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The philosopher Ian Hacking described a looping effect, whereby people adjust themselves to become more like the labels foisted upon them. “Sometimes, our sciences create kinds of people that in a certain sense did not exist before,” he wrote in “Making Up People” (2006). By constructing types of being, with clusters of traits that correspond to a psychiatric classification, medical authorities “make up” embodiments of their invented category. One’s subjectivity is captured by those elements delineated in the classification. To be recognised, one learns to express oneself by those parameters. Not to conform is to be unable to be helped.
Subjectivity is tricky for psychiatry. The discipline pretends to an objective classification of people, borrowing language (“diagnosis”) from physical medicine, which assigns the label of disease following the identification of a pathology, which, one hopes, can be targeted and cured. But the analogy fails in psychiatry. There are few known biological pathologies. And who is to say what cure is?
In Towards Deep Subjectivity, The philosopher Roger Poole wrote about the power play integral to assumptions of objectivity:
“Objectivity…takes as a premise that facts can be deployed in an objective, context-free way, even when the facts are about human beings. This insistence upon objectivity in facts concerning human life is what gives rise to the impersonal jargon of military strategy, where the tragic is buried under the official phrase. The facts of the situation have to be accepted for what they are: all subjective, ethical inquiry about the status of the facts under discussion is down-graded as sub-rational. An inquiry into facts which begins…by questioning the status of the facts themselves, when re-integrated into their human context, is simply disregarded as dangerous to objectivity.”
A psychiatrist once told me my depression was partly due to low blood sugar. In retrospect, I needed Kierkegaard and Freud; she prescribed cereal bars. My despair, to her, was an imbalance to be corrected, rather than a relationship with the world—a relationship explored in a rich and serious literature, from philosophy to novels, and a relationship which meant I was alive, excruciatingly so.
“Objectivity selects what it intends to consider very carefully,” continues Poole. “It selects those parts of a problem which are either quantifiable or empirically governable or both. There is a continuous retreat from the general to the particular, from the whole to the parts, from the difficult to the simple, from the complex to the naïve, from the adequate to the banal.” Certain sections of psychiatry are obsessed by “symptoms.” The parts—the type and regularity of your symptoms—come to define the whole. The line between receiving the label of “disorder” or not is risibly arbitrary. Worse, you are your parts. The criteria which led you to earn the label then become the substance of the label, providing a pseudoexplanation.
The quest of much psychiatric intervention becomes to remove the symptom. If the symptom is removed, the label can be withdrawn. And without a label, one exits the parameters of psychiatry. (At this point, consider briefly the contrasting aim of psychoanalysis, which does not make it its first task to remove the symptom. “The analyst asks neither that the subject get better nor that he become normal,” wrote Anny Cordié. “The analyst requires nothing, imposes nothing.”)
The motivation to remove the symptom has resulted in what Poole calls an “ever-increasing proliferation of context-less achievements…local scientific successes which precede even the remotest notion of how to deal with them ethically or how to integrate them into the needs of the totality.”
Leaders of psychiatry have admitted their discipline is rife with context-less achievements.
“Whatever we’ve been doing for five decades, it ain’t working,” said Thomas Insel, former director of the world’s largest funder of psychiatric research, the US National Institute of Mental Health. “And when I look at the numbers—the number of suicides, number of disabilities, mortality data—it’s abysmal, and it’s not getting any better.” In a later interview, Insel conceded that, “while I think I succeeded at getting lots of really cool papers published by cool scientists at fairly large costs—I think $20 billion—I don’t think we moved the needle in reducing suicide, reducing hospitalizations, improving recovery for the tens of millions of people who have mental illness.”
We tend to think that “the important problems, the ones that need solving, are the ones that are handed down to us as significant,” wrote Poole. Psychiatry’s problem has become finding a solution to suffering, a solution which apparently rests on identifying, classifying, and alleviating what are taken to be symptoms of as yet undiscovered underlying pathologies, reified “disorders” inside the sufferer. But this approach may have turned the problem upside down. The “symptom” is the crux of our engagement with the world. The conflict therein is the hinge of our contact with the real. If to have an ethical stance is to respect the other as an embodied subjectivity, then to take a screwdriver to that hinge—to dismantle the parts of another’s subjectivity in the name of remedy—is to disrupt very seriously the notion of ethical intervention.
