The brilliant Foucaultisdead and I have been having an interesting conversation surrounding asperger’s syndrom and my recent remarks on the symptom that reminded me of this piece I wrote a number of years ago surrounding concerns about how diagnosis functions in contemporary American clinical contexts. In response to his call take opportunities to make Lacanian psychoanalysis more available to the mainstream media and lay public, I wrote a rant worthy of my recent mood, that reminded me of this piece:
I tend to be a bit more pessimistic about what is easy from the standpoint of the mainstream media and lay people, as it seems to me that a good deal of the contemporary constellation in the United States where therapy is concerned is premised on the complete eradication of the subject from discourse. From the side of the various therapeutic orientations, not only do we have the vested economic interests of insurance companies that would like to see the minimization of lengthy costly treatment through medication and a set number of consultations (usually around twelve, sometimes more though at a frequency of every two weeks to every month), but also the rise of the predominance of the discourse of the university where every patient must be neatly subsumable in a diagnostic category in advance such that there are no surprises (hence the DSM-IV, which is largely for the benefit of insurance companies, not practitioners).
On the side of those seeking treatment, the growing collapse of various identities due to globalization in economics and media technologies and the continued crumbling of the big Other, has led to a corresponding increase in symptoms of hysteria such as anxiety disorders, as well as omnipresent depression (what’s being mourned here?). As a result, rather than a discovery of oneself as a subject as in analysis, therapy– which I always distinguish from analysis –has precipitated the search for a master capable of naming the subject, thereby guaranteeing a minimal ontological substantiality. The new names of the subject are strange indeed: Borderline, depressive, schizoid, dissociative, panic, etc. In being given these names– the name of the symptom here always comes from the guru therapist, and is not an act of self-naming with respect to the symptom as in the case of analysis… One wonders why the therapist feels compelled to diagnose at all –the patient assumes a minimal identity.
Or to put it a bit differently, one wonders why it isn’t more widely recognized and thought about that nomination or diagnosis is not simply descriptive of a pathology, but also is performatively formative of identity for the patient that then identifies with the nomination and takes it as a descriptor of his being. Addiction becomes all the more powerful in *nominating* myself as an addict, for instance; and, of course, we can recognize the performative and ritual aspects of this performativity in 12 Step programs where the first step is “admitting you have a problem”, i.e., agreeing to nominate yourself and bring a certain identity into being, thereby positing the Other or making it exist at one and the same time (it’s not a mistake that one of the steps consists in placing oneself in the hands of a higher power).
Although they have no idea what they are in their day to day interpersonal relations (how could they in a world where there are layoffs every couple of years, where family relations continously crumble, where relationships are virtual, and where ethnic and national identities progressively recede) their new name as “depressive”, “anxious”, “dissociative”, “borderline”, etc gives them an identity, a *knowledge* (in the imaginary), of who they are that then serves both as a self-reinforcing feedback loop (the patient must enact the identity and begins to read up on their “disorder” in the self-help section to play the role and disover who they are), and a new set of rights and protocols surrounding victimhood in their interpersonal relations. These are unheard of nominations that have come to replace the older and failing nominations like family names, national names (American, German, French, English, etc), and ethnic names (Jew, Catholic, and so on…), and therefore provide the new ideal ego (for the ego ideal of the therapist’s gaze) of a very peculiar sort.
All of this functions as a massive defense formation against the void and singularity of their unconscious and the way in which life in contemporary capital calls for us to give way on our desire. The focus on the subject has always been what has guaranteed psychoanalysis the status of a “ghetto science” and has always invited a sense of defensive horror. “What, no master to name me or university to categorize me? What, an auto-elective nomination? Gasp!” As Kurtz says at the end of Apocalypse Now, “The Horror! The Horror!”
Although I’m not entirely sure that my argument fully holds up in terms of more recent developments in my thinking about psychoanalysis, I think much of it remains solid. I believe this post also converges with some of N.Pepperell’s thoughts on self-reflexivity and critique. Hopefully others will find it of some interest. I’m really rather shocked that no one has written a Foucaultian style analysis of the history of the DSM-IV and how it’s used in Anglo-American clinical contexts. Without further ado:
No doubt there is a measure of truth in this evaluation, but, as is so often the case with conventional wisdom, this point is true for the wrong reasons. The standard fantasy underlying the opposition between hard and soft sciences is the thesis that these sciences (psychology, anthropology, sociology, economics, history, etc.) are themselves ultimately reducible to the principles of the hard sciences, but have not yet been reduced by virtue of our inability to pierce the complex set of variables involved in these phenomena. Thus we look to fields like neuroscience and the field of genetics as possibly offering us the bridge through which social phenomena will finally be reducible to physical phenomena.
