There is currently an acrimonious spat developing between psychiatry and clinical psychology. The catalyst for this is the imminent publication of DSM V, but this argument goes back much further and is a lot deeper than simply arguments about what should and should not be classified as a ‘mental illness’. A series of articles in last Sunday’s Observer gives a flavour of the battle to come – and the war that has been ongoing for at least the last fifty years.1 The current argument focuses on the question of diagnostic categories, with the psychiatrists continuing to support their utilization, whilst the clinical psychologists question whether they have any validity at all. However, as the Observer articles demonstrate, the argument about diagnosis is being confounded by another one, which concerns the causes or aetiology of mental illness.
The Division of Clinical Psychology (DCP), which is part of the British Psychological Society, makes it clear where it stands on the question of diagnosis.2 Their position statement (on DSM V) argues:
Psychiatric diagnosis is often presented as an objective statement of fact, but is, in essence, a clinical judgement based on observation and interpretation of behaviour and self-report, and thus subject to variation and bias.
The dominance of a physical disease model minimises psychosocial causal factors in people’s distress, experience and behaviour while over-emphasising biological interventions such as medication.
It is therefore somewhat ironic, perhaps, that the DSM has very little to say about aetiology; rather, it is a set of symptom classifications. In the process, as its critics are quick to point out, it effectively ‘invents’ or constructs a whole set of illnesses – or, to be more precise, conditions – which didn’t exist before – even in previous incarnations of the DSM. Many people are now arguing that this insidious, ever-creeping medicalisation of life is being driven not be science or medicine, but by profits; more precisely, by the interests of the large pharmaceutical companies. Psychiatry invents a new condition and, surprise surprise, the pharmaceutical companies come up with a drug which treats such a condition.
However, as I said earlier, this is to confound two different arguments. The fact that the DSM may be being (mis)used to boost the profits of the pharmaceutical companies has nothing to do with whether psychiatrists believe that, in the last instance, all mental illness has a biological cause. Some psychiatrists do indeed subscribe to this view, but so do some clinical psychologists. On the other hand, many psychiatrists do not subscribe to this argument at all. Most would argue that mental illnesses are complex and multi-faceted, and that usually they are the product of a mixture of genetics, neurobiology, childhood experiences, individual psychology, and current socio-economic conditions.
It’s also important to point out that clinical psychology has its own agenda, which is basically to replace the (somewhat mythical) genetic-neurobiological paradigm of psychiatry with what is essentially a cognitive-behavioural paradigm of human experience. This is not for one minute to defend the DSM, but neither is it to subscribe to the opposite view which effectively throws the baby out with the bath water. The reason I say this is that, at the moment at least, the clinical psychologists do not appear to offering an alternative way of conceptualising mental illness. Or, to be more precise, they are not (apparently) offering an alternative diagnostic framework within which to conceptualise mental illness.
This rather begs the question: do we need any form of diagnostic framework? Interestingly, in view of their criticisms (and the way this story was presented in The Observer), the DCP opens its statement by acknowledging that:
Classification is fundamental in medicine. To be effective, it requires a reliable and valid system for categorisation of clinical phenomena in order to aid communication, select interventions, indicate aetiology, predict outcomes, and provide a basis for research. Medical diagnosis is the process of matching an individual’s pattern of symptoms and biological signs to a standard pattern in the classification, and ensuring that similar but alternative patterns are discounted in the matching – the process of differential diagnosis. The patterns themselves are commonly categorical; if it is one it cannot be the other, but several can co-occur (co-morbidity).
It is also interesting to note that there is no mention of ‘objectivity’ in this paragraph, even though the DCP then goes on to criticise the DSM (and it’s counterpart, the ICD-10) for presenting interpretation as ‘objective fact’. The point here, surely, is that all medical classification is based on interpretation, not just psychiatric classification. This harks back to a much older and more fundamental argument regarding the status of ‘mental’ illness; that, somehow, it is different from ‘physical’ illness.
Leaving this argument to one side for the time being, and going back to the question of diagnosis, is there another way to look at it? The short answer is yes, there is another way, and it’s the approach taken up by Lacanian psychoanalysis. Bruce Fink, in his very readable A Clinical Introduction to Lacanian Psychoanalysis, explains the Lacanian position very succinctly. 3 Essentially, there are just three diagnostic categories: neurosis, perversion, and psychosis, and they are based on three different forms of negation: repression, disavowal, and foreclosure. As Fink points out, these are actually Freud’s categories, although he probably wrote more about repression and disavowal than he did about foreclosure, which is the mechanism of negation for the psychotic.
The critical point about these categories, compared the ones used by the DSM and the ICD-10, is that they are structural, as opposed to phenomenological. The DSM uses the latter approach, by clustering together various symptoms and, to all intents and purposes, constructs or even invents an illness. This has nothing to do with the underlying aetiology of the condition, because there isn’t one. These symptom clusters are not symptoms in the sense of referring to an underlying or hidden causal mechanism. They are purely descriptive.
Of course, it could be argued that the three mechanisms of negation deployed by different subjects are pure fabrications. However, the idea of structural mechanisms is quite common in modern science, and forms the basis of a complete epistemology, namely critical realism. The crucial point about the Lacanian diagnostic categories is that they form the basis for a direction of treatment. For example, an analyst would work very differently with a psychotic patient than he or she would with a neurotic one. And this brings us back to the whole question of diagnosis and diagnostic categories: do we need them in order to work with troubled and disturbed people, i.e. those that some like to describe as being mentally ill?
Perhaps one way to approach to this question is to ask: what would happen if we didn’t have some form of diagnostic framework? In my view we would be left with an extreme version of phenomenology. In other words, we would be left with the individual’s account of their troubled experience – but would be unable to respond in any way. The problem here is that this ‘account’ would not just be in words, but in actions, and such actions could become very problematic for both the individual and those around them. And what would then happen would the very (coercive) response from psychiatry and other agencies that the opponents of the DSM and other forms of diagnosis were trying to get away from in the first place.
The point here is that in many ways, psychiatry is already more than half way to this position. The DSM is not about the causes of mental illness; rather, it’s about managing the behaviours and experiences of people whose behaviours and experiences have become problematic – both for themselves and the wider society. There is no attempt to try and engage with such experiences and behaviours, and to situate them in the wider context of the person’s history.
At least the Lacanian approach to diagnosis opens up the possibility for such an engagement.
- http://www.guardian.co.uk/society/2013/may/12/psychiatrists-under-fire-mental-health?INTCMP=SRCH [↩]
- http://www.madinamerica.com/wp-content/uploads/2013/05/DCP-Position-Statement-on-Classification.pdf [↩]
- Fink, B. (1997) A Clinical Introduction to Lacanian Psychoanalysis: Theory and Technique. Cambridge, Massachusetts, Harvard University Press. [↩]