Tuesday, 14 January 2014

3 Questions (and 3 answers)

At this point in the "psychodiagnosticator" project, I keep meaning to review my thoughts on psych diagnosis. So far I have never found a good organising structure for a post; there is lots I want to say as a sort of recap but my ideas have been too sprawling. Then, last week @agteien posed three questions on Twitter and cc'ed me in for a response. I have taken the opportunity to write a self-indulgent review of where my thinking is at the moment.
I am not especially positive towards existing diagnostic structures-I see that it is insulting and disempowering to speak of "personality disorders", that Schizophrenia is probably not an unitary illness construct, capturing people with divergent (not always pathological) experiences; that the DSM is still too embedded in its past (American psychoanalytic psychiatry) to claim "theory neutrality". Equally, once I started interrogating the case-against, I found that the most sound arguments seemed to be for revisions to particular diagnoses, additions to the diagnostic system, possibly a new way of diagnosing. Critics who put all these elements together into a general call to reject diagnosis entirely are trying to make a case which is more than the sum of its parts. In some versions of the debate, the idea of diagnosis per se seems to become a blank screen onto which all the angers and frustrations of mental health get projected, with the accompanying promise "if only we stopped diagnosing people, then we could have a humane mental health system". I don't buy it. I am not especially positive toward keeping today's psych diagnosis system, but I think it has acquired a near-mystical status of evil in some people's eyes, and that stymies interesting debate.
Maybe this one is the question best fitted to me, I not only struggle to imagine doing without some form of classification, I think that DSM's critics can't do without one either. In his new year "message from the chair", Richard Pemberton of the DCP reflected on the division's statement against the DSM-5 back in May. In the same paragraph he announced forthcoming DCP publications "understanding depression" and "understanding psychosis". You don't, of course, need to construe depression or psychosis as medical "illnesses", but the DCP's use of these terms raises an interesting question about what we necessarily do when we classify. If we reject an illness model of mental health problems but nonetheless continue to speak of them as distinct entities then we are not travelling very far from the position of diagnosing. Depression and psychosis remain things that are worth talking about and "understanding"; they remain things about which clinical psychologists presume to write and explain. If we think we can develop an understanding of their causes, course and potential interventions, in what way are we doing anything radically different from those who "diagnose"? To recognise a problem and believe you can generalise from other similar cases to provide help is, to my eyes, to confer a diagnosis. The broad rejection of diagnosis starts to look more like a turn away from a specific type of diagnosis and it's historical/theoretical implications.
In the spirit of a debate that is a bit more developed than can be allowed on Twitter, I would encourage people to whom this last question is aimed to reply to it in the comments section on this post; I too would be interested in the answer.


  1. My vague impression of psychiatric diagnosis, and this is very vague and comes from a complete outsider, is that it attempts to carve Nature at its joints, and fails. It promises a separation of disorders that it cannot deliver. The importance of a few general factors of instability (or perhaps even just one general factor) are widely ignored, with an over-emphasis on hair-splitting between conditions so comorbid (and, I suspect, so similar in genetic etiology) that it's very hard to truly differentiate.

    The field reminds me of the "faculty psychology" of the 19th century, when human mental abilities were held to be unrelated, the products of unique "faculties" of the mind, though no one was quite sure what these faculties were, and the experts often produced frustratingly overlapping concepts. Mercifully Spearman came along to establish the general factor of mental ability (g) by empirically showing that mental abilities do in fact substantially intercorrelate, no matter how outwardly diverse the test material. Psychiatry is in a very similar place today, to my eyes, as intelligence research in the pre-Spearman era.

    But I have no patience for suggestions that diagnosis is the root of individual problems with mental health, or that it is the fundamental cause of problems within the mental healthcare system. Don't be silly.

    1. Hi CM-thanks for your comment; you conclude with more or less the same view as me. The point that psych diagnosis tries to carve nature at the joints is an interesting one. Sometimes this point is made with the underlying assumption that there are no joints at which to carve-I don't know whether this is true. Certainly DSM creates distinctions where none may exist, but that doesn't mean there aren't any to be found. It seems a significant problem that we haven't hit upon very many convincing ways to distinguish one mental "disorder" from another. Should we be more interested in statistical clusters; phenomenology; biological distinctions? More food for thought. Thanks for stopping by!

    2. My suspicion is that there are some joints at which reasonably precise carvings can be made, just not quite as many as the DSM currently pretends, and the carving can never be perfect (perhaps we need a new metaphor!).

