the connection between diagnosis and treatment can only be made through a conceptual understanding that holds the vicissitudes of identity as utterly central
the connection between diagnosis and treatment can only be made through a conceptual understanding that holds the vicissitudes of identity as utterly central. In this case, the emphasis will be on the relation between the subject and the Other. This is not by coincidence: the main contention of this book will be that identity is acquired only in relation to the Other. Consequently, any potential pathology must also be diagnosed on the basis of this relationship. Finally, it is only through this relationship that the treatment can be effective. This latter idea is confirmed by numerous studies that reveal the therapeutic relationship itself as the decisive instrument.
DIAGNOSTICS AND DISCOURSE
Introduction: Clinical Psychodiagnostics versus Medical Diagnostics
The son is caught between his parents, his behavior clearly cannot be understood outside of its context. From a psychoanalytic perspective one would say that his behavior provides an answer to the desire of the Other, that is, his parents, with the proviso, however, that the boy himself is not, or is only barely aware of it. “The unconscious is the discourse of the Other” (Lacan). Systemic theory would say that the boy shoulders the symptoms of his family. A cognitive behavioral approach would see his behavior as learned, which leads us to the following question: From whom does one learn what, and why? Whatever approach one takes, a common factor emerges: the diagnosis cannot be limited just to the boy. The impact of the Other is fundamental
The son is caught between his parents, his behavior clearly cannot be understood outside of its context. From a psychoanalytic perspective one would say that his behavior provides an answer to the desire of the Other, that is, his parents, with the proviso, however, that the boy himself is not, or is only barely aware of it. “The unconscious is the discourse of the Other” (Lacan). Systemic theory would say that the boy shoulders the symptoms of his family. A cognitive behavioral approach would see his behavior as learned, which leads us to the following question: From whom does one learn what, and why? Whatever approach one takes, a common factor emerges: the diagnosis cannot be limited just to the boy. The impact of the Other is fundamental. This is the first major difference between medical diagnostics and psychodiagnostics: clinical psychodiagnostics cannot be restricted to the individual. Psychic identity, with its potential psychopathology and aberrant behaviors, must be conceived in such a way that it grants the other a place equally important as the individual’s.
In medical diagnostics the symptoms are interpreted as signs pointing to an underlying disturbance that can be both isolated and generalized. In clinical psychodiagnostics we are confronted with signifiers that carry endlessly shifting meanings in any given interaction between the patient and the Other.1 The signifier “Mercedes” will never carry the same meaning in any other clinical situation as it does here. The universal element is missing; the clinical psychodiagnostic process results in a category in which N = 1. The clinical psychodiagnostic questions are thus not so much “What disease does this patient have?” but “To whom or what do the symptoms refer? What are their meanings and functions, and who do they relate to?” There must be an underlying and, as yet, invisible structure determining the whole that intersects in the patien
in psychopathology, there is no firm link between objective, assessable parameters for a specific psychological problem and the way it is subjectively experienced and expressed
Suddenly, we have become teachers and treatment becomes a question of learning or of (re-)education through which the pupil must be brought as closely into line as possible with this ideal result
People frequently get into difficulties when their ideals have been shattered.4 But to spoon-feed them new ideals at such a time, albeit with therapeutic intent, resembles a detoxification treatment that replaces opium with morphine. Instead, psychotherapy must give them the chance to interrogate the hows and wherefores of these ideals, that is, their subjective history, so that certain choices can be (re-)made
To think naively in terms of adapted or unadapted behavior, or even desired or undesired behavior, is to enter into dangerous waters. Who desires what, and in whose name?
What I simply wish to underline here is the way all psychological development takes place in interaction with an Other, and that the impact of such an Other must not be neglected in clinical psychodiagnostics
In the case of psychopathology, an alternative temporal structure can just as easily be put forward, one based on retroactivity, or Nachträglichkeit, in which elements from the past are interpreted by way of the present (Freud 1978 [1918b]). A depressive patient, for example, will stress the negative elements of his life’s story because of his depression. But to consider this negative past the cause of his depression would be to jump to a conclusion too quickly.
