Here are some responses to points/questions that recently arose on twitter, in longer than 140 characters:
A celebrity has died, apparently by his own hand. Amidst expressions of grief and condolences to the bereaved are a profusion of obviously incorrect, deeply ideological pronouncements on the nature of suicide.
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.
As a final word on epistemology, it is worth noting that the prop which keeps CBT concepts upright, and which supports most of empirical psychology, is the area of psychometrics. Psychometrics is psychology’s proudest achievement, and perhaps the only body of knowledge unique to it. As with CBT, however, its epistemological base is as dubious as the uses to which it is put. Continue reading
The following was presented at a meeting of the Lacan Circle of Melbourne in July, 2013:
Marie-Helene Brousse (2013, p. 24) said of diagnosis that it was considered by Lacan ‘as an act, implying a decision requiring logical argumentation and clinical confirmation’. Alas, this is not the modus operandi for mainstream psychiatry and psychology.
Returning to the contradictions of anti-stigma campaigning in psychiatry and medicine, I recently saw this article, which supports my notion that those who grasp at reductionist, anti-subjective explanations for psychiatric conditions inadvertently harm those they purport to defend. This paper is “evidence-based” (evidence here meaning statistics, for the most part, as it always does in psychology and psychiatry), but nonetheless supports what can be deduced from general principles:
Even commentators who continue to advocate for describing people as having a “brain disease” agree that “research has shown that disease explanations for mental illness reduced blame but provoked harsher behaviour toward an individual with mental illness”, that “biological explanations may also imply that people with mental illness are fundamentally diﬀerent or less human”, that “there is research evidence that biological arguments may actually strengthen dangerousness stereotypes” and that “in contrast to biological arguments, psychosocial explanations of mental illness have been found to effectively improve images of people with mental illness and to reduce fear”.
In short, the bioreductionist arguments are not merely false, but also unethical and harmful, even when peddled under the aegis of dubious anti-stigmatisation. A few short points are worth making here, and perhaps I can expand on them subsequently:
1. All medical and psychiatric practice necessarily involves interpretative, conceptual interpolations (i.e. ‘labelling’) to organise symptoms, diagnosis and treatment, and this applies no less to a broken arm than to a case of melancholia.
2. To mistake the label/signifier/diagnosis for the thing itself betrays a fundamental bungling of diagnostics, as well as of basic linguistics.
3. Attempts to phrenologise psychiatric diagnosis in the name of a narrow ‘science’, whether by way of the NIMH’s biomarkers, or the correlative ‘traits’ of psychometricians, will continue to stumble over the inconvenient fact of subjectivity, and therefore continue impede, rather than clarify diagnosis.
4. There is no coherent definition of a mental disorder, and likewise, there can be no watertight notion of ‘mental health’. Even the likes of Jerome Wakefield (a contributor to the DSM) more or less concede this, despite heroic attempts at reconstituting a mythological disordered essence for clinicians to diagnose.
5. Suffering is no less real for being subjective and, in any case, as Freud puts it in Civilisation and its Discontents, pain is but a feeling.
Rather obviously, this is a mere image. It is not for smoking. It is not the thing itself. Yet captivation by the image is where the most labour is expended today, in the world of “mental health”, and elsewhere. As long as the sufferer (of depression, or some other malady) or the ψ professional concerns his or herself with a therapeutics of the image, a positive opinion-mongering of the image – be it in the form of self-regard, “self-esteem”, confidence, body image, or whatever – he or she is doomed to be operating in the wrong place.A subject is neither his/her image, nor his/her opinion of said image. To cultivate love of one’s image is rightfully understood as narcissism. And, like so many interventions that revolve around the aggrandising of images, treatments of the image can only intensify alienation rather than alleviate it.