The dream is that someday all psychic phenomena will be reducible to brain events and interpretable in terms of electro-chemical reactions. This has already had a tremendous impact on both psychological theory and practice, where mental disorders are regularly reduced to certain electro-chemical profiles in the brain and treated through various chemical cocktails. This approach is regularly supported through observations of the brains of people suffering from these disorders, coupled with studies of families in which these disorders appear.
Two points should be made at this juncture: First, patients suffering from disorders such as obsessional neurosis, psychosis, depression and whatever other illness we might like to cite will show certain electro-chemical profiles in their brain. The person influenced by psychoanalysis should not be ashamed of admitting this point. Though, as we shall see, it should be admitted with reservations. Second, it is likely that in many of these cases certain mental disorders will appear consistently in the families of those suffering from these disorders. Psychoanalysis should unabashedly admit both of these points.
However, as is so often the case, the problems with the physicalist approach to the study of human phenomena are to be found at the level of certain fundamental theoretical assumptions that are not philosophically or theoretically sound. In short, physicalist psychology and the therapeutic practice that accompanies it is based on a fundamental confusion surrounding the notion of causality and how it functions in the field of social phenomena.
Here– deviating a bit from Lacan’s analysis of causality as it functions in psychoanalysis (“Science and Truth”), though not disagreeing with him –we might say that physicalist psychology confuses what Aristotle called “material causality” with what he called “efficient causality”. For Aristotle, the material cause of something consists of the substance that thing is made of. Thus, for instance, the material cause of a statue might be the bronze of which it is fashioned. By contrast, the efficient cause of something is that by which the thing comes to be. In the case of the statue, the efficient cause would be the artist who fashioned the statue.
The problem with physicalist psychology is that it treats the material cause (the brain, genetics) as if it were the efficient cause of mental disorders and then proceeds to treat the material cause rather than the psychic structure itself. If this approach is mistaken, it is mistaken first because the simple presence of an electro-chemical profile in the brain is not enough to establish that the brain is the cause of the mental disorder. All we have established here is that all psychic phenomena require an inscription of some sort. This does not establish the origin of the inscription. Assuming that we adopt some sort of materialist ontology (in other words, that we reject any mind/body dualism), it should come as no surprise that any psychic phenomena will express itself as a trace in the brain. But this is not enough to establish that the brain is the cause of the mental disorder, only that the mental disorder is inscribed, as it were, in the brain.
The case is similar with respect to genetics. The fact that a certain mental disorder can be found to repeat in a family is not sufficient to establish that the disorder is genetically grounded or caused. The very mark of the social is to be located at the level of language or the transmission of “codes” that, like DNA, replicate themselves and proliferate through the field of those upon whom they supervene. In fact, such structures are a necessary condition for something being a family at all. As Lacan has shown us, these symbolic structures inform the nature of self-identity and interpersonal relationships in a way that cannot be underestimated, and thus can produce the repetition of disorders (in much the same way that a curse repeats throughout the family of Oedipus) through a family. This is true even in the case of adoptive children that display mental disorders found in their biological parents. The simple fact of being the adopted child, of being the child without a parent or the abandoned child, can produce far reaching effects in the psychic economy of the child. There is no reason to suppose that these mental disorders could just as easily be explained from a social or environmental perspective (a symbolic, rather than genetic perspective).
It seems to me that these variables tend to go unexplored in the field of US psychology. No doubt this is for the reasons that Derrida has cited regarding the nature of the signifier… Namely, that the very fact that in speech I hear myself speak tends to produce the illusion of a relation of immediacy between the act of speaking and hearing myself speak such that I overlook the constitutive role the signifier plays in structuring my thought and self-identity. I efface my alienation in the act of speaking, but in such a way as to further alienate myself.
The problem with contemporary psychology is that it is founded on what might be called the medical gaze. This has profound consequences for how therapy is actually practiced in the United States. The medical gaze is that gaze in which the doctor treats himself as being independent of the illness from which is patient suffers. Thus, for instance, when a doctor diagnoses his patient with cancer it is clear that the doctor cannot be thought of as a part of the patients cancer or that his diagnosis has any causal effect on the patient’s cancer.
