Language and Diagnosis

 

The BPS has been tackling some important issues in mental health. In 2014, this involved publishing the ‘Understanding Psychosis’ report, and more recently, the BPS has published guidelines on ‘functional’ diagnostic nomenclature,  in which clinical conditions and treatments are articulated in non-medical language. In both cases, the BPS has identified an area of difficulty – perhaps even crisis – in mental health. Psychosis is poorly conceptualised and haphazardly treated. Diagnostic language in psychiatry was never ‘scientific’, and the farcical DSM-5 has eliminated any last vestige of credibility from these sorts of conceptual systems. There can be no doubt that the BPS has the best interests of what it calls ‘service users’ at heart when it attempts to tackle these problems and devise workable solutions to them.

What strikes me, however, is that there are at least two perspectives missing from these attempts. Firstly, there is a complete absence of any psychoanalytic perspective, despite psychoanalysis having tackled – and arguably, come to terms with – these problems some decades ago. To watch the wheel being constantly reinvented is rather unedifying for both ‘service users’ and the profession itself. Second, the BPS’ interventions are marked by a lack of political and philosophical analysis. Here, more than perhaps anywhere else, there is an urgent need for Foucauldian analysis of power and discourse, or of austerity and its ideological effects, yet precisely here, this is missing.

What are the consequences of these lacunae? In the latest guideline, the idea is that medical terminology ought to be substituted for plain language nominations of suffering and treatment. Thus, ‘bipolar disorder’ is rebaptised as ‘mood swings’. A ‘patient’ is a ‘client’ or ‘service user’. ‘Treatment’ is reworked as ‘help’ or ‘support’. The guiding principle is that the contested nature of psychiatric concepts be indicated through the use of these terms, and that the emphasis is on destigmatising the suffering in question.

Following from the two missing perspectives outlined above, however, it seems to me that there are at least two significant objections to these guidelines. The first derives from a psychoanalytic perspective. In psychoanalysis, nomination – or naming – is an essential element of praxis. A nomination does not merely gesture toward some referent, but alters the construction of said referent, at least as far as psychical life is concerned. We can therefore think in terms of relatively good or bad nominations for suffering. Depression as ‘illness’ is a particularly destructive nomination, as it situates the subjectivity of the subject as something which has nothing to do with itself (i.e. the ‘illness’ systematically removes subjective implication and historical determinants from the ‘mood’ at issue, necessarily barring the way to a cure).. It thereby promotes submission to prevailing doctrines and further alienation. It can be contrasted with the nomination ‘Aspergers’, for instance,  now abolished from the DSM system, but which has been – to some extent, at least – re-appropriated by its bearers in the term ‘Aspie’. It is a nomination in which one has symptoms, to be sure, but one can do something with them, attempt to treat them with savoir-faire. It is far from demonstrated that ‘plain-language’ nomination is going to be better than the old medical language, rather than a substitution of one jargon for another. In any case, what seems to have been missed by the BPS is that, whether one employs medical terms or ‘functional’ ones, as long as it is the clinician who is making the nomination, it is always matter of the subject being imposed upon from without. ‘Functional’ diagnosis is no less authoritarian than medical diagnosis, and possibly throws a good deal of nuance out the window at the same time. (For example,, an erotomanic delusion would be the same as any other ‘relationship difficulty’ under the new regime).

The other objection concerns the level of obfuscation involved in such language. If somebody makes an appointment at their local mental health service, it is presumably because they have a problem of some sort, and they want assistance with it. At this point, the suffering subject enters a system in which professionals will attempt to assess their problems, situate them within a conceptual framework, and conduct one form of intervention or another. If one adopts medical jargon for this process, one is at least making explicit the biopolitical nature of the procedures involved, and drawing attention to the imbalances of power at stake in the exchange between subject and professional. Under the ‘functional’ model, all this is obscured. Specific problems are rendered indistinct by the ‘plain’ language. The BPS is an uncritical supporter of CBT, a coercive, authoritarian system of indoctrination marketed as a ‘therapy’. Under the proposed jargon, a patient who attends a community health centre and receives CBT for depression will now be a ‘service user’ with a ‘difficulty’ for which they received ‘help’. The equivocal nature of this ‘help’ is occluded by the duplicitous language involved. Far from challenging power, this language assists it in proceeding undetected.

In this light, the ‘functional’ language seems of greater benefit to the clinician than ‘service users’, allowing them to evade the crisis of contemporary diagnosis, and the dubious nature of their ‘interventions’ by cloaking mental health procedures as something akin to having an amiable chat with a friend or relative. That the interventions are undertaken by public servants for the purposes of discipline and surveillance of the suffering is passed over in silence. Here, and everywhere, what eases the (justifiably) bad conscience of the clinical psychologist ought to be strictly differentiated from that which is in the best interests of the ‘service user’, whose ensnarement has simply been shifted from one framework to another.

 

For another perspective, see also this blog post by Huw.