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Psychiatric Diagnosis Needs Rethinking

Psychiatric Diagnosis Needs Rethinking: Psychologist Richard Bentall’s Alternative Paradigm

Psychiatric DiagnosisFor many years, British psychologist Richard Bentall has promoted rethinking about the way psychiatric diagnosis has been conceptualized. When I first read his book, Madness Explained (Bentall, 2006), I was immediately impressed by his carefully researched and referenced arguments that challenged many mainstream views on mental illness. For example, he challenged the prevailing assertion that genetic research has demonstrated conclusive evidence that schizophrenia and bipolar illness are genetically determined and are fundamentally medical diseases. His work is careful not to rehash outdated arguments of nature versus nurture or mind/body dichotomies, but rather to put into proper focus the evidence and limitations of such research.

Bentall’s justification for abandoning the Kraepelinian model for mental illness is built upon Kraepelin’s presupposition that mental disorders are discreet entities, like diseases. The medical model of madness insists that mental disorders exhibit the same characteristics as physical processes and have etiologies rooted in identifiable alterations of the organism’s structure. To that end, neurotransmitters, brain regions, and genetic associations have been researched and are promoted as causal.

However, biochemistry, structure, and ancestry do not directly predict any mental disorder and are, rather, descriptions of how the human organism functions—not why. Whereas some neurotransmitters are clearly related to certain psychological phenomena, such as pleasure, excitement, or comfort, none are pathognomonic to any specific conditions. In fact, no specific genetic findings for specific mental illnesses have been established. Instead, research is favoring multiple etiological factors as both biological and experiential.

Given the complexity of contributing factors, Bentall also notes that some psychiatric categories are outdated artifacts of ancient traditions and concepts. Schizophrenia is not a “split mind,” nor is hysteria a “wandering womb.”  Instead, Bentall proposes a psychiatric diagnosis based on the patient’s presenting complaints, with careful consideration being given to hearing the patient’s life story. The need for an encompassing category (i.e., a psychiatric diagnosis) is both unnecessary and potentially misleading. He advocates for the individuality of the patient, rather than the fitting of the patient into preconceived categories.

Given the constantly expanding number of mental disorders being developed by the DSM system (American Psychiatric Association, 2013), it is clear that no category completely captures the significance of each patient’s needs. When used as a glossary of technical terms, the DSM is clearly useful for operational definitions; where it fails to be useful is in capturing the humanity of the patients under examination. Perhaps the consideration in the DSM-5 for dimensional diagnoses, as seen in the section on personality disorders, may extend across all of the conditions.

Perhaps too, we will stop talking about conditions or disorders, and consider people. Ironically, at the same time that progressive societies espouse the importance of difference and tolerance, we are also pathologizing and labelling each other with great confidence. 

For more on diagnosis, see DSM-5 Diagnoses and Defenses.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Bentall, R. (2006). Madness explained: Why we must reject the Kraepelinian paradigm and replace it with a “complaint-oriented” approach to understanding mental illness. Medical Hypotheses, 66, 220-233.

Value of Psychoanalysis

Some of you have read my earlier blog, “Isn’t Psychoanalysis Dead?”  I lamented that psychoanalytic theory is often excluded from discussions in psychology courses—at what I believe is a great loss to future clinicians’ ability to understand their clients/patients deeply.  Well, I recently ran into another example of the value of psychoanalysis, of its omission from typical training, and of the limitations that excluding it from training may pose to successful treatment, even beyond psychotherapy.

I was recently talking with a young woman who is completing her doctorate in Physical Therapy.  When she learned that I am a psychologist, she mentioned that she’d taken Abnormal Psychology to fulfill an undergraduate requirement and how interesting parts of the course had been.  “Which parts had been most helpful?” I asked, trying to gain some pointers for my own upcoming class in Abnormal Psychology, which includes many exercise science majors.  She noted that, while depression and anxiety can affect a person’s physical health, some things in the course hadn’t felt relevant–she felt the course had been too limited.  And then SHE began lamenting that no one had ever even talked about Freud or the possible value of psychoanalysis or psychoanalytic psychotherapy.  She added that her psychology instructor had said they would be skipping the chapter on psychoanalytic theory “because no one uses it anymore.”  She continued, “sure, he developed his theory a century ago, and some aspects may make more sense than others, but wasn’t some of it still helpful to know?  And what about all the new stuff now coming out in neuropsychology and neuro psychoanalysis?  Aren’t psychology teachers aware of it?”  One of her colleagues, who apparently had been introduced to some basics in psychoanalytic theory, commented that he’d actually recently seen a case of a Conversion Disorder, with physical symptoms without physical basis—“like with Anna O!”  He noted the many possible connections between some physical symptoms and unconscious conflicts, and how helpful that notion had been to his work.  Having many lenses through which to understand an individual’s experience is helpful to those in fields both inside and outside of psychology.