      I've read some excellent papers factor analyzing common mental disorders (first seems to be Krueger 1999: hit me up on @AndrewSabisky on twitter for links). These statistical clusters, as you say, seem to be worthy of attention. Secondly the broad clusters need to be reduced, as far as possible, to their own distinct set of biological phenomena. I suspect we will have a much better idea of what phenomena to look for once the clusters of instability are properly defined, allowing for a new psychiatry that advances by hypothesis-refutation, rather than being purely descriptive (as it is now).

      But do bear in mind this is coming from someone who is almost utterly ignorant of this stuff, coming from a completely different background (individual differences in personality and intelligence, mostly). The psychometrics of mental disorders is just a hobby that I delve in my spare time.

  2. Any characterisation of a patient could function more or less like a diagnosis. The problem, IMO, 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. (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).
    IMO, 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. It also can 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.
    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.

    1. Thanks for this; it is nice to have a Lacanian analyst come by and comment here. I read Verhaeghe's On Being Normal and Other Disorders and found it to be a fascinating way to think about not only the shortcomings of DSM diagnosis, but also the role of diagnosis socially and psychologically-who does it make feel safe; who's professional interests does it protect?

      Unfortunately, there is a reluctance on the part of psychoanalytic practitioners to do much to make their work testable or operationalisable. In the US there is the PDM and the working group of dynamic practitioners who put it together, but that has achieved only minimal uptake and coheres moderately closely to the DSM.

      The biggest problem with the Lacanian system is that it seems to rely entirely on the authority of the "master" (for analysands this is the analyst, for the analysts this is Lacan). Who is to judge when repression is present, especially in an age when most cognitive psychologists agree that there is no evidence to suggest that the phenomenon even exists? Many psychonalysts treat such evidence, and indeed psychometrics, with a rather haughty disdain, but that is unfortunate as it splits them and their phenomenology from mainstream scientific practice and theory, leaving only the true believers to their own devices. What is the source of your rejection, in this comment, of psychometrics? Does a tick-box (which after all allows a degree of transparency) necessarily entail flippancy? Why?

  3. Thanks for your response – I elaborated on my comments a little more here: http://melbournelacanian.wordpress.com/2014/01/15/an-alternative-to-the-dsm/
    Verhaege makes for an interesting read, though I should add that his views on diagnosis are not ‘orthodox’ Lacanian psychoanalysis, but rather, a kind of rapprochement between the latter and empirical psychology.
    The key problem with the DSM, as I see it, is that it lacks basic logic. There is no coherent definition of a mental disorder – the status of a disorder is determined by committees of the self-interested. Empirical psychology has it exactly arse-about in this regard, compiling statistics and measures for concepts and systems that are intrinsically absurd.
    Psychometrics is a great example of ideology posing as science. It harks back to 19th century facultyism and phrenology, and fundamentally distorts (and invents) that which it purports to measure. There may be some exceptions to this – certain kinds of neuropsych tests, for instance – but using psychometric to reduce and quantify ‘personality’ and psychopathology is a mistake. The phenomena in question are, in the first instance, qualitative, and whilst numerical measures make perfect sense in some areas of medicine (white blood cell counts, blood pressure, etc), it’s bizarre for them to be relied upon to prop up hypothetical, ill-considered concepts. I think it’s reasonable to ask, for instance, with respect to personality tests – what is the ontology and epistemology being proposed here? Is it some reified grab-bag of ‘traits’ searching for a metaphysical peg to hang off? And if so, why should anybody take it seriously? And what is transparent about this? I can understand the use of such tests in the corporate world, in HR departments, etc, but I think the clinical realm is too serious for psychometrics.

