Paradigms across psychiatry, psychology and psychoanalysis

The dominant  paradigms within psychology and psychiatry, whilst far from being internally homogenous, nonetheless have more similarities than differences. Notwithstanding the division of labour between psychiatrists and psychologists in hospital settings (for instance), the two disciplines have a largely overlapping epistemic basis. Even psychology’s supposedly unique contributions – a body of knowledge about general, non-pathological psychological functioning – have been largely absorbed into psychiatry.

When psychologists press for prescription rights, or for the power to determine ‘rational’ suicides, they are aping their psychiatric colleagues. When psychologists employ psychometric evaluations, they are undertaking a second-rate mimicry of medical testing. And when psychologists, such as those who advocate CBT for psychosis, argue on the basis of ‘empirical validation’, accepting into the bargain conditions of a ‘standardised’ dose of treatment, reductive quantitative outcomes, universality of assessment criteria, etc. – they are thereby accepting virtually all of the assumptions of psychiatric epistemology. Psychologists and psychiatrists therefore, by and large, occupy different positions within the same overall domain, notwithstanding the presence of localised disputes.

If there is a difference to be discerned, it is between the medical paradigms (i.e. classical psychiatry, aped by psychology), and neoliberal paradigms of self-management and ‘wellness’ (much of CBT, mindfulness as pacification, etc). Whilst both of these approaches utilise ‘science’ as a figleaf (or master signifier), the medical approach, problematic as it is, is to be preferred. My impression is that the medical approach is losing to the neoliberal one, and that ‘clinical judgement’ may eventually be increasingly replaced by tick-a-box actuarial methods, all in the name of efficiency. Beyond these two domains are the marginalised, disruptive or emerging approaches focusing on subjectivity and discourse, such as psychoanalysis, and critical psychology.

It is not sufficient, in my view, to nurture ‘holistic’ pretensions by maintaining that treatment is the cultivation of a therapeutic relationship, and the administration of scientific technologies. At some point, these two positions must come into conflict. At some point, the clinician must choose whether to treat subjects or objects. One of the chief innovations in Freud’s discoveries was to recognise that treatment is not the application of a method or techniques to a relationship, but rather, was the relationship itself. (Even his critics, such as Foucault, in Madness and Civilisation, grant him this). The implicit premise of the biopsychosocial approach is that one can, as a clinician, have it all. One can see and quantify every relevant, occupy every position necessary for help, and so forth. What is obvious is that the psy-disciplines resemble something much more akin to Heisenbergian uncertainty, whereby visibility in one realm (for instance, the subjectivity of the subject) necessary occludes others (such as the quantification of person qua object), and vice versa.

 

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