Patrick Landman – The struggle waged by psychoanalysts for the last forty years, mainly in the field of mental health, is a paradigm of a certain development in Western culture and of what Freud called its “discontents.”
Let us go back to 1975: psychoanalytic psychiatry was then quasi-hegemonic, and psychopathological models were accepted and used by most practitioners; other behaviourist practices were of minor importance and psychoanalysts had learned to make use of the advances of pharmacology. And yet a shadow was already looming over the picture: the parents of autistic children were scandalised by the idea that their child’s autism could be causally related to the early mother-parent interaction or the question of the parents’ desire; they criticized the guilt-inducing effects of these unfounded hypotheses. They were convinced that the beginnings of autism should instead be situated in a biological dysfunction of a genetic origin, even though it was unclear how exactly it resulted in autism, and that the problems of interaction were secondary. History has since largely confirmed their beliefs.
Some Reasons for the Decline of Psychoanalysis Linked to the DSM
The Autism Wars
The “Autism war” turned out to be very costly for psychoanalysts, for a number of reasons:
Firstly, psychoanalysts did not wage this war against other professionals, but instead against the parents of disabled children. Having to deal with the effects of their child’s disability earned these parents a certain capital of sympathy and empathy, capital which these professionals lacked, thus damaging the image of psychoanalysis. In the United States, the beginnings of this “war” also coincided with the growth of the psychiatric service users’ movement, some strands of which were strongly anti-psychiatric. The struggle against authoritarian psychiatry and the struggle against psychoanalytic arguments became intertwined, which seemed particularly unfair, because throughout the country psychoanalysts had done a great deal to “open up psychiatric services” and give as much place as possible to the patients’ speech.
It is a historical paradox that psychoanalysts, who had worked so hard to humanize psychiatry, to give it a human face, almost in Levinas’ sense — to make it more dynamic in order to avoid chronicization — were accused of apathy or even therapeutic nihilism. Parents criticized them for neglecting educational methods and “waiting for the child’s desire to emerge,” thus allegedly wasting time and opportunities. Some parents tried to adopt and later impose educational methods that at times resembled animal training and whose supposed scientifically-proven efficacy turned out to be very much debatable. The DSM supported their claims: first, by providing a purely behaviourist definition of autism and, second, by increasing the prevalence of autism by grouping all or nearly all severe and invasive development pathologies under the category of Autistic Spectrum Disorders. However, because of its increased prevalence, autism became a public health problem, requiring political attention and funding, which opened up the way for dynamic lobbying or even the activism — so-called “evidence-based activism” — of the parents.
DSM III: pragmatic and a-theoretical
Starting from the 1970s, under the pressure from American insurance companies that wanted to streamline reimbursements, and given the general consensus that psychiatrists were unable to provide reliable diagnoses, the American Psychiatric Association (APA), the professional body of American psychiatrists, decided to modernize psychiatric nosography using operational criteria and choosing an a-theoretical approach. The different mental diseases became “disorders,” favouring utility and especially interrater reliability (the probability that two practitioners will issue the same diagnosis for the same clinical picture) over validity.
The creators of the DSM III were inspired by pharmacological research, in which drug testing tends to include the most homogeneous group of patients, i.e., those who present the same type of symptoms, in order to be able to compare efficacy using statistical tools. In the minds of the promoters of the DSM III, this breaking away from theory was not directed specifically against psychoanalysis; nonetheless, critics of psychoanalysis used it to assert the advantages of a psychiatry founded on observable symptoms, thus limiting ad maximum the subjectivity bias of the observer. They also denounced psychoanalytical concepts, which they considered too abstract, non-consensual and insufficiently discriminating, comparing them with the pragmatic advantages of an a-theoretical manual. The DSM, a statistical tool initially used for pharmacological and epidemiological research, has since gradually become a training manual and especially a reference book for establishing diagnosis. In less than thirty years, the “psychoanalytic” generation that received psychiatric training founded on the observation of behaviours has been replaced by the DSM generation which favours normative behaviourist and pharmacological methods as a first response.
The image of psychiatric diagnosis
Long considered as discriminatory because of its implied moral or political judgment and a risk of objectivization and ontologisation, the psychiatric diagnosis did not generally used to be announced by the clinicians to the patients or their families. It was useful to psychiatrists in order to determine whether psychotropic medication should be prescribed, but the same psychiatrists simultaneously denounced its low reliability. For example, it is not rare for the same patient and the same symptomatic picture to receive, over the course of his life, the diagnosis of bipolar disorder, later of schizophrenia and finally borderline disorder, which would be unthinkable or at least very rare in the case of a somatic disease.