The greatest danger in such an approach is the same one facing the entire clinical psychological field. To maintain that everything must be situated in chronological terms implies that the present can be explained on the basis of the past, and that both of these determine the future. Put differently, it implies that what is actual can be entirely explained by the past, not just disorders, but normality as well. The risk, then, is that the following message is implicitly sent: anything that can be traced back to a life history is explainable, comprehensible and, hence, acceptable. The hyperbolic but logical extension of the so-called “mitigating circumstances” serves as an illustration. “He beats his wife, but what do you expect? He had an unhappy childhood.” Nevertheless, even insanity has ethical limits. Throughout this book, I will emphasize over and over again that these two fields—the field of clinical psychology and the field of jurisdiction and normativity—must be clearly separated.
Any diagnosis that uses psychological testing, even with today’s computerized renditions, always yields relative results. This relativity has as much to do with the fact that the results need to be evaluated against a representative group to which the tested person belongs, as with the fact that the parameters for measurement themselves can never be exact. As I said before, there is no precise unity of measurement for anxiety, for neurosis, and other states. This is the classic problem of reliability and validity (as discussed below). Consequently, the results still require interpretation, and it is at this point that the experimental field proper is left behind
The great majority of recent studies of psychotherapeutic efficacy indicate that the most important operative factor is the therapeutic relationship, and this is established right from the first interview, even if that has a merely diagnostic aim. As a result, it is far from self-evident that the diagnostician and the therapist need be two different people. When this does occur, a predictable enough scenario ensues. Often, the therapist regards the first interview as a rapid recapitulation of what already occurred in the diagnostic examination, while the patient complains that she or he “has to say it all over again.
The second difference is potentially even more significant. The goal of medical diagnostics is to indicate the correct treatment for eliminating the illness. Earlier, we noted how psychic symptoms carry meanings and have a function that transcends the individual. Now we can go a step further and say that psychic symptoms invariably come down to a patient’s economic attempt at a solution for an underlying, structurally determined problem. “Economic” here signifies an accounting paradigm of loss and gain. By “structural” I mean to indicate that the problem is not limited to the individual, but must be understood from within the terms of a relation with significant others. The teenager’s joyriding, for example, was his solution to the problematic position he adopted toward his parents and their own relationship. To put it briefly, let us simply recall that classic argument of psychoanalysis: psychic symptoms are the patient’s attempts at recovery.
a psychotherapeutic approach ought rather to be directed toward the underlying structure. Should the therapist forget this, she unwittingly collaborates in restoring the symptom’s economic gain
Central to medical diagnostics is the gaze, whose focus is on detecting signs that point toward objective, measurable parameters. In contrast, in clinical psychological diagnostics the focus is laid primarily on listening to signifiers that remain open to interpretation. Medical signs pertain to an illness scenario; signifiers, on the other hand, derive their meaning and function from a specific relation with an Other. The distinction between illness and health can be measured and generalized, but psychic normality and abnormality are always relative and, hence, particular. Moreover, certain psychic symptoms can best be understood as attempts at a solution for a particular structural relation with the Other
2
Categorical Diagnostics versus Clinical Praxis: A Matter of Impossibility
He asked an actor to play a normal person, interviewed him about his case history, and presented the audiotape to experts from our profession: twenty-five psychiatrists, twenty-five psychologists, and forty-five psychology students. Before listening to the tape they heard a very respected colleague tell how “this patient’s subtlety makes him seem neurotic but in fact he is completely psychotic.” The result: fifteen psychiatrists diagnose psychosis and ten neurosis; seven psychologists find him psychotic, fifteen neurotic, and three healthy; among the students, five diagnose him psychotic, thirty-five neurotic, and five found the man sane. Conclusion: the clinical intuition of professionals is evidently just as unreliable as that of lay people
All that is needed is for an authority to discover a new syndrome, or to breathe new life into an old one, for a massive increase in this diagnosis to occur. An example in this respect is the sudden revival of the old Tourette’s syndrome following the publication of Oliver Sacks’s (1986) best-seller, The Man Who Mistook His Wife for a Hat (1986 [1985]; see Minderaa et al. 1988). In the meantime, this has been replaced by the more recent rage for ADHD. Throughout the history of psychiatry and clinical psychodiagnostics, various such fads can be identified. Clearly there are epidemics in psychological disorders as well, but the question is, Who falls prey to them, the patient or the clinician?