    1. As for flippancy – I’m speaking from my own, anecdotal experience, but the illogical DSM system has led to overdiagnosis and misdiagnosis on a large scale. Certain disorders in particular – I’m thinking of bipolar and ADHD – tend to be misused. The result is overtreatment, especially of children and adults in abusive situations, and patients themselves sometimes over-identify or misidentify with labels that were misapplied in the first place. Moreover, when one sees 100 people in a row with a diagnosis of depression, for instance – a common scenario in private practice – the diagnosis comes to mean very little, other than that a professional somewhere has sought to assimilate someone’s private suffering into some general category.
      ‘Mastery’ is indeed a serious charge to level at Lacanians. I think that some schools of psychoanalysis have, in the past, been dogmatic and authoritarian – the IPA has elements of this. I don’t believe it to be true of Lacanians. An analysis is essentially a self-analysis, but since one has an unconscious, another person is required to ensure the self-analysis does not lapse into motivated ignorance. I think we’ve discussed this before, but interpretation in the Lacanian style is vastly different to say, CBT, with the latter’s brutal denouncement of ‘wrong’ thinking. An interpretation in psychoanalysis is significant for its effects, and any ‘resistance’ is on the side of the analyst, not the analysand.
      There is a very strong tradition in the Lacanian schools of critiquing ‘mastery’, indoctrination and the like, and, unlike in ego psychology, for instance, the analyst is not held up as a model for the analysand’s identification, and nor are his/her interventions sacrosanct. Institutionally, Lacanians are not answerable to their analyst, and their status as analysts in determined rather by peers, in a process known as ‘The Pass’.
      How might one identify repression? It is a good question, and best answered by undertaking one’s own analysis. In any event, assessing repression is a matter of carefully compiling observation and evidence into a logically defensible argument (Lacanians tend also to be big on supervision and case presentation). Represson always presupposes an unconscious (not such a controversial concept), but an unconscious which keeps very specific knowledge from consciousness (a more radical concept). So, the effects of repression might be discernible in a number of ways, such as the existence of parapraxes/slips; the partitioning (especially in men) of objects into those for sex and those for love; the correspondence of symptoms with specific fantasies; or symptoms possessing a metaphorical/metonymical character. (This list is not exhaustive, and there are plenty of other things to consider!).

    2. Interesting stuff. There is much here that makes sense, but I am not with you all the way. Certainly the definition of disorder in the DSM is a little vague and seems to come rather "after the fact" (many of the significant "disorders" existed in the minds of psychiatrists before the definition). I don't follow you as far as "intrinsically absurd" though. The DSM categories may not be "disorders" in any particularly interesting sense, but they do have the status of reliably identifiable behavioural clusters and do thereby link in to a clinically useful research literature.
      You don't really make a substantive case against psychometrics (beyond rather obscurely saying that the clinical world is "too serious"), you say it links into facultyism and phrenology, but we both know we can link psychoanalysis to no less egregious (and more recent) intellectual mischief-not least the pathologisation of homosexuality. If used in a mutually informative way with theoretically sophisticated interrogation of the processes that might underlie thought and behaviour, then there is no particular reason not to take it seriously.
      Flippancy does and can arise in a realm where diagnosis becomes relatively easy. Of course all psychological measures, including the DSM come with a "health warning" that they remain only one form of assessment. Part of a "nomological net" to borrow from the language of construct validity. In isolation, the application of bare psychiatric criteria can lead to absurdity, and I would agree that all the editions of the DSM have contained more than their fair share of nonsense categories.
      I do recognise that Lacanian psychoanalysis allows for a critique of the notion of mastery, but I find this weirdly undermined by the baroque language and deliberate obscurantism. Who can participate in this discourse other than those inducted into the particular way of talking? What starts as radical critique looks, to the outsider, like exclusivity and authoritarianism.
      Finally, by identifying repression as entirely subjective, discovered only when you have invested time, money and emotion in your own analysis , strikes me as a little fishy; even more so seeing as it receives no validation outside of the field which has so much riding on it. Beyond tortuous theory, how do we explain the sporadic nature of the phenomenon; the way many unpleasant things are not "repressed" and pleasant things are?

  4. I think the point about the lack of a coherent definition of ‘disorder’ is significant, particularly from an ethical and political point of view, since documents such as the DSM are used as justification for all kinds of coercive, normative practices. They play a crucial ideological role for thousands of people, and it seems inadequate to me that their foundations are manifestly hollow.
    To return to the allegations of mastery in psychoanalysis: again, I think we can contrast US-based, IPA psychoanalysis (which essentially persecuted homosexuals) with other schools, such as the Lacan’s. Remember, Lacan emerged in the Paris of Foucault and Deleuze, both of whom attended his seminars, and I would argue that his positions are radically anti-authoritarian. To go even further, I would argue that Lacanian psychoanalysis is probably the least authoritarian practice among the psy-disciplines – compare and contrast the ideological micromanagement, direct use of instruction and suggestion, and implicit conformism of cognitive and behavioural therapies. It is true that the language is difficult, forbidding even, but this in itself could be said of many other areas also.
    This brings us to psychometrics, my objections to which could be summarised as follows:
    1. It is based on the reification of dubious, hypothetical constructs, and upheld by an incoherent ontology, invalidating it from the beginning.
    2. The attempt at science by norms is both conformist and authoritarian, and arguably detrimental to the individual.
    3. The attempt at quantifying the qualitative is a conceptual mistake.
    4. Further to point 3, psychometrics functions as a reverse of Freud’s maxim – ‘Where I was, there shall it be’, with ‘it’ standing here for an alienated subjectivity, reduced, captured and objectified. However scientific this quantification may appear, there are strong epistemological reasons for thinking it does violence to subjectivity itself, and strong ethical reasons to view this as a dismissive procedure.