The situation changed thanks to new laws: the duty of information practically obliged psychiatrists to give a patient a diagnosis, and, more importantly, service users started organising in order to demand a diagnosis in order to have more control or decision-making power, thanks to information found on the internet, over their course of treatment. Users tend to organize around a shared diagnosis, creating and using information websites and social networks. The psychiatric diagnosis has become a kind of claimed identity. It gives the patient the possibility to become an expert in oneself, to have a kind of expertise of experience which is valued just as much, if not more, as clinical or scientific expertise. The development of the DSM has also seen negotiations between stakeholders who wish to introduce such and such diagnosis into the diagnostic manual, given that it can also be a means of accessing welfare benefits and other support.
The consequences could be summed up as follows. Prior to DSM III, the subject supposed to know the diagnosis was the clinician; after DSM III, the subject supposed to know the diagnosis is the diagnostic manual, the result of negotiations between different stakeholders. The diagnosis has become democratised and is now widely accessible, so that is possible to self-diagnose.
Psychoanalysts, though not condoning the previous state of things, have overall struggled to rally behind this new regime, because their understanding of diagnosis is quite different from that of the DSM. Psychoanalysis works with a conception of diagnosis linked to the question of transference. Diagnosis is structural: neurosis, psychosis, perversion, borderline states, autism. The psychoanalyst is trying to understand the structure of the subject, which is understood as a predominant way of functioning, in order to adapt the framework of the treatment to the individual case. For example, when treating psychotic cases, one should avoid too much interpretation; in the cases of borderline patients the emphasis is on containing, and so on. This approach, though not necessarily contradictory to the DSM, has nothing in common with it. Yet psychoanalysts have suffered, together with others, from the decline of the clinician’s role.
The Psychoanalysts’ Response
The anti-liberalist reaction, the medical economy and Big Pharma
It is clear that the DSM was used by the medical economy because it is an epidemiological tool to determine the prevalence of a disorder, and evaluate the nature of the active file of consultations and hospitalisation centres, the activity of specialist centres and so on. Because we know that health, though it may be priceless, does have a cost, DSM psychiatry has been justly accused of encouraging public health policies that emphasize permanent evaluation and the profitability of reduced lengths of hospitalisations thanks to excessive medicalisation, while suppressing frameworks focusing on receiving and welcoming patients, providing a refuge and a place for life. These political choices have been attributed to “liberalism” and its concern with profitability, cost-cutting and favouring the private sector over the public.
The DSM is the result of a collective work of American psychiatrists. However, it has turned out that these psychiatrists had major conflicts of interests with pharmaceutical companies. This situation, denounced by the American press, rightly fuelled the idea that the DSM is a product of Big Pharma. This anti-liberalist response further politicised the struggle against the DSM. Its advocates tried in vain to present the struggle of psychoanalysts as part of the outraged reaction of “extremists,” or even dismiss the criticism of Big Pharma as conspiracy theories.
It is true that some psychoanalysts used the occasion of the fight against the DSM to convert their former anti-capitalist stance into a present-day anti-liberalist position, but others have pointed out that the DSM could also serve anti-liberalist policies; that it can easily become a tool of bureaucratic authoritarianism, etc. The DSM is simply a tool — what is problematic is the way it is used. As for the conflicts of interest, they are balanced by the influence of other lobbies such as insurance companies or user associations. These voices have warned against the debate becoming over-simplistic.
The humanistic response, the singular versus the general and the meaning of the symptom
As a result of the DSM and its various categories of mental disorders, each subject is asked to fit into a diagnostic “slot,” making it easier to enforce standardized guidelines and treatment protocols. Psychoanalysis has instead emphasized the need to look at each case individually, to focus on the singularity of each human subject. This is a strong objection, because symptoms are not simply a final common pathway — in the sense that all phobias or all compulsions resemble each other — but they are also correlated to the signifiers proper to the given individual and their history, and this dimension, which appears in the person’s speech, must be considered. This requires a diagnosis based not just on the observation of behaviour but also on listening to the patient. Unless this singular dimension is heard, we run the risk of dehumanising psychiatry completely. Psychoanalysts have been the defenders of a humanism threatened on all sides by DSM psychiatry. They are the guardians of a case-by-case practice which focuses on the individual’s difference, a practice that is always bespoke rather than reaching for ready-made solutions.
More and more patients feel a relief when their symptoms fit what Lacan called the “scientific universal,” in the sense that a diagnosis with a scientific allure gives a name to their mental pain. For some, the idea that science can actually do something is therapeutic in itself, just like the idea of finding the meaning of one’s depression, anxiety or even a delusion can be for others. Also, today, to speak about science and neurotransmitters rather than language and the signifier is considered epistemologically superior.
The anti-naturalist response, false science and the denial of psychic suffering
Faced with the advances in our knowledge about the brain, psychoanalysts at first remained in denial, then made certain attempts at collaboration. They now agree that the cognitivist sciences have brought many advances and their models have resulted in a number of applications that benefit the treatment of psychiatric users.
For example, in the field of autism, the new knowledge of the genetically-based sensory disorders has allowed the environment and framework of treating autists to be modified. Some hypotheses have also led to the creation of suitable educational strategies and so on.