after all, not so rare…In the second part of his experiment, Rosenhan (1975) gave the institutions a “second chance.” He published his results, shook his admonishing finger, and let it be known that in the following months further “normal” test subjects would be sent for admittance, in the hope that this time the right diagnosis would be made. And, in fact, this time the normal patients were exposed. Unfortunately for the institutions, however, Rosenhan hadn’t actually sent anyone.
In the second part of his experiment, Rosenhan (1975) gave the institutions a “second chance.” He published his results, shook his admonishing finger, and let it be known that in the following months further “normal” test subjects would be sent for admittance, in the hope that this time the right diagnosis would be made. And, in fact, this time the normal patients were exposed. Unfortunately for the institutions, however, Rosenhan hadn’t actually sent anyone.
The results of such findings brought the societal ideological upheaval indoors as well. The former psychodiagnostic categories and accompanying methods had lost so much of their credibility that a worldwide search began for an accessible and, above all, reliable system for psychodiagnostics. It was as if a new Enlightenment was taking shape, whose final form we know today as the DSM.
The success of the DSM can be historically understood as emerging from the anti-psychiatry movement, more specifically from dissatisfaction with confusing psychodiagnostic terminology and the accompanying multiplicity of disparate theories and opinions
none of the studies succeeded in demonstrating the categorical character of the personality disorders. In concrete terms, this means that there is no clear-cut demarcation between normality and pathology and that there is a considerable overlap between the different categories
It became rapidly clear that the very same patients received a different diagnosis depending on the instrument used (questionnaires, semistructured interviews), and that even with the same instrument many people fit the criteria for several personality disorders. In fact the studies (Hellinga 1992) discuss an average of 3.75 to 4.60 personality disorders per patient!8 The most frequent diagnosis, then, is of course the latest DSM blanket term, namely Personality Disorder Not Otherwise Specified.
We can conclude, therefore, that the chief difference between the DSM diagnostics and their antecedents comes down to the fact that the DSM diagnostics have greater international currency than any preceding nosological system, and this is unquestionably a significant gain
Meanwhile, we have lost sight of one of the most important motivations of the anti-psychiatric movement, namely, to address the typically authoritarian relation between the expert and the patient. So the final question is: Has the DSM diagnostic changed anything in the relationship between diagnosticians and patients? The answer is an unqualified no
The use of terms such as “normal,” “deviant,” “undesirable,” and so on inevitably implies a norm that implicitly carries a power relation. This means that right from the start there is a danger of a crossover between the juridical-normative and the clinical-psychodiagnostic fields. We must be expressly aware of and attentive to this.
One of the primary contentions of this book will be that content (naming) and form (relation) are two sides of the same diagnostic coin and that each performs a role in every psychodiagnostic process
this disjunction of impossibility at first appears to be of a practical, and hence solvable nature. Just a bit more research, preferably strictly objective and scientific, and the ultimate system will be found. In Lacan’s discourse theory, this is not the case. The relationship between the agent and the other has to do with merely the upper level of each discourse; what it veils is a fundamental relationship containing a second underlying disjunction. Extending this first disjunction to its underlying second one, the disjunction of impotence, shows that there is a lot more going on.12 The impossibility of reaching a final diagnostic pronouncement has to do with this underlying impotence. In Lacan, this impotence is structurally determined and hence insoluble. I would like to suggest that, rather than losing our way among the diagnostic trees, we must uncover the structure of the diagnostic forest, namely, what this impotence involves
the object of psychodiagnostics is first and foremost a relation rather than an object per se
these ideas have become quite literally self-explanatory and we can scarcely imagine any other way of thinking. The subject–object divide, renamed as the body–soul dualism, completely determines how we think. A holistic structural approach, wherein each part is indeed only a part of a larger whole, conflicts with the inherent dualism in our way of thinking. This is reflected, moreover, in our training: soma for the medical world, psyche for the human sciences. Attempts to join these two a priori separated structures together—psycho-soma-tics—are indeed nothing but attempts to glue a preconceived break together.