The medical gaze is uncritically extended to the practice of therapy in the US as well. Thus, for instance, when the therapist (not the analyst) diagnoses someone with a particular mental disorder they do so on the assumption that they are not a part of the disorder and that their diagnosis has no effect on the disorder. In other words, the therapist thinks of him or herself as being independent of the person that they diagnose… As being numerically or ontologically unrelated to that person. This is equivalent to saying that the relation between the suffering patient and the therapist is conceptualized as an external relation such that the patient would be what they are regardless of whether or not she entered the therapist’s office.
The therapist/psychologist is thus the one who subtracts herself from the equation. In doing so she adopts an observational view of the patient, in which the patient is conceived as being something simply looked upon such that the looking does not effect that which is looked at. While I am certainly simplifying things here, there can be little doubt that there’s more than a little truth in this evaluation of how therapy is today organized. This is immediately evident the moment you walk into a therapists office and are given a five hundred question test to take in which your disorder is neatly categorized according to the prevailing wisdom of the then current university discourse.
Here, then, in this final point, we at last reach Lacan. For it is with respect to 1) the material causation of psychic phenomena, and 2) the belief that diagnosis has no effect on the person diagnosed, that we find the difference between psychoanalysis and psychology. As the sociological theorist Niklas Luhmann has pointed out, social systems differ from classical physical systems in that they 1) have the ability to represent themselves, and 2) the manner in which they represent themselves can have an effect on how the system itself is organized. Zizek makes a similar point in his amusing discussion of what he calls “the subject supposed to believe.” From the perspective of the functioning of social systems, what is at issue is not what I myself believe, but what I believe my neighbor believes. Thus, for instance, at the beginning of Bush’s term I, being a savvy, intelligent person, might very well believe that Bush’s rhetoric about the waning economy is really a lot of hot air, but I think that my friend Larry and a lot of his friends are complete morons who will take this rhetoric seriously (i.e., believe it) and start selling their stocks madly. For this reason, if I am prudent, I too will sell my stocks lest I become the victim of the ignorant belief of my fellows. Here the description of the system (Bush’s description of the economy) comes to have an effect on the economy even if I think descriptively that it is nonsense.
The therapist, as opposed to the analyst, is someone who believes that the normative and descriptive use of concepts can be clearly kept apart. In other words, they fail to take account of the self-referentiality of social systems or the manner in which descriptions of social systems are themselves causal variables of these systems. In their use of diagnostic categories drawn from the DSM-IV, the therapist believes that their act of naming or diagnosing their patient is a purely descriptive act, with no normative dimension (Here U.S. psychological practices scream for a Foucault-style genealogical analysis that examines the relations of power implicit in these categorizations. An academia myopically fixated on the continent as if it were the only place where history takes place, has not yet taken on such an important task… At least, not to my knowledge). Why else would the therapist reveal her diagnosis to the patient? The only rationale for revealing a diagnosis is the belief that the diagnosis is a purely descriptive affair that has no effect on the patient and how the patient comports herself.
Unfortunately, social and psychic systems, unlike physical systems such as those found in two billiard balls hitting one another, are such that it is impossible to clearly separate the normative and descriptive functioning of categories. The minute that a descriptive category is applied to a patient, it already begins to function as a normative category.
For instance, when a patient is diagnosed as suffering from borderline bi polar depressive disorder, that diagnosis comes to function as a norm for the patient in which all actions are evaluated. Suddenly the patient finds a way to comprehend and understand all their past actions, as well as a way of determining their future actions. For instance, we can imagine a patient that begins to let herself run loose a little bit more simply because she is a borderline bi polar manic depressed person.
Moreover, these diagnoses have great importance in interpersonal relations as well, given that they allow the patient to change their social status, getting benefits for their disorder and sympathy for their suffering. In other words, diagnosis proves to be a path to jouissance or enjoyment. For this reason, mental illness might today be one of the real forms of protest against the system of capital and the way in which it shackles us to interminable labor. Through mental illness we are able to recoup some of our stolen jouissance by forcing business and state to afford us special privileges. Could the person suffering from mental illness be one example of the modern proletariat or subject of revolution? How might the plethora of multiplying symptoms be transformed from mute inscriptions of alienation to revolutionary subjectivity? In other words, how might this proletariat be brought to consciousness about the true meaning of their symptom… Or how might they move from “enjoying their symptom” in an unconscious way, to becoming the agent of their symptom?
