psychoanalytic perspective.
First – the good news. In contrast to the tedious, closed circuit that constitutes academic discourse in psychology, this publication expresses itself clearly, without undue regard for scholastic convention. It is particularly pleasing to see non-academic contributors, and to see the discourse of patients themselves given significant space in the text. The authors place symptoms (especially hallucinations) in their cultural context, and whilst this might make a few biologically-minded psychiatrists nervous, it helps to avoid the bioreductionism that still plagues many contemporary approaches to the psychoses. Quite rightly, the report asserts that there can be many reasons for hallucination, only one of which is psychosis. The authors seem cognisant that the psychoses themselves are something of a mess in the DSM system. The most famous – schizophrenia – masks incoherence and radical heterogeneity, and that’s before we get to the dispersion of the other psychoses throughout the system, such as manic-depression (now bipolar), the cluster A ‘personality disorders’ (i.e. paranoid psychosis), the psychotic melancholics, and more controversially, dissociative identity disorder, so-called borderlines, and autism. Australia is thought by some to be a world leader in the treatment of psychosis, but its most famous exponent here advocates simplistic assessment tools in the service of pharmaceutical interventions. The medical model for psychiatry deserves critique, though in my view, one must be cautious not to replace it with something worse. The BPS report goes well beyond this, setting aside the silly myth that speaking with psychotics ‘strengthens delusions’ and so forth, advocating for an approach in which professionals work within the patient’s frame of reference. The preventative measures recommended in the report generally call for a better society, and it is difficult to see anybody other than radical individualists finding fault with this. All of this is relatively new to canonical, Anglophone psychiatry and psychology, and all, in my view, is to be commended.
On the other hand…I could not but be struck by the complete absence of a single psychoanalytic reference in the entire report. One expects psychoanalysis to be marginalised these days among native English speakers, but the BPS report read like a comprehensive excision. This is all the more disappointing since psychoanalysts have been supplying theoretical accounts the psychoses for well over a century. By far the most sophisticated psychological accounts of psychosis derive from analysts. I come at it from the perspective of Lacan, and his work on foreclosure, the Name-of-the-Father, the Sinthome, etc, but one could also consider Melanie Klein, or Bion, or Fonagy. Moreover, the task of listening carefully to psychotics with full respect to their singularity is, in essence, a psychoanalytic approach. Psychoanalysts do this already. I would struggle to find an analytic colleague in Melbourne not working with psychotics, and analysts such as the GIFRIC group run entire treatment facilities on psychoanalytic lines. The complete absence of analytic thought in the BPS report is all the more galling in that the authors invoke a number of flash-in-the-pan therapeutic fads with no substantial account of psychosis at all (ACT for psychosis? Really?). The report’s advocacy of CBT for psychosis is also something I strongly oppose, and of which I have written elsewhere. CBT has done more than probably any other psychotherapy to reduce therapy itself into a purely technocratic numbers game, and even by its own debauched and degraded ‘empirical’ standards, it fails the test.*
Whilst the advocacy of CBT for psychosis only constitutes a relatively small portion of the report, the broader influence of the paradigm is evident in a number of places, and most problematically in the conceptualisation of delusion.* In a psychoanalytic paradigm, delusion (and not hallucination) is the hallmark of psychosis. (This leads to some difficulties in a psychoanalytic conception of autism, for instance, but that is another story). The BPS authors seem to have an understanding of delusion whereby it is a largely undefined, relative concept. A delusion is merely whatever belief an authority or professional finds bizarre, based on content alone. This is in keeping with the overall project of CBT, which holds that psychopathology derives from mistaken cognitions. In this perspective, a psychotic delusion is but one more example of a distorted belief; quantitatively stronger than the others, perhaps, but essentially on a continuum. The authors can conclude that ‘paranoia’ is common, since, after all, almost everybody has worrisome thoughts now and then.
This outlook departs from psychoanalysis – and classical psychiatry, for that matter – which give ’delusion’ a much clearer meaning based not on the allegedly ‘strange’ content of the belief, but rather, the belief’s form and function. A delusion (whether erotomanic, persecutory, etc) assigns a radically external locus of control to its power, and is held with unshakeable conviction. (Nietzsche and others have long held doubt to be on the side of neurosis, and certainty on the side of madness). The delusion plays a central, explanatory, structuring role in the patient’s subjective experience, and is not merely some superstition or other, of which all subjects possess more than a few. Based on the form and function of a delusional belief, one may well find psychotic delusion in adherents of mainstream religion or politics, whilst marginal beliefs are no firm indicator of any diagnostic structure. By misconstruing and cognitivising the nature of delusion, the BPS report proceeds to a second, related error, namely, making psychosis a spectrum condition, merely quantitatively different to ‘normal’. (In contrast to psychoanalysis, which distinguishes between neurosis and psychosis, the BPS report dichotomises between psychosis and the ‘normal’, albeit, sometimes ironically).