from Descartes more or less onward, the scientific method has been characterized by the imperative principle of objectivity, confirming this fundamental dualism (res cogitans versus res extensa).2 The scientific manual is immediately legible: an objective, “Cartesian” reconnaissance of the “Aristotelian” object so as to find the underlying “Platonic” invariant
Under Kant, the very concept of what science is will be shaken to its foundations. To put it schematically, Kant concludes that science can never study the thing-in-itself, the Real, but only the thing as it appears to us. Consequently, science can only construct a representation of reality, nothing more
Noticeably, it is in the positive sciences that Kant and Darwin have had the most impact; so far, at least, they have made little impression on the human sciences. Evolutionary psychology has barely got off the ground. In the hopes of being similarly scientific, the majority of the human sciences continue to reflect the naive empirical-Aristotelian model that the hardier brothers of the hard sciences have already left behind. In psychodiagnostics, the effects of this model are clearly visible. Science is the objective study of the object—of the immutable object, no less. As a result, phenomenological diversity must be reduced to its universalizable essence. This is why the history of psychopathology can chiefly be understood as the history of a changing and ever-increasing nomenclature that tries to embrace the essence of clinical reality
Classification has now taken the place of diagnostics, and the distinction between classification and diagnostic systems has been lost (Van Hoorde 1986a,b). As a result, we are left empty-handed. Clinical knowledge is disappearing and thus so is the clinic itself. The former all-too-rich diversity has been lost, and is replaced by a tendency toward a globalist psychiatry characterized by fluent transitions between neurosis and psychosis, while perversion seems to have been reserved for forensic psychiatry and potential literary uses
Furthermore, a number of peculiar neurobiological diagnostic kinds of logic are emerging: if someone responds favorably to antidepressants, she or he must suffer from a depressive disorder; if someone responds favorably to antianxiety medication, he or she must suffer from an anxiety disorder
It is immediately striking how the diagnosis itself already demands arbitrary thresholds: a diagnosis of borderline has to meet at least five of the nine characteristics. Why five? Why not four or six? No one can give a meaningful answer to this question; the “border” has to be located somewhere. Moreover, for a characteristic to be present, a certain quantity has to be transgressed each time: intense, marked, frequent, recurrent, markedly and persistently, frantic. The diagnostician must weigh things up, asking him or herself: is this intense enough, is this sufficiently inadequate or marked?
The problem with the DSM is not simply a result of the DSM’s own failure. As explained above, this manual is the final culmination of a certain scientific tradition that upholds the centrality of the object’s transparency and immutability, albeit as a problem often enough. For the DSM, this operated not so much as a problem but as an assumption: the object is transparent. Hence one of the most overriding problems of epistemology was not taken into consideration, namely, what is the relationship between the scientific description and the object of study, in this case, between the nosological designation and its clinical reality? Or, more broadly: What is the relationship between the word and the thing?
In this view, there is only one correct way of ordering, independent of and prior to any research. The scientist’s task is to discover and understand this order in a progressive, cumulative way. Such an ordering seems to have been accomplished in botany with the Linnaean system, but psychodiagnostics still has a long way to go. Secondly, this approach situates all certainty in the object, being persuaded that a precise order, a fixed lawfulness, exists independently of the researcher who merely gives it a name: “What’s in a name? That which we call a rose, by any other name, would smell as sweet” (Shakespeare, Romeo and Juliet, Act II, Scene 2). This harks back to medieval realism, as a Catholic-inspired rewriting of Plato and Aristotle, which holds that in reality there is a preexisting order and lawfulness determined by God.