Recently, I have travelled through Twitter observing debates on the philosophy of psychiatry, and the merits and demerits of various approaches. The stakes feel high, which is enlivening. But there seems little appetite to engage with others who question the “facts” upon which one’s own position is staked, little appetite to abandon, that is, the objectivity which appears critical to proceed in argument. To do that requires stepping outside the guard rails of accepted thought, and it is questionable how genuinely alive any inquiry can be which refuses to do that.
“Anyone who does not see the ‘obvious’ as the obvious will be taken…to be suffering anyway from an impaired sense of objectivity,” wrote Roger Poole. “But as a sufferer from ‘mere subjectivity’ he can be safely ignored.” Or, as Luisa Muraro asked in “The Symbolic Independence from Power”: “What happens to thought when it encounters the unthought?”
Moreover, there seems little engagement in these debates with what should be the central question of psychiatry: who has the authority to do what to whom? People ask for help because they want to stop suffering. To be not able to bear oneself is a laceration sometimes deeper than language. But one is never in greater jeopardy than in that moment of submitting to another, of ceding the terms of one’s existence to an “expert,” who has had conferred upon them—indeed has sought out for themselves—the authority to receive it. If one is unlucky, in that moment, one unwittingly gives oneself up to a power game, in which one’s task is then to conform to, or resist, diagnosis, treatment, and the normative definitions of what it is to be a patient, and perhaps, eventually, not a patient.
“For our purposes, the most important form of despair is ‘the despair which is ignorant of being despair, or the despairing ignorance of having a self and an eternal self,’” wrote the philosopher and therapist John Heaton, quoting Kierkegaard. “This applies roughly to the person who considers him- or herself to be successful, who knows what’s what, has most things sussed out, can put people who obviously are in despair and distress in neat categories that he or she thinks defines them and distances them from his or her own state of successful mediocrity. It is a state of spiritual mediocrity…”
To be caught there is to meet a dead end, perhaps too literally; despair, once categorised, is transmuted from a cry for life into evidence of proximity to death.
“The psychiatrist or psychotherapist often sees himself or herself as in the position of the master, the one who knows, who is to free the Patient from his slavery; of course, the Patient often sees himself or herself as a victim, depending on the psychiatrist to free him,” Heaton continues. “The result is the Patient becomes a slave to psychiatry or psychoanalysis.”
So let us turn from psychiatry to psychoanalysis. Freud wrote that analysis should be conducted under conditions of maximal frustration. The analyst should resist the analysand’s demands for collusion in the latter’s phantasies, one of the most common of which is that the analyst has the “answer” to the analysand’s problems—their despair, depressions, obsessions. The analyst does not; there is no answer to be had. Instead, the terms of the problem must be redefined; the analysand must learn to realise their autonomy, and to grasp that the problem is not that there is no answer, but that one continues to need an answer from another.
In the light of this, much psychiatric assessment and provision implies a potential of relief that is undermined by the very conditions of its administration. Furthermore, the position from which diagnoses and treatments are administered goes unexamined. People become patients who have “good” done to them by “experts.” The question of what is “good” has already been decided, Heaton wrote, by those who assume the power and knowledge to do so.
(Of course, power and knowledge underlie much conflict within psychiatry. The NHS says a third of young women have a “probable mental disorder,” while the chair of the DSM-IV task force, Allen Frances, says: “There is no definition of a mental disorder. It’s bullshit. I mean, you just can’t define it.” Some psychiatrists claim that information about the effects of antidepressants is being withheld from patients; others deny this.)
But following Poole’s observation about inherited problems, the question may not be what works to relieve symptoms, and what doesn’t. After all, how does one measure relief? How long must a cure against despair last, to be said to work—six weeks, six months, or six years? A better question may be: what enables someone to assume their own authority? And therefore to refuse subjugation to the dominant objectivity? It is this acceptance and deepening of subjectivity which, Poole argues, enables the possibility of thought, and of ethical space.
“The thinker shapes himself as he thinks…In deciding what he wants to become, he decides indirectly what he wants his world to become. All thinking is legislative.” Someone who does this cannot be shaped by the looping effect that Hacking describes, cannot be “made up” by someone else’s categories, will not be sanded into smoother states of thinner being.
Consequently, those in positions of authority—both in the clinic and in debate—might assume less knowledge about how to remove symptoms, and instead promote “our power to ‘suffer and think,’” as Muraro put it, “to remain in the state of impotent desire, to pierce the horizon in which the real is inscribed and takes on this or that name.” One can suffer and think; indeed, the power to do so deserves far more attention than projects to reduce the pain of thought.
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