And yet these advances remain very modest and cannot by any means justify the scientistic excesses, false science, the scientific fake news and orthodox naturalist positions. No genuine biological markers have been found for any mental disease; diagnosis remains a matter of clinical approach and the importance of neuro-imaging is largely overestimated. There is only a rhetoric of promise: biological psychiatry does not yet exist, what exists is a pharmacological psychiatry.
Let me give you a very specific example of an abusively naturalist approach: Attention deficit disorder, with or without hyperactivity, usually referred to as the ADHD, which has “replaced” hyperkinesia. This disorder had been considered a behavioural disorder until DSM IV-R, but in the most recent version it has become a neuro-developmental disorder, together with autism. However, in reality the large majority of children diagnosed with ADHD are in fact “difficult” or “unmanageable” children, impossible to “manage” by their parents, schools, society etc. By making ADHD a neurodevelopmental disorder — in other words, a disorder linked to a brain dysfunction, thus erasing social, educational or pedagogical issues — we naturalise this “impossibility of management,” which has potential political and ethical consequences. This naturalism is of course no longer presented as a rigid view of things, because the notion of brain plasticity is constantly being promoted and sometimes inappropriately expanded, but this naturalist tendency at times leads as far as to refuse the very existence of a psychic reality; the only thing that exists is the brain and its information processing, the rest is obscurantism and spiritualism founded on anachronistic cartesian dualism.
Psychoanalysts find it vital to take care of the individual’s psychic suffering and sustain a mind-brain dualism that is epistemological rather than metaphysical. The early 21st-century denial of suffering and the psychic reality thus replaces the denial of infantile sexuality of the early 20th century.
Questions of normativity, overdiagnosis and over-prescription
Freud argued that there is a healthy part in everyone, even the most insane. While psychoanalysts, as opposed to psychiatrists, do not take the non-existent “normal person” as their reference, they do nevertheless work with a certain reference to a norm. The subsequent editions of the DSM gradually reduced inclusion thresholds for a number of disorders and thus helped pathologize a number of behaviours, especially among children, leading to overdiagnosis and over-prescription. Psychoanalysts have entered into the struggle against excessive medicalisation, such as in the case of grieving (which now should only last two weeks or it becomes a depression) or more recently regarding the issue of screen time.
Paradoxically, this position against overdiagnosis and over-prescription finds an echo among the advocates of liberal economy, who understand it as a struggle against wastage and work absenteeism.
The alliance with service users
Psychoanalysts have become aware of the importance of user associations, not all of which are obviously serving Big Pharma. There are three reasons to justify the alliance of psychoanalysts and users:
First of all, before a psychoanalyst begins to practice, he must subject himself to the experience of analysis; he is a “user of psychoanalysis” and combines clinical expertise and experiential expertise in his own practice. Also, because in the analytic treatment it is the analysand who is speaking, a psychoanalyst should spontaneously find it quite easy to admit that users need to have their say. Finally, more and more psychoanalysts who are also psychiatrists have been connecting with psychiatric service users’ associations to support the latter’s struggle for their rights, fighting against segregation, denial of civil rights, abusive coercive methods, red tape, etc. Faithful to the traditional role of psychoanalysis and thanks to listening to the unconscious and handling transference, they have also provided support in more complex and subjective matters, for example in trying to find a new life project, rebuilding oneself, re-establishing one’s social life, emancipating oneself from diagnosis and so on.
Psychoanalysis and evaluation
Starting from the 1980s, evidence-based medicine (EBM) has become hegemonic in psychiatry, including a consensus over a strict hierarchisation of evidence. Clinical studies to evaluate psychoanalytic treatments have long existed, but psychoanalysts who published for the most part unique cases saw their publications being downgraded to the lowest rank in the evidence hierarchy. They faced a dilemma: either they would refuse the EBM system of evaluation using solid arguments, given that it is based on the model of randomised double-blind clinical trials used to demonstrate the efficacy of medication, and as a consequence psychoanalysis would become non-consensual, or they would adapt to the EBM system. Today the debate continues and the objections against entering into the EBM system are serious and well-argued. However, psychoanalytic researchers have also managed to demonstrate the efficacy of psychoanalytic treatments, especially in treating autism, without “betraying” the ethical foundations of this treatment.1
To conclude, the psychoanalytic struggle against the DSM has multiple forms and contains numerous paradoxes, contradictions and excesses; however, it is also a lucid work of culture and civilisation, faithful to the role Freud assigned to psychoanalysis in his more anthropologically-oriented texts.
1. J.M. Thurin, M.Thurin , D.Cohen, B.Falissard ; Approches psychothérapiques de l’autisme. Résultats préliminaires à partir de 50 études intensives de cas Neuropsychiatrie de l’enfance et l’adolescence 62 52014) 102-118