A reply to Peter Kinderman:
For me, a psychologist is bound to run into problems if s/he wishes to jump paradigms without proper consideration of epistemology, or if s/he wishes to consider the ethics of forensic intervention whilst completely ignoring Foucault (among others). This article exemplifies such an approach.
Kinderman argues that the medical model, based on notions of disease, and embodied in the now-ridiculed DSM, would be best replaced by a ‘psychosocial’ CBT-style model. The idea is that this latter approach might allow the experts to determine who is ‘mad’ and who is ‘bad’, and to allocate treatment or punishment accordingly. The elementary point that is missed here, of course, is that treatment is the punishment, especially when we are dealing with coercive psychological ‘therapies’. Prison deprives the subject of liberty, and cages and disciplines bodies. Treatment of the psychosocial variety, whilst superficially more ‘humane’, wants to take this discipline one step further, into the domain of the soul.
How could such an obvious point have been missed? The answer, I believe can be found in the psychoanalytic theory of discourse.
The medical-pathology model belongs to scientific, academic discourse. Its critics quite rightly observe that beneath the preoccupation with empirical data, objectivity and the like, there lies a clear will to mastery (of those subjected to it). At its extreme, this leads to psy-clinicians reifying diagnosis in a manner that is practically delusional, and I mean this in quite a precise sense. It imposes some limits on clinical practice, however, since it necessarily orients this practice to subjective suffering (here rebaptised as ‘pathology’).
The ‘psychosocial’ and CBT discourses, however, are between the scientific and those discourses which can be called capitalist, or neoliberal. Kinderman makes clear – the object of intervention in his vision is always ‘quantifiable’. In contrast to the categorical approach of traditional medicine, his is a numbers game. Truth in postmodern capitalist discourse is a defunct category, and one sees this clearly both in Kinderman and in the Understanding Psychosis project. What is true is what ‘works’ according to the clinician, or what pleases the affect of the subject, or what can be negotiated and bargained on. Happiness and reason are effectively one and the same, Nietzsche, Schopenhauer and Kierkegaard be damned!
Here we no longer find patients, but consumers, or ‘service users’. Here the role of ‘services’ is not merely to address suffering but also to act as a prophylactic. Far from limiting its jurisdiction to the negative goal of banishing of pathology, the psychosocial approach is a positive one, aimed at ‘resilience’, ‘enhancement’ and all-round efficiency. It should be obvious that this discourse, when compared to the medical-scientific, supports more intervention rather than less, since its remit is totalising, and not limited to hypothetical pathology. And this is exactly what we find, since the use of SSRIs and CBT is practically ubiquitous whenever one is dealing with ‘treatment’ in a forced or forensic setting. Ultimately, the medical expert qua doctor is replaced with the neoliberal ‘life-coach’. It is no coincidence that the paradigm in question was founded by failed psychoanalysts of the 1960s, but only really reached its potential in the era of Thatcher and Reagan, of deregulation, self-regulation, and case managed deinstitutionalisation.
It should be clear that merely abolishing the concept of illness, whatever the salutary epistemological effects this produces, does little to improve the ethical and political dimensions of psy-intervention. For this, you need a paradigm outside of both the medical-scientific and the neo-liberal/CBT model, and burning a copy of the DSM – whilst reasonable, in itself – does absolutely nothing to achieve this.
Sorry if I am somewhat off topic but I need to vent. Psychologists in America have little understanding of psychoanalytical theory. There are a lot of problems surrounding EMDR therapists that use bilateral stimulation to undo repressions only to end up traumatizing their patients. CPT ends up being safer because it is ineffective. Fortunately I had read Alice Miller before the symptoms of transference neurosis began to appear in me. The first time I criticized my therapist in the transference, she went so berserk that I could not continue therapy with her. I rue what psychology has become. So much potential has been lost
Thanks for your comments, Rubin. The idea of trying to smash through repression through EMDR and other techniques is quite concerning.
It takes time to discuss difficult things, and this necessity for patience, delicateness and ingenuity in the handling of problems goes against the imperatives which dominate mental health today, namely, that it be cheap, efficient, and standardised. If it takes somebody 6 months or two years to begin discussing some of their problems, this should be understood as a necessary part of the therapeutic process, and not as some barrier or resistance. Trust cannot be fabricated, no matter how ’empirically validated’ one’s treatment supposedly is.
I coundn’t agree with you more. I wish there were therapists with your attitude and understanding in the US.