Psychologists in generally have a tendency to refuse the qualitative in favour of the quantitative, but nowhere is this approach more dangerous than with psychosis. If we took a good, Beckian approach, and used the BDI-2 to assess mood, for instance, we would obliterate any distinction between neurotic and psychotic depression, effacing it into spectrum phenomena, or classifying it with a ‘mild’, ‘moderate’ and ‘severe’ categorisation. This has significant implications for treatment, since a psychotic subject – depressed or otherwise – may be much more prone to perceiving suggestions as imperatives, or to observing persecutory intent in enigmatic places. One cannot simply whittle away delusions like other symptoms; as Freud argued (and as the Menninger quote in the report hints at), they are an attempt at recovery. Abolishing the qualitative distinction in favour of a continuum could be expected to quite literally result in premature terminations of treatment, suicide attempts, and other risks, as bumbling clinicians privilege their quantitative ‘understanding’ of psychosis above the qualitative irreducibility of the patient in front of them. To be sure, from one perspective the ’spectrum’ approach may look polite, or politically correct, insofar as it ‘normalises’ what may seem odd to some; but what it does in practice is force, conceptually in the first instance, a kind of assimilation. It marks a lack of respect for radical difference,and for singularity.
Moreover, if psychosis is to be situated on a spectrum, then why treat, or speak of it as ‘psychosis’ at all? Why highlight one variable among innumerable others? Turning treatment of psychosis into a distressology is no satisfactory way around this problem, unless one assumes that the psychoses have no bearing on the nature of the distress in question. It is worth recalling that, in psychoanalysis, diagnostic questions are construed at the level of structure, and not a structureless phenomenology. To put it simply, the difference between a neurotic and a psychotic is not that one is ‘better’ or more pathological than the other, but that the neurotic lives in subjective division, on the basis of unique and idiosyncratic organising principles (deriving from repression). In psychosis, these principles are lacking, and must be created ex nihilo. Now, a neurotic’s ‘plan’ for life, his or her organising principles, may be self-sabotaging, or even outright lethal (consider anorexia, addiction, inter alia), but they constitute something rather different to a lack of plan/structure, and it is this latter that corresponds to psychotic delusion, as well as the famous ‘negative’ symptoms characteristic of many psychoses. There is an enigma at the heart of psychosis, and it goes hand in hand with the psychotic’s (frequent) exclusion from certain social bonds, if not from life itself. Listening is one thing, but to try too hard to ‘understand’ this enigma risks a projection of one’s own imagination onto the figure of the suffering patient. It risks a pseudo-understanding, which is to say, a purely narcissistic version of empathy.
Further to this point, we must avoid the reduction to trauma in diagnosis and formulation, and avoid the attempt to sneak around the ‘black box’ of subjectivity. The BPS report holds that ‘bad things make you crazy’, that psychotic symptoms are an ‘understandable’ response to painful stimuli. This again risks abusing the notion of understanding, since no symptom, psychotic or otherwise, is ever self-evident. When large numbers of people experience collective disaster – I take the Siege of Leningrad as an example, as I’ve read something about it – it’s not at all understandable why one subject collapses into depression, whilst another develops an aggressive ‘hunger psychosis’, whilst yet another tries to modulate their suffering through forms of social solidarity. And even is an ideal society, in which all preventative measures were undertaken with gusto, does anybody seriously believe that the phenomena at stake in psychiatric intervention would simply disappear? Even assuming that Judge Schreber, for example, suffered the worst of traumas, how could anybody deduce from this that his particular delusion would involve him becoming God’s wife, penetrated by ‘divine rays’, besieged by the ‘fleeting improvised men’?
What is unique in a subject’s symptom is precisely what is not ‘understandable’, and what we should not be in a rush to ‘formulate’, bureaucratic pressures to the contrary notwithstanding. There is no single treatment for psychosis, and nothing resembling a cure. There are merely different approaches with no guarantee of success. The pharmaceutical approach is little more than quantitative guesswork, which explains the discomfort of some psychiatrists on this issue. Psychologists ought not to be in any rush to emulate them. Psychoanalysis takes up this position on treatment from the outset, but BPS psychologists are obliged to educate the psychiatrists and the cognitivists that their strategies and drugs have effects which are strictly non-generalisable. And this is where the psychoanalytic approach differs most strongly from the BPS one: for psychoanalysts, particularity and difference are paramount, but for mainstream psychology, even when, like here, it is relatively progressive, the tendency is to generalise, assimilate and quantify.The BPS project would, in my view, be a surer step in the right direction if clinical psychologists could better listen to (rather than ‘understand’) their patients, and listen also – a little, at least – to their chaise longue-owning colleagues, who have been applying themselves to these problems for so long.
*I am aware that CBT is, by now, an acronymic shorthand/Trojan horse for ‘scientific’ psychology, and that many things that take its name have virtually nothing to do with actual, Beck-inspired CBT. Nonetheless, the shorthand is important here, as it determines the psychological paradigm to a large extent, and provides the cover for those seeking ‘scientific’ garb for their ideology.
*The CBT paradigm is also clear in the ‘formulation’ on display in the report, in which a clinical vignette is condensed into what amounts to a cognitivist formula. It should be obvious that a model based on language and signifiers, for instance, and not with cognitive (mis)learning at its heart, would lead to some rather different formulae.