“The medicalization of love” is one of a series of papers in which Earp, Savulescu and others explore the ethical ramifications of administering neurochemical interventions to address problems of love. The authors rightly observe that love is, in many ways, already ‘medicalized’, and anticipate some ethical objections to neurochemical interventions in human relationships. Specifically, the authors reject charges of neural reductionism, and disagree that neurochemical interventions need necessarily increase “pathologization” and the expansion of medical-social control. I wish to argue that these conclusions are, from many points of view, misleading, to say the least. Continue reading
The recent Maudsley debate examined the question of whether CBT for psychosis had been ‘oversold’. This is my minor contribution to the debate.
There are no theoretical grounds for supposing that any of the ‘techniques’ specific to CBT are of any therapeutic benefit to psychosis in any respect. CBT was developed as a doctrine designed to treat disorders of affect, particularly anxiety and depression. This doctrine was itself linked to a specific cognitive theory of the emotions which, whilst utterly wrong, theoretically and empirically, at least had the virtue of containing some minimal internal coherence. Even this modicum of reason is lacking in CBT treatments for psychosis, which probably accounts for why the methods of such treatment are typically vaguely-worded by their proponents.
Delusion is the hallmark of psychosis, and to go about ‘correcting’ delusions via CBT is to utterly misunderstand their nature and function for the subject who bears them. Above all, delusions are characterised by certainty. Such an enterprise – panel-beating delusions until they adopt a ‘rational’ form – is arguably delusional itself. The figure of the clinician in this set-up is to be, as always, in CBT, an all-knowing, coercive. Other. Such an Other is the perfect fodder for paranoia, and CBT’s authoritarian techniques are dangerously likely to be construed as persecutory by a psychotic subject. In short, we have reason to expect that CBT with psychotics is not merely useless, but harmful, and indeed, the outcome studies show disturbingly high levels of drop outs and death. Indeed, the psychoanalyst Florencia Fernandez Coria Shanahan recently touched upon, in a fine case study, the ‘disastrous effects’ of CBT on a psychotic woman.*
Some supporters of CBT for psychosis argue that CBT’s limited (probably non-existent) success with psychotic symptoms is no deterrent to the treatment because, after all, there is more to psychological therapy than symptom reduction. This kind of position could conceivably be credible with therapies which value ‘insight’, the ‘therapeutic alliance’, ‘growth’ or whatever, but not with purely technical, standardised, manualised approaches like CBT, which derive ‘scientific’ status precisely through relentless and reductive focus on symptom reduction. If CBT conceded that, for instance, the quality of the therapeutic relation was the curative factor, and not some dubious technique or theory, the entire ideology would disappear in a puff of smoke.
All of this inevitably raises questions about the nature of the psychoses, and their treatment. In my view – and this view is psychoanalytic, but not indicative of anybody but myself – psychosis is not curable in any strict sense, though it can be stabilised. Indeed, there are many recovered psychotics who leave happy and meaningful lives, but the means they took to stabilisation vary widely in each case, and merit further study. My suspicion is that these means will be generalisable only at the very highest levels of abstraction. I have never encountered a psychotic subject who was helped by coercive attempt to bludgeon their delusions away through CBT. In short, the path to stabilisation involves something like the construction of a sinthome, and not adherence to some trite, bureaucrat’s notion of functionality as defined by CBT.
In view of this, two facts are unsurprising. First, as one would expect from a theoretical perspective on psychosis, there is no credible data to support the use of CBT as a treatment. Second, the proponents of CBT are utterly undeterred by this lack of scientific evidence, and continue to speak, act, and construct policy without the slightest compunction. But then, such debates are fundamentally ideological and political, and are about control much more than scientific evidence. CBT has virtually none of the latter, and far too much of the former.
*Fernandez Coria Shanahan, F. (2012). In me more than me. Psychoanalytic Notebooks, 24.
What is biopolitics? This term, put simply, refers to bodies of knowledge and practices of power over subjected populations, and over life itself. Different populations become the object of differentiated techniques of discipline and surveillance. In Australia, such techniques are particularly grotesque with regard to the Aboriginal population and to refugees, but also to the unemployed, the disabled, and those within the health and mental health systems, among others. Many have justly pointed out the duplicity of the surveillance state in the case of NSA, for instance, but many more intensive forms of surveillance remain almost invisible. Moreover, some practitioners of CBT claim that their doctrine is on the side of ‘human rights’; yes, we might agree, but the ‘human rights’ in question are those of paternalistic neoliberal interventionism, of which the horrors of Iraq and Afghanistan were the most chilling examples in the past decade.Two recent examples of the role of CBT and psychology at large in biopolitics may help to illustrate my points above. Continue reading
The state of ethics in psychology, in Australia, at least, is lamentably primitive, and the politics of psychological practice virtually unspoken. If psychology is presumed a science, after all, how can it be political, any more than the laws of thermodynamics, or quadratic equations? Ethics is taught as a subject to psychology students, but it amounts to little more than a few strictures and prohibitions – do not fleece patients, do not maintain conflicts of interest, no sexual relationships, etc. By themselves, these prohibitions are perfectly reasonable, but they hardly constitute a level of ethical discourse beyond that which the average five-year old might grasp. The continuities between the biopolitics of the clinic and those of the factory, the school, and the prison are invisible. Foucault, Laing, Szasz and others go unread and misunderstood; ‘anti-psychiatry’ is even used as a term of abuse, as if criticism of this or that diagnostic system was tantamount to nihilism. If academic psychology avoids direct confrontation with complex ethical questions, the same can be said of regulators, at least in Australia. The regulators certainly enforce prohibitions and punish violators, and there is plenty of evidence that they are rapidly escalating regulatory requirements (and, of course, fees). None of this gets to the heart of the matter. The more important question, generally evaded by the discipline, is what is it that is happening, ethically and politically speaking, when one does psychology? And when one does CBT, in particular? Continue reading