The Ethics & Politics of Intervention: A Critique of CBT as Ideology (Part 5

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?

A Note on Psychometrics: A Critique of CBT as Ideology (Part 4)

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.

An Alternative to the DSM

My comments here are an elaboration of my response to this post:

There are many problems with the DSM system (and many of its counterparts), but the main problem, in my view, is that it operates with no coherent definition of what constitutes mental ‘disorder’. By extension, it likewise has no watertight notion of mental health. Instead, it determines disorder by committee. Even assuming for the best committee possible, this would remain an intellectual embarrassment. In any event, with the many vested interests at stake, the committees are far from optimal. Any diagnostic system which tries to evade this point – on the lack of a logical definition of disorder – cannot be taken seriously. Statistical tests of reliability and validity are very much of secondary importance here, since what is that value of undertaking statistical analysis on a nonsensical concept?

This problem is not unique to the DSM-5, either, though it is this latter document which has recently attracted criticism (in my opinion, thoroughly deserved). At this point, whilst the DSM is of bureaucratic importance in some parts of the world, it is now rather like a magician whose secret compartments have been revealed. It has lost its symbolic efficacy.

Now, any characterisation of a patient could function more or less like a diagnosis. The problem is not diagnosis per se, but the shoddy and untenable basis for it given by the DSM and ICD systems. This in turn leads to flippant, tick-a-box diagnosis for patients, with all the requisite consequences.
So, in short, I would abolish all diagnosis deriving from DSM-type recipe books, as well as those deriving from psychometrics.

A viable and much more rigorous alternative can be found in Lacanian psychoanalysis, in which everybody (not merely the ‘pathological’) fits into one of a small number of structural categories. (Of course, within each category, there is infinite room for variation). For instance, a key distinction is that between neurosis and psychosis, and the main determinant for diagnosis one or the other is the presence/absence of repression (to put this in Freudian rather than Lacanian terms, for now. There are many other determinants, but these are of somewhat lesser importance). Now, one will not necessarily observe repression in a questionnaire or an interview or two, and diagnosis can take months. (The absence of repression, on the other hand, in certain psychotics, for example, might be discernible rather quickly).
This system of diagnosis comes closer to the ‘formulation’ proposed by some in the UK in that it allows for richness and complexity without too much stigmatising and reduction. In fact, if one takes ‘formulation’ seriously, it is difficult to see how one can arrive at any detailed assessment of a person’s subjective interaction with their circumstances without a psychoanalysis, or something very much like it. This structural framework can, to an extent, be made to work with the categories of classical psychiatry (though not so much those of the DSM). For instance, melancholia/depression can be differentiated on the basis of whether the person experiencing it is psychotic or neurotic. Moreover, it is broadly consistent with the more robust areas of empirical sychology, such as attachment theory.
Further, merely listing and identifying symptoms is not really adequate for a thorough assessment. Anybody can diagnose a phobia – indeed, most phobics are perfectly capable of self-diagnosing – but at least part of thorough diagnosis should involve consideration of what the symptom is doing for the patient, namely, details of its history, phenomenology, sustaining factors, associations, support in certain fantasies, etc. Psychoanalysis – in particular, that inspired by Lacan – is a credible, and rigorously logical alternative to the shambles that is contemporary psychiatric diagnosis.

 

 

 

 

 

Psychoanalysis and the DSM – a brief discussion and critique

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.

Back to anti-stigma…

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.