The problem with diagnosis is not diagnosis, but discourse

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In the UK and elsewhere, there is a growing movement to abolish diagnosis in psychiatry and clinical psychiatry. Leading the movement are a group of clinical psychologists and a range of critics of mental health practice. I would like, once more, to revisit the question of diagnosis from a psychoanalytic perspective, in the hope that it may shed some light to those without an analytic approach. Continue reading

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Suicide, selfishness and “illness”

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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.

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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.

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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.

Anti-stigma campaigns that restigmatise…

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When it comes to campaigns against stigma in ‘mental health’ that actually restigmatise their objects, Stephen Fry is not the only offender, or even the worst. He is one of the most famous, however, and has spoken openly of his own experiences. Nonetheless, the above comment, seemingly part of an anti-stigma campaign is, (with the exception of the words on friendship), utterly incorrect and a counsel of despair.

Depression, like all emotions, is defined principally by its subjective component. The psychiatric classifications make this a sine qua non condition of diagnosing the disorder.  Yet Fry, like so many anti-stigma campaigners, wishes us to believe that our own subjectivity is alienated, has nothing to do with us, is much like the weather. Not only is this false – there are vast numbers of reasons why people become depressed, and many ways in which they perpetuate their condition – it also makes those with depression the passive victims of their condition.

Fry is not the only one to peddle these kinds of fantasies in the interest of fighting stigma. Unfortunately, these sorts of campaigns tend to promote two key falsehoods: firstly, a reductionist (usually biological) distortion of a subjective condition, and secondly, the foreclosure of any ethical implication on the part of sufferers. We are led, absurdly, to a subjectless disorder of subjectivity, and one for which nobody has any responsibility. Individuals are constructed as the passive victims of problems beyond their control, a conception which is implicitly belittling. The logical corollaries of this are, of course, defeatism, drugs, and techniques of distraction.

This is a great shame, as there may be some benefit in supporting those with various difficulties in life in getting help. Nonetheless, they will be implicated in those very difficulties, and far from being stigmatising, this is a very good thing, as it means that even the most wretched of melancholies may yet have a way out. An attitude of bad faith to one’s own subjectivity – pretending that it is ‘like the weather’ – can only intensify alienation, and hinder the movement of one’s subjectivity to a better place.