Value of Psychoanalysis - Eric KandelEric Kandel, renowned neuroscientist, would agree with the enormous value of psychoanalysis.  I know I’ve quoted Kandel before, but he’s a Nobel Laureate(!) and worth mentioning again.  In 1999, he wrote, “…psychoanalysis enters the twenty-first century with its influence in decline.  This decline is regrettable, since psychoanalysis still represents the most coherent and intellectually satisfying view of the mind” (1999, p. 505).  

Writing about couples therapy, Judith Siegel, well-respected object relations couple therapist, has also noted that, “while object relations concepts provide a wealth of information regarding the ways family systems influence their offspring and the ways grown children revisit these influences as they select partners and engage in adult intimacy” (2010, p. 134), “today’s therapists enter training programs that do not uniformly include the psychoanalytic theories that were previously regarded as the cornerstone of therapy” (2010, p. 134). 

How sad. 

And it isn’t just recent courses in psychology.  I too—several decades ago—had been taught that psychoanalytic theory had long since been “disproven.”  (Just as I’d also been taught that the whole nature-nurture debate had been settled…)  In a graduate psychology class, I’d even written a paper extolling the virtues of cognitive-behavioral approaches and arguing that psychoanalytic theory was a waste of time.  And I believed it.  Until I began to work with clients/patients for whom CBT was not enough…  

Don’t get me wrong.  I do believe that CBT can be helpful, as can humanistic approaches, Gestalt therapy, narrative therapy, mindfulness exercises, etc. etc.  But therapy is not a “one size fits all” undertaking.  The value of psychoanalysis is that it respect the “individualness” of the individual–it provides us with means to promote an awareness and understanding of the inner world and its influence over relationships in our patients.  Psychoanalytic theory provides a valuable lens through which to understand the human condition and our patients’ suffering, and tools to help them build a meaningful life. 

What was your introduction to psychoanalytic theory in your own undergraduate and/or graduate training?  Was it dismissed for you as well?  I’m wondering if this is primarily an American phenomenon, or if it’s world-wide and would love to get your input! 

Please email me at mgersonphd@psychstudies.net regarding your experiences, and indicate whether I may share them in a future blog.

References

Kandel, E. R. (1999). Biology and the future of psychoanalysis. American Journal of Psychiatry, 156, 505-524.

Siegel, J. P. (2010). A good-enough therapy: An object relations approach. In Alan S. Gurman & ProQuest (Firm). Clinical casebook of couple therapy. New York, NY: Guilford Press.

Jacques Lacan: A Real, Imaginary, and Symbolic Psychoanalyst

Jacques Lacan: A Real, Imaginary, and Symbolic Psychoanalyst 

Jacques LacanAs a practicing psychoanalyst for the past 30-plus years, I have sought to integrate the wisdom from many mentors. My supervisors and training analyst guided me through the collected works of Freud, Klein, Winnicott, and Spotnitz. While writing my doctoral dissertation on clinical psycholinguistics, I learned of the work of Jacques Lacan, a French psychoanalyst.

The more I read of Lacan’s ideas, the more fascinated I became with his unique take on the role of language for shaping the mind and the practice of psychoanalysis. Equally intriguing were the stories about Lacan, the man, who fought to promote a view of psychoanalysis that dared to challenge the prevailing orthodoxy of the psychoanalytic establishment.

Psychoanalysis has been fraught with in-fighting, exclusiveness, and dogmatism since its inception, which bears an embarrassing irony toward unresolved Oedipal feuds. Fortunately, my training had encouraged an appreciation for psychoanalysis as one of the humanities. Art, literature, religion, culture, philosophy, and music are all expressions of the human experience that are essential for venturing into a serious consideration of the psyche. Lacan’s masterpiece, simply titled, Écrits, included discussions of all of these topics and more.

Certainly his writing is dense and difficult; yet, I found it compelling as a source of provocative ideas and observations. A learned colleague once warned me that life is too short to read Lacan. In fact, most of my colleagues have shared similar negative biases, although they had never read his work themselves and relied, instead, on second- and third-hand critiques. Like most contemporary textbooks on psychology that summarily dismiss Freud out of ignorance or misinformation, these colleagues were content to preserve their allegiance to a particular school of thought.

Some Lacanian theorists have since become a somewhat esoteric group in the US, often adopting an obscure and cryptic style, perhaps in homage to the master. Whereas Lacan’s concepts are complex, both philosophically and logically, my reading of his work suggests that he sought to promote creative and relevant applications by clinicians, not to develop sycophants.

As an addition to Freud’s structural model of the mind consisting of the Id, Ego, and Superego, Lacan proposed that our subjective experience is contextualized with regard to how phenomena become registered in the mind. He identified three constituent contexts for the mind: the Real, the Imaginary, and the Symbolic. Broadly described, the Real is fundamentally a derivative of our senses, the Imaginary is derived from perceptual and fantasied mental processes, and the Symbolic is derived from culture and through language. These registers function as interlocking systems of knowing that collectively form one’s sense of awareness.