Further consideration shows how this perspective depends on a naive approach to language. The thing dwells in the external world, waiting until the right word is found for it. In terms of discourse theory, this implies that in scientific activity, knowledge (S2) is equivalent to the object of study (a), which, by these means, becomes transparent. But this is not even true of children’s language, except perhaps in onomatopoeia. Medieval realism is untenable, even for the frequently cited example of botany. Lévi-Strauss (1976) demonstrates in The Savage Mind how the classification systems of certain South American tribes are more efficient than that of Linnaeus insofar as the system has a different functionality (the quest for food). Apparently, a rose is not always just a rose.
This brings us to a second approach, radically opposed to the first. Its starting point is the idea that we gain access to reality only through our individual representations based on perception. While we provide the links, build categorizations, and construct abstractions that appear empirically recognizable, these nevertheless exist only in the mind and are imposed upon reality afterwards, in a second moment. “It is the theory that determines what observation tells us.”12 From this perspective, there is no preexisting order, it is we who create and impose it. In the final analysis, this imposition always happens in the same way: by naming, through the giving of names. Hence the name of this approach, nominalism, which dates back to William of Occam.
The extension of this approach leads to the extremes of solipsism, even to nihilism, where nothing is assured and any word can mean anything. This ultimately leads to the denial of the existence of the world itself
science can only make constructions and models of reality and test them on their predictive merit. Scientific progress is the replacing of one model by another that is presumed to be a better approximation of reality at the time. Nevertheless, a model remains first and last a model, nothing more
The production of meaning comes from the difference between the mutual signifiers, indicating that it is always the context that produces signification. A single signifier signifies nothing; it is only in the combination of several signifiers that meaning is produced, drawn from the surrounding signifiers
From this perspective, so-called reality is at least partially a product of the Symbolic, reality becomes materialized, realized. Reality is indeed what has been actualized, made operational for us.
So-called reification, the fact that things are called into life by words, is less the exception than the rule in human reality.15
So-called reification, the fact that things are called into life by words, is less the exception than the rule in human reality
Postmodern science, in contrast, is both neo-Kantian and neo-Darwinian. Since “the thing-in-itself” can never be known, science concentrates on “the thing-for-itself,” which must be conceived in terms of evolutionary adaptation. Following on the heels of this, the development of quantum mechanics and evolutionary theory has made determinism questionable, shifting the emphasis onto contingency.16 Contemporary science leans toward a new version of nominalism: we make constructions, models of reality whose impact and range we try to empirically verify
Freud and Lacan study the human being first and foremost as a being that manipulates symbols and undergoes their effects
The difference between humans and animals can serve as an illustration. Animals have no need of science because they have direct knowledge of their surroundings, that is to say, an unmediated knowledge that operates through signsystems originating in their phylogenetic and ontogenetic development by way of imprinting and prewired connections. Despite the frequent complexity of animal communication systems, it is precisely as a result of their unmediated nature that they lack one central characteristic of mankind’s, namely, the ability to reflect
lack is the primary condition that makes displacement possible. Without lack, displacement cannot occur in the symbolic system. The combination of lack and displacement makes reflection possible: to think about thinking and to make choices founded upon such a mediated meta-standpoint
Even the logical need for lack in the functioning of a symbolic system can be shown, see Gödel’s argument on this score. A simple children’s toy gives a practical illustration. Think of those sliding tile puzzles that only work if there is one tile missing to provide a preliminary opening space
ordinary human language is unable to get ahold of the thing-in-itself, so that there is always a gap between every form of symbolization and the Real.22 In Lacanian psychoanalysis, this is known as the lack in the Symbolic order, signaled paradoxically by the object (a). But this paradox disappears once we understand its accompanying logic: this Real object (a) is lacking in the Symbolic,23 and refers to Freud’s originally lost object, that which never can be refound and for which every one of us continues to search. It is precisely this object that is lost by and through the acquisition of language, the object that we have left behind, the “answer” to desire beyond words.