Regardless of whether or not this is the case, the category thus begins to function as an imperative of how I act and behave and thus effects the psychic system that it originally set out merely to describe. This is an example of the strange logic of apres coup or the manner in which the signifier functions in terms of “what it will have been”. The odd thing about social and psychic systems as opposed to physical systems is that they do not obey the ordinary temporal logic of cause and effect. In physical systems (at least those at the Newtonian scale) we are accustomed to the notion that the effect follows the cause. However, strangely, in social and psychic systems what is taking place in the present can have effects on what is taking place in the past such that the manner in which the past functions with respect to the present is itself transformed. This, for instance, is what occurs when we arrive at a new picture of what happened in the past such that we transform how we behave in the present. Reinterpretations of the colonization as they’ve functioned in the struggles of American-Indians here come to mind. On the one hand we have pre-critical theories of colonization in which matters were framed in terms of the famed meeting of the Pilgrims and the Indians, on the other we have the pictures of brutal colonialist exploitation that have served as a catalyst for rethinking the status of existing American Indians today. The signifier thus does not simply describe past events– it is not merely descriptive or referential –but has an entirely different temporal structure than the sort of structure we find in ordinary physical phenomena such that it can actually PRESCRIBE certain phenomena. It is precisely this dimension that is overlooked in the contemporary field of therapy, where words are thought to function in a way that is only referential, for the sake of communication. The simple act of naming something, already transforms the way in which that thing behaves.
Closely connected with this phenomenon of apres coup, is that of imaginary transference. The issue here would be that the patient already approaches the therapist as the one who has knowledge of their symptom and, who’s favor, they would like to win. In other words, they look at the therapist as a potential friend or figure of authority who’s favour could be beneficial and serve as a source of pleasure. A failure to take account of this intersubjective dimension of the relationship between patient and analyst leads to further complications with diagnosis in that we can imagine all sorts of scenarios in which the patient imagines themselves into the symptomology of the disorder as a way of filling what she believes the therapist desires her to be. A great deal more should be said on this. What is here important is that the therapist subtracts herself from the therapeutic setting at both her and her patients peril.
It is very simple to see what follows from ignorance to the interrelated phenomena of apres coup and transference in the therapeutic setting: A failure to be aware of how these things function and effect psychic and social systems cannot but lead to alienation. The first alienation would be at the level of the university discourse, in which the patient is alienated in an abstract system of significations (S2, the system of medical knowledge) that prevents him from discovering the concrete way in which his own psychic system is structured or even discovering that his symptoms are in fact meaningful (physicalist psychology is distinct from psychoanalysis is that it is based on the premise that symptoms do not mean or signify anything, but are just accidents of electro-chemical and genetic malfunctions). Second, it is alienation incarnate in that the relation between therapist and patient is asymmetrical in that the therapist is held to have knowledge of the patients symptom while the patient is ignorant. In short, it does not lead the patient (now analysand) to that point in which they discover that the only real authority or subject supposed to know is the unconscious itself. For this reason, the patient never reaches that moment of separating from the big Other or discovering that the big Other does not exist. Their very attempts to heal themselves, thus further lead to alienation such that their actions themselves come to reinforce the power of the very forces against which they were originally fighting. This is what Judith Butler, following Foucault, has referred to as the danger that arises should it be true that subjects are themselves produced by the juridical systems of power in which they seek representation. This suggests that the very attempt to seek representation produces further subordination to power and domination in that the categories of psychological knowledge are themselves discursive constructions that produce particular subjectivities. The value of psychoanalysis, in this context, is that the silence of the analyst with regard to diagnosis and the emphasis on the speech of the analyst allows the analysand to separate from the big Other (as represented by analyst) and discover those hollows or spaces where the Other lacks as those places where it, the analysand, might come to be. Analysis provides the possibility of a leap out of these infantalizing power relations.
It is for these reasons that psychology can be nothing but alienation incarnated. So long as these things are not taken into account, psychology cannot but maintain us in an infantile state in which autonomy and singularity are never reached. No wonder that the only solution currently offered to us is that found in chemical cocktails, in which one is prescribed the life of a waking dream, rather than knowledge of the real of their desire and the separation from the big Other that comes with it… No wonder the only thing offered to us is further alienation in the big Other or the set of diagnostic categories prescribed by the DSM-IV in which our sole consolation is that our psychic structure comes to be normalized by being medicalized and thereby socially acceptable. This is not nothing, but it also cannot compare to discovering the real of one’s desire.