  5. Subjectivity is the key term here – that something is subjective does not render it non-existent, just difficult to study. (All pain, for instance, is at bottom subjective, which doesn’t mean that its make-believe). Psychoanalysis is an attempt to make a science of subjectivity whilst avoid the objectivist lures of so-called empirical psychology, which gives it a great richness but limits its conclusions outside of analytic settings. Now, there is some empirical evidence for motivated forgetting outside of psychoanalysis, but a detailed consideration of repression would have to clarify the definitions at stake. The operation of repression is not so much to do with unpleasantness, and more to do with an incorporation of certain aspects of language and law.
    To take an example I gave – the splitting of love objects and sexual objects, known in common parlance as the ‘Madonna-whore’ dichotomy/complex – how might one account for this phenomenon without a theory of repression? It is possible that people pick it up through some social conditioning, but this wouldn’t really explain the deeply-held ferocity this complex can assert over some people’s romantic lives. And ‘slips’ most certainly do occur, at least, in an analytic setting. People really do ‘accidentally’ talk about wishing that loved ones were dead, or that they could sleep with a colleague, before quickly correcting themselves. Such slips, being the detritus of language, are easily ignored, but in psychoanalysis, they are evidence of a division within the person speaking them. In sum, this division can be understood as repression, in the Freudian sense.

    1. Well regarding your first point I think it is both true and significant than DSM diagnoses are reified and lead to many pernicious consequences. There is a layer of construction wrapped around these ideas that, as you say, permits institutions to undertake coercive and often unpleasant practice. This is a question of how diagnoses are thought about and used in society and I think it is extremely pertinent.
      I take your point that Lacanian psychoanalysis is in a sense less authoritarian than the ego psychology of the US, but I do not take Lacan's emergence in mid 20th Century Paris as any special testament to the liberating quality of his thought. To begin with my point still stands, with such an obscure body of work and rarefied field of practice who actually benefits from this radical stance? Further, having spoken to some Lacanians and seen an intriguing, pleading email from a psychologist practicing in France, I have no reason to believe that Lacanian theory is more resistant to dogmatism or authoritarianism than any other. What "mainstream" psychology has to a greater extent than psychoanalysis, is clear rules about what constitutes theory development and viable knowledge. This is not to dismiss psychoanalysis out of hand, but to raise it's biggest epistemological problem, which has to be weighed.
      I still don't think we can dismiss psychometrics:
      1. It does not necessarily entail reification, it guides theory.
      2. A science by norms is not necessarily entailed by psychometrics, which principally examines only see how constructs and their measurement work in populations.
      3. Quantifying the qualitative is ultimately by definition impossible, but efforts toward it are not without utility.
      4. You resort to a metaphorical "violence" in your point 4, which points in fact to common enough feeling that one's complete subjectivity is not captured in a form. Well plenty of complex things cannot be entirely captured in measurement, but that has not stopped us making rather satisfactory and useful measurements.
      Finally, pain and repression are simply not analogous. Pain is a direct experience (another on, incidentally, which we inadequately but nonetheless usefully try to measure) while repression is a theoretical concept imposed on a set of experiences. I forget, I remember, I am told it was repression. Psychoanalysis provides many different ways of thinking about our emotional lives, many of which I do feel have value, but a big problem is how you distinguish between things you have genuinely learnt about your mind, and compelling-seeming explanations the analyst has convinced you are correct. Psychoanalysis is a distinctive way of talking about the strong feelings that exist in close families (translated in terms of the complex you mention) but it cannot claim some luminous privileged truth-value. Like CBT and, perhaps all therapies, it is impossible to say with confidence that there is not suggestion taking place as a result of the bias towards convincing oneself (and one's therapist) that the game is being played successfully.