Paradigms across psychiatry, psychology and psychoanalysis

The dominant  paradigms within psychology and psychiatry, whilst far from being internally homogenous, nonetheless have more similarities than differences. Notwithstanding the division of labour between psychiatrists and psychologists in hospital settings (for instance), the two disciplines have a largely overlapping epistemic basis. Even psychology’s supposedly unique contributions – a body of knowledge about general, non-pathological psychological functioning – have been largely absorbed into psychiatry.

Ordinary Psychosis

There are no shortage of psychoanalytic theories of psychosis. The Lacanian account of psychosis that derives from the 1950s – and which we may think of as ‘classical’, in Lacanian psychoanalysis – can be found best expressed in Seminar 3, and the paper entitled ‘On a question prior to any possible treatment of psychosis’ in the Écrits. To put it very simply, psychosis is conceived of as a structure, not a checklist of symptoms, or a particular phenomenological condition. Where neurosis is characterised by the fundamental operation of repression, and perversion by disavowal, in psychosis, foreclosure is paramount. To illustrate: in repression, signifiers and thoughts become unconscious. It is as if they were swept under a carpet; out of sight, but leaving a lump, nonetheless. In foreclosure, not only is the same material not swept under the carpet, but it is never admitted entry in the first place. This has ramifications for a subject’s entire place and function within the symbolic order (i.e. the order of discourse and law). It is as if a set of organising principles are lacking, at least, relative to those found in neurosis under repression.

Understanding Psychosis

The British Psychological Society has released a major report on psychosis, which pushes the debate on this topic further than anywhere else in mainstream psychology in the Anglophone world. The report calls for, among other things, listening to psychotics themselves; seeing psychotic experiences as ‘understandable’ responses to distress, on a continuum with ‘normal’ phenomena; a rethink of bioreductionism and the medical model more generally; advocacy of ‘formulation’ rather than diagnosis, and advocacy of patient rights more generally; and finally, the provision of psychotherapeutic treatments alongside pharmaceutical approaches. There are numerous online responses to this report already, some supportive, some hostile. I would like to offer a few words from a critical, psychoanalytic perspective.

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.

Biomarkers and Dualism (after Nietzsche)

To criticise the dominant, bioreductionist paradigms in psychiatry and psychology risks is to invite to supposedly scandalous epithets –  ‘anti-psychiatrist’ and ‘Cartesian dualist’.

Yet to distinguish between disciplines – on the one hand, those with historical, discursively-constructed objects (such as linguistics, or history) as against the ‘hard’ sciences (such as mathematics, or physics) – implies nothing in the order of mind/body dualism. Notwithstanding any biological correlates, psychiatric phenomena fall clearly within the first category of disciplines.

The irony is that those who trumpet their materialism and monism with an emphasis on biological correlates – or, better yet, the search for elusive ‘biomarkers’ (neural or genetic) – are in fact far more dualistic than their allegedly anti-psychiatric opponents. What is the search for biomarkers other than an attempt to look beyond the materiality of discourse to invent a kind of ding an sich, that would serve as the truth of a subjective complaint?

Supposing this quest for a psychiatrist’s El Dorado came to fruition, and biomarkers were found by our closet dualists. The clinician could conceivably ignore a subject’s speech and history, and come straight to a diagnosis by way of a biological test. In this way, the biological test would serve as the subject’s supra-sensible ‘reality’, beyond any subjectivity.

Yet what could such a biomarker (eg. for depression, or anxiety) possibly mean in the absence of a corresponding complaint? To borrow from Nietzsche: such knowledge would be as inconsequential as a chemical analysis of water must be to a boatman facing a storm.

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.

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.

Psychology, Epistemology, Theory and CBT: A Critique of CBT as Ideology (part 3)

Having explored the dubious history and origins of CBT, it is time to turn our attention to its theory, epistemology and methodology. Despite shrill appeals to science and reason, there has been much critique of CBT from an a priori perspective, three fine examples of which can be found here, here, and here. I will not repeat their points. Much of what I say here of CBT is applicable elsewhere in mainstream, Anglophone psychology. The failings of CBT in particular, and of psychology generally – and they are many and serious – are, in my view, both avoidable and instructive. I discuss them here in order to learn from them, with a view to constructing a better psychology (by which I do not mean merely a more refined CBT, or an empirical psychology with better-researched norms).

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.