With the premise of these mental registers, I will attempt to describe Lacan himself. The Real Lacan was a man trained as a psychiatrist in the first half of the twentieth century. He appeared as an intellectual and scholar who studied philosophy, art, science, medicine, and politics, as well as psychoanalysis. His personality is described as intense, passionate, and charismatic. Reportedly, he successfully obtained the release of his wife from Nazi custody by charging into Gestapo offices and demanding her immediate release.

The Imaginary Lacan is the one we know as we read his words. The thoughts and questions that emerge as the reader forms associations to his ideas and through his playful use of words that tease us to push our thinking a bit further.

The Symbolic Lacan is a provocateur of psychological theory. The word “Lacanian” has come to represent courageous and radical commitment to understanding the depth and vastness of the human condition, with full acceptance of the impossibility and ineffability of that task.

Whereas Lacan is mostly known in the US in terms of applications to literary criticism and socio-political theory, he is considered one of the most influential psychoanalytic thinkers in Europe and South America. Regardless of the difficulty that some of his ideas pose, the questions he raises about self-authenticity and one’s capacity to retain sanity in a civilized society has never been more timely.

To learn more about Lacan, see Jacques Lacan: Introductory Overview.

Psychoanalysis, Resilience, and Meaning-Making

Psychoanalysis, Resilience, and Meaning-Making

Psychoanalysis, Resilience, and Meaning-MakingCan psychoanalysis help build resilience?  Psychoanalysis, resilience, and meaning-making may go hand-in-hand.

Resilience involves being able to do better than expected in the face of difficult circumstances.  It requires inner strength.  What factors may help promote such strength?  Meaning-making—finding a sense of purpose and meaning in life—seems to be especially important.

Research has long pointed to the potentially important role that spirituality can play in building psychological well-being and resilience (e.g., Anum & Dasti, 2016; Fombuena et al., 2016; Foskett, Marriott, & Wilson, 2004; Porter et al., 2017; Smith & Carlson, 1997).  Studies have explored many aspects of spirituality—experiences of transcendence and awe that can come from sensing something greater than the self, feelings of connection with others, and the meaning-making involved in a personal search for purpose and meaning in life (intrapersonal spirituality).  A recent study (Gerson, 2018) has found that intrapersonal spirituality—meaning-making—best predicts both resilience and life satisfaction, at least in early adulthood.

The study explored predictors of resilience and life satisfaction in over 400 undergraduates at two universities in the US.  Measures included sense of purpose and meaning in life, spiritual connection to others, and feelings of spiritual transcendence, as well as a host of other variables.  Contrary to many current studies which have focused on the importance of transcendent spirituality and social support, the study found that, at least in young adulthood, resilience is best predicted by more individual factors, including a personal sense of purpose and meaningful life.  And the relationship between resilience and meaning-making is strong.

What implications may this finding have for psychoanalysis?  We know that psychoanalysis seeks a deep understanding of the human psyche—rather than focusing merely on behavior change or symptom resolution, psychoanalysis explores deeper motivations and the potential sources of emotional turmoil.  Psychoanalysis and intrapersonal spirituality share a common goal—that of meaning-making.  Resilience requires stamina in the face of hardship.  It makes sense that a mindset of seeking understanding and a meaningful life—and resilience—may be strengthened by the process of psychoanalysis. Psychoanalysis, resilience, and meaning-making may go hand-in-hand.   

To learn more about psychoanalysis, see Classical Psychoanalytic Theory or other courses in psychoanalytic psychotherapy.  You may find the brief article on Psychoanalysis and Mindfulness interesting as well.

References

Anum, J., & Dasti, R. (2016). Caregiver Burden, Spirituality, and Psychological Well-Being of Parents Having Children with Thalassemia. Journal of Religion and Health, 55, 941-955. doi: 10.1007/s10943-015-0127-1

Fombuena, M., Galiana, L., Barreto, P., Oliver, A., Pascual, A., & Soto-Rubio, A. (2016). Spirituality in Patients With Advanced Illness: The Role of Symptom Control, Resilience and Social Network. Journal of Health Psychology, 21(12), 2765–2774. doi: 10.1177/1359105315586213

Foskett, J., Marriott, J., & Wilson R. F. (2004). Mental Health, Religion and Spirituality: Attitudes, Experience and Expertise Among Mental Health Professionals and Religious Leaders in Somerset. Mental Health, Religion and Culture, 7, 5-22. https://doi.org/10.1080/13674670310001602490

Gerson, M. W. (2018). Spirituality, Social Support, Pride, and Contentment as Differential Predictors of Resilience and Life Satisfaction in Emerging Adulthood. Special Issue on Positive Psychology, Psychology.

Porter, K. E., Brennan-Ing, M., Burr, J. A., Dugan, E., & Karpiak, S. E. (2017). Stigma and Psychological Well-Being Among Older Adults with HIV: The Impact of Spirituality and Integrative Health Approaches. The Gerontologist, 57(2), 219-228.  doi: 10.1093/geront/gnv128

Smith, C., & Carlson, B. E. (1997). Stress, Coping, and Resilience in Children and Youth. Social Service Review, 71(2), 231-256. doi: 0037-7961/97/7102-0004

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