The effect of this fundamental condition and its mode of functioning is double: not only the object, but also the speaker is continuously displaced by the signifiers, to become a divided subject. “A signifier represents a subject for another signifier,” says Lacan, following the Freudian “the ego is not master in its own house” (Freud 1978 [1917a], p. 143). One recognizes, in the first place, a psychological doubling in this divided being: I am the son/daughter of, but also husband/wife of, father/mother of, brother/sister of…From an analytic point of view, the division goes considerably further: the subject does not speak, it is spoken. As a result, the subject floats on top of the spoken words. Indeed, when “I” speak, I do not know what “I” am about to say, unless I am reading it or have learned it by heart. In all other cases, “I” is spoken by a desire outside my consciousness that drives me, sometimes with my approval, sometimes without. And what I do say always comes, in the final analysis, from the Other (see the section on alienation in Chapter 8).
There are four different discourses, because the four terms (in a fixed sequence) can change across the four different positions: the agent or the speaker, the other or the one spoken to, and the product. What Lacan calls the truth lies beneath the agent, as the starting position of each discourse. Within these four fixed positions are two disjunctions, one above, the other underneath. Moreover, and even more importantly, each discourse epitomizes a certain social interrelation, depending on how the disjunctions are handled
Normal discourse (that is to say, the Hysteric’s discourse) is as follows: the divided subject S is driven by the truth of the lost and hence desired object (a), whereupon this subject turns the other into a master, S1, who must produce the relevant knowledge
Normal discourse (that is to say, the Hysteric’s discourse) is as follows: the divided subject S is driven by the truth of the lost and hence desired object (a), whereupon this subject turns the other into a master, S1, who must produce the relevant knowledge, S2:
The essence of discourse theory is as follows: the lack of object, that is, the object (a), is both the cause and the condition of possibility of every symbolic system, and therefore also of science. It is the cause because it is precisely the loss of the Real effected through language that drives our endless attempts to recover this Real. It is the condition of possibility because it maintains the necessary opening of the Symbolic system that enables displacement to take place
As a result, every symbolic system—and thus science too—will never be able to reach the “thing.” Indeed, as a symbolic system, science increasingly produces this lack of object, which is why the object (a) appears in the righthand space below. It is this that I call the constructive misunderstanding that lies at the foundation of every science.26 The more scientific—that is to say, symbolic—we become, the further from the Real we are, from the very thing we wanted to get ahold of in the first place. But what we gain in the meantime is a perpetually changing model of reality. That this is not merely a hypothesis is shown by the ever more impossible objects of theoretical physics, which the scientists themselves confess to not knowing whether or not they really exist
The importance of this shift cannot be overestimated because it forms the foundation for all subsequent relations. First and primarily, the child quite literally receives the images and words for its internal experience from the other. Under normal circumstances, the mother’s reaction will be a mirroring that reflects both the child’s pain and its first regulation (“Does it hurt? Come here, Mommy will kiss it all better”). Moreover, from this primary interaction, the originally purely somatic tension takes on a psychological dimension. To put it more strongly, the somatic pain is transformed into psychological pain the moment that the Other doesn’t respond. It is at this point we encounter the primary traumatic situation, separation, understood as the experience where the inner tension remains unresolved by the Other, that is, by the Other’s specific action that would relieve the tension. The tension and the other are linked together by the cry. Even more, the cry is the expression or representation of the tension. And this then becomes the central problem: How can the subject express its tension, in psychological terms, in representations (Vorstellungen) or words? We will return to this presently
The child’s reaction to this unpleasurable situation is prototypical and provides the foundation for all subsequent intersubjective relationships. The helpless baby turns to the other by crying. The other is supposed to take care of the “specific actions” that will relieve the inner tension (Freud 1978 [1950a (1895)], pp. 317–321; Freud 1978 [1926d], pp. 169–172). Such an intervention will always consist of a combination of acts and words, indicating to the child that the Other has understood the demand and tried to respond to it. Note that this prototypical foundation thus indissolubly links an originally somatic pain and tension with the Other. In other words, the somatic drive has an intersubjective dimension right from the very beginning. The importance of this shift cannot be overestimated because it forms the foundation for all subsequent relations. First and primarily, the child quite literally receives the images and words for its internal experience from the other
Clinically speaking, two consequences emerge (cf infra, Chapter 10). The original experience of pain acquires an affective coloring, namely, anxiety. Separation gives rise to a primary depressive reaction displaying the main characteristic of later adult depression, namely, the loss of identity