The problem with diagnosis is not diagnosis, but discourse

In the UK and elsewhere, there is a growing movement to abolish diagnosis in psychiatry and clinical psychiatry. Leading the movement are a group of clinical psychologists and a range of critics of mental health practice. I would like, once more, to revisit the question of diagnosis from a psychoanalytic perspective, in the hope that it may shed some light to those without an analytic approach.

In psychoanalysis, diagnosis is indispensable. In particular, determining whether a subject holds the position of psychotic or neurotic orients almost every element of the treatment. The decision to make a diagnosis need not be rushed. If it takes months to arrive at a correct diagnosis – a diagnosis that is defensible through observation, discursive indicators, and rigorous clinical logic- then so be it. Whilst a psychoanalytic diagnosis has enormous implications for psychoanalytic treatment, it is virtually meaningless outside of this. A diagnosis of ‘ordinary psychosis’ (for instance) will mean nothing to the general practitioner or psychiatrist unless they are schooled in psychoanalytic theory. Likewise, it is difficult to imagine the courts paying much heed to diagnosis in these terms. The act of diagnosis is limited to the relationship between analyst and analysand. As opposed to the DSM system, a psychoanalytic diagnosis refers to something productive rather than to a deficit vis-à-vis a norm. There is no moral judgement implicit even in such politically incorrect terms as ‘hysteria’.

We can contrast this with mainstream diagnosis in the psy-disciplines. Here, diagnosis and treatment have a rather different relation. That a patient receives treatment in the form of SSRIs, or CBT, or psychoeducation is no indicator at all as to what their diagnosis might be. The diagnosis itself is often made under pressured, time-limited circumstances. It is entered into some database or other, and often haunts the patient across a range of settings, long after its relevance. A range of considerations beyond logic and clinical observation are brought to bear; for instance, the political economy of health in some jurisdictions necessitates a diagnosis, appropriate or not, in order for treatment to be funded.

The implications of diagnosis in mainstream practice are therefore very different to those of psychoanalysis. In contrast to a psychoanalytic diagnosis of psychosis, for example, a diagnosis of schizophrenia can have grave consequences for a patient’s medical and social life, irrespective of whether the diagnosis itself is well or badly-founded. It can raise the possibility of a range of coercive treatments, from ‘sectioning’ to involuntary ECT.

To be clear, the mainstream business of diagnosis involves a separation between the epistemological or nosological bases of a given diagnosis, and the function of said diagnosis. To be diagnosed as ‘borderline’ or ‘personality disordered’, whatever the foundations of the diagnosis, means to be regarded by clinicians as ‘difficult’, possibly untreatable, and perhaps even unlikeable. It may mean that a patient with this diagnosis is refused treatment or admission to a psychiatric facility, or that their speech and behaviour are a priori dismissed as ‘attention-seeking’.

We might consider ADHD in this light as well. Defenders of the diagnosis will no doubt point out that there can be found individuals with neurocognitive impairments that more or less correspond with ADHD as defined in the psychiatric manuals. All of this, however, has little to do with how the diagnosis itself is used, which in the US (and to a lesser extent in my country, Australia) is as a means of subjecting children (especially boys) to forced regimes of regulation and medication. It is retained for its utility in scapegoating within dysfunctional families/schools/systems, localising pathology within the figure of an individual subject who is ill-equipped to defend him or herself. In short, the diagnosis has a brutal political function, notwithstanding its epistemological underpinnings. (And in the case of most DSM diagnoses, these underpinnings are slight).

A couple of recent interactions with different elements of the mental health profession reminded me of these points. A patient of mine – a so-called ‘borderline’ – had had contact with the public mental health system. A representative of this system, a psychiatric nurse, rang to say that the system had no help for my patient. The patient had ‘sprayed verbal vomit’ at the nurse during the assessment interview, apparently profusely tearful in relating the various calamities of her life. The nurse concluded that ‘this one won’t last in treatment’. Well, if the patient gathers that her clinician regards her verbal productions as excreta, then no, she probably will not ‘last’ in treatment. That a nurse with whom I had never spoken previously felt at ease to speak this way strongly suggests that this style of discourse was supported within the mental health service itself.

On another recent occasion, a patient had been diagnosed by neurologists as suffering severe amnesic symptoms, attendant upon fugue states and conversion disorder. In other words, she presented with symptoms with no discernible organic basis (which is not to say that no basis exists). The patient for her part was distressed about her situation, and wanted to speak to a psy-clinician about it. Her general practitioner strongly encouraged her not to see one, since her condition was not amenable to treatment by CBT, and what is the point of any treatment if one’s memory is faulty in any case? Again, the adverse power of diagnosis was clearly in evidence here, but again, the fault lay with the systemic (mis)uses of the diagnoses rather than from their epistemological foundations.

The problems resulting from diagnosis, then, are principally a consequence of their function, and these problems are entirely removed in a psychoanalytic context. To my colleagues who oppose diagnosis, I therefore encourage some consideration of the psychoanalytic literature, rather than a reinvention of the wheel.

The fundamentally political and ideological function of the psy-disciplines is also what renders calls for ‘more research’ (etc) largely moot. It is unsurprising that psy-academics feel that the solution to every problem is more academia. Nonetheless, the hunt for neurological underpinnings of mental disease (see the NIMH project, for instance), apart from being conceptually redundant (as observed here) do nothing to address the ways in which diagnoses are used. Or, to put it differently, the call for more or different research betrays the tendency to continue the status quo, in which ‘science’ launders ideology.

This is a problem that can be conceived in terms of Lacan’s four discourses. Wherever a clinician wishes to directly treat a ‘symptom’, we are dealing with a Master’s Discourse, a call for the patient to see things the way his or her clinician sees them. Moreover, this is rather more ethically and politically more problematic in psychology and psychiatry than in podiatry or radiology. We are also dealing with a Master’s Discourse wherever a psy-clinician arrogates to him or herself what are essentially judicial functions (determining who is ‘mad’ or ‘bad’, like this fellow here), or coercive practices, or projects of normalisation. Again, to abolish diagnosis as stigmatising but retain its symbolic efficacy in another form (through ‘dimensional’ assessment, for example) is missing the point.

Psychoanalytic discourse must stand in steadfast opposition to both academic psychology and to the medical model. It must also stand opposed to assimilationists like these who, too lazy to concern themselves with language-learning and idiosyncrasy, wish to translate all endeavours of the psy-disciplines into a ‘common language, as useful as Esperanto’. One can see the barbarian impulse on display by these assimilators, to plunder what they can make use of, and to sully that which they leave behind.  As ever, the problem is not one of diagnosis (or even categorical terminology) per se, but of the position of diagnosis within a given discourse. And if your discourse derives from the Master or from the University, then frankly, you are doing it wrong, whatever your opposition to ‘stigma’, or your ability to render it in ‘common’ language.

Most likely, none of this will be news to the psychoanalytically-inclined. But to those who are presently struggling with the conceptual and political problems of diagnosis, psychoanalysis offers solutions other than the ethical bankruptcy of the DSM system, and the intellectual nihilism that would abolish any categorisation whatsoever.

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