The Problem with Randomised Controlled Trials (RCTs)

I have recently been debating the merits and problems of objective, quantitative research in mental health. (One of my interlocutors has posted a lengthy response here, arguing in favour of ‘objectivism’). RCTs are a methodological device introduced into mental health from general medicine. Whilst they are merely problematic in the latter, they are outright misleading in the former. Continue reading

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Reductio ad traumatum

In 1933, two servant girls in Le Mans, France, Christine and Léa Papin, murdered two of their employers.(1) Madame Lancelin and her adult daughter were bludgeoned and knived repeatedly, to the point of unrecognisability. Each had their eyes gouged out. The Papin sisters had spent much of their young lives in institutional care. Their family had a history of incestuous abuse, and at least one of their relatives had died by suicide. Continue reading

Notes on Fantasy

 

The following are some brief notes of reflection on Freud’s 1908 paper on hysterical phantasy, delivered at a meeting on 16th August 2014:

 

  1. Speaking very broadly, in the early Lacan, there is an emphasis on desire and its interpretation. Later Lacan focuses on jouissance and knotting. (I have discussed some of this elsewhere). Fantasy is the bridge between them, and is theorised extensively between Seminars 10 to 14. The fantasy contains an element of desire or wish, but in later Lacan, also corresponds to Imaginary consistency, something which holds the world together for a subject. Freud’s insistence on the ‘bisexuality’ of (some) fantasy seems to me to merely suggest that a fantasy can contain multiple points of view.
  2. Fantasy is a formation of the unconscious, and can be interpreted as such, but not necessarily in quite the same way as dreams or parapraxes. Fantasy – especially in th form of worldview or ideology – has a hard time of surviving analysis and interpretation. Both Freud and Lacan are clear on the point that the fantasy precedes the symptom, even though this is the reverse order in which things are addressed in an actual analysis.
  3. There is a question about the nature of fantasy and enjoyment. Certain forms of jouissance – a self-administered addiction, for instance – is held by some analysts to be without fantasy, an example of pure narcissism. We can infer a distinction between a ‘discrete’ fantasy, of the sort discussed by Freud (where fantasy accompanies specific enjoyments, masturbation, etc) and a fundamental fantasy. To clarify – administering substances to oneself for jouissance may not require any discrete fantasy, perhaps, but may nonetheless fit within the coordinates of a fundamental fantasy (eg. of oral jouissance, identification with the ‘addict’, etc).
  4. Lacan significantly extends Freud’s theory of fantasy, in that ‘reality’ itself is fantasmatic (that is, consists by way of the imaginary). Again, this is somewhat different to Freud’s notion of discrete fantasies for specific wishes and enjoyments. Fundamental fantasy constitutes the coordinates within which a subject can manoeuvre. These are the unspoken assumptions that allow ‘reality’ to cohere.
  5. Following Freud’s logic, fantasy is diagnostic. The fantasy/delusion distinction allows one to differentiate between neurosis and psychosis. (Lacan’s work on fantasy also allows for a structural distinction regarding perversion, as evidence in Seminar 14, for instance). Beyond structure, however, an analysis of fantasy can show one’s trajectory within a set of subjective coordinates. To analyse things in this fashion is to move from general diagnostic categories to what is absolutely particular to a given subject.
  6. Fantasy – especially of a sexual nature – can be understood in terms of the later Lacan as that which covers over the lack of sexual rapport. By situating the subject relative to objet petit a, fantasy gives the subject an entry point into sexual enjoyment in the face of radical non-rapport. Or, to put it differently, if a subject could not derive enjoyment from a masturbatory fantasy, they may find it nearly impossible to obtain enjoyment from sex with a partner also. This is a Lacanian rather than a Freudian position.
  7. The failure of the fundamental fantasy – whether this is in the form of incompleteness, or inconsistency – is one of the causes of anxiety. When the imaginary and symbolic is ripped away, one is left with the gaping maw of the real. Specific, ‘discrete’ fantasies tend also to be accompanied by anxiety. It is generally easier for somebody to disclose their sexual acts than their sexual fantasies, since it is the latter which carry more subjective implication.

Suicide, selfishness and “illness”

stavrogin

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.

Continue reading

Love, technology, ideology and ethics: A critique of “neuroenhancement”.

“The medicalization of love”[1] is one of a series of papers[2][3] 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

CBT for psychosis?

 

exercise

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.

Project for an Unscientific Psychology: Critique of CBT as Ideology (Part 7)

In undertaking the negative task of criticism, it has been with the view to identifying the shortcomings of CBT (and psychology), not merely to point them out, but to avoid them in constructing a better psychology. To create an alternative psychology is no easy task, but there are some useful starting points. Continue reading