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On Being Normal and Other Disorders

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The central argument of On Being Normal and Other Disorders is that psychic identity is acquired through one's primary intersubjective relationships. Thus, the diagnosis of potential pathologies must also be founded on this relation. Given that the efficacy of all forms of treatment depends upon the therapeutic relation, a diagnostic of this sort has wide-ranging applications.Paul Verhaeghe's critical evaluation of the contemporary DSM-diagnostic shows that the lack of reference to and governing metapsychology impinges on the therapeutic value of the DSM categories. In response to this problem, the author sketches out the foundations of such a metapsychology by combining a Freudo-Lacanian approach with contemporary empirical research. Close attention is paid to the processes of identity acquisition to show how the self and the Other are not two separate entities. Rather, subject formation is seen as a process in which both the subject's and the Other's identity, as well as the relationship between them, comes into being. By engaging this new theoretical approach in a constant dialogue with the findings of contemporary research, this book provides a compass for the practical applications of such a differential diagnostic. Post-modern categories of anxiety disorders, personality disorders, and post-traumatic stress disorders are approached both through the well-known neurotic, psychotic, and perverse structures, as well as through the less familiar distinction between an actual pathology and a psychopathology. These two outlooks, which involve the role of language and the subject's relation to the Other, are spelled out to show their implications for treatment at every turn.

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1. Introduction: Clinical Psychodiagnostics versus Medical Diagnostics

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A 4-year-old child wakes up one morning with a rash. She is sweating, apathetic. The young, and therefore worried, parents call the doctor who does a quick examination, concludes it is chicken pox, reassures the parents, and prescribes an anti-itching powder.

This short sequence is a perfect illustration of medical diagnostics; incidentally, it is a perfect illustration of an implicit social relationship as well, something that we will return to later. The young patient displays a number of symptoms that are collated by the doctor so as to identify—diagnose—a distinct syndrome. This is done in accordance with an established knowledge that maintains both a notion of etiology and a clear diagnostic distinction between health and illness. In this way, the doctor makes a diagnosis, usually with the help of various instruments (thermometer, stethoscope, etc.), forms a prognosis, and suggests a treatment on the basis of her observations. The intent is to return to the status quo ante, the earlier state. The model is in fact essentially circular and can be put schematically in this way:

 

2. Categorical Diagnostics versus Clinical Praxis: A Matter of Impossibility

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Clinical psychodiagnostics has its origin in medical practice, and emerged historically out of psychiatry. The implications are thus that clinical psychodiagnostics not only developed out of a particular type of knowledge, but also that it possesses a very specific relationship with the object of this knowledge, namely, the patient. The contribution of this relationship to the doctor's success or failure with his patients, beyond the mere question of his or her knowledge, is considerable, because it is precisely in and through this relationship—and never apart from it—that such knowledge operates.

Nevertheless, this relationship is implicit, and the participants— both doctor and patient—are barely aware of it. Even in medical school, this critical factor remains simultaneously both tacit and axiomatic. The medical student not only acquires knowledge and technique but, through constant contact with instructors, also learns how to behave in relation to patients. This only becomes explicit in situations of crisis, when the relationship as such takes center stage and the respective positions of both participants are called into question.

 

3. The Impotence of Epistemology

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In the previous chapter I argued that at the level of content— the identification and the naming of a psychic disorder—clinical psy-chodiagnostics always implies at least a partial failure. In this chapter we will see how this failure has everything to do with the problem of naming itself. What does one call a certain phenomenon? What influenced that choice of name? What are its effects? This is not just a philosophical but also an epistemological problem: What do the no-sological designations refer to? In other words, What is the relationship between the nosological designations and clinical reality? The specificity of this question shouldn't blind us to its more general, epistemological nature.

In the first section, we will review the historical background in an attempt to discover the object of clinical psychodiagnostics and to see how it came into being. The second section examines the relation between psychodiagnostic designations and clinical reality from a wider perspective, namely, how science conceives of the relationship between words and things. The third section concludes that one cannot avoid making ethical choices, and that the object of psychodiagnostics is first and foremost a relation rather than an object per se.

 

4. Know-how in Clinical Practice: Doxa as the Result of Impotence and Impossibility

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A completely comprehensive theory, supported by an effective epistemology, would seem to be an illusion. Nevertheless, Candide must continue to cultivate his garden (translator's note: as in the final pages of Voltaire's Candide). Clearly, for the field worker, job satisfaction in itself is not enough: her work must also be conceptually grounded, which is why she scours the markets seeking the definitive scientific justification for her job.

Such “definitiveness” quickly becomes relative, and yesterday's certainties have become today's cast-offs. For a growing number of people the ensuing doubt is barely tolerable. Consequently, we see the emergence of a highly characteristic solution, which was anticipated and critiqued as long ago as Socrates: if epistèmè (knowledge) is unable to found arètè (truth), people fall back on doxa (opinion), or in today's terms “paradigm.” We have already seen this in Kuhn (1970), who re-introduced these ideas into contemporary terminology.

The contextualizing paradigm's real function, apparently, is to guide. Depending on which psychological theory is chosen, one intervenes in x or y manner. Still, as the years go on, it is becoming increasingly clear to me that the most divergent paradigms do not necessarily lead to particularly divergent practices. Indeed, in a number of cases, such practices proved profoundly monotonous, compared to the raucous ways the various doxa competed with one another. Presently we will see how even what seem to be diametrically opposite paradigms ultimately amount to the same thing, particularly when it comes to their mutual disdain for the subject.

 

5. Conclusion: The Need for a Metapsychology

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On the basis of Part I of this book, I can put forward the following conclusion: every paradigm offers its own specific way of handling the question of guilt. The question of etiology is a scientific and hence unblemished renaming of the quest for a culprit whose two extremities are the exoneration of the subject by way of an external causality, and the blaming of the subject through an internal causality.

We can deplore this, complain about it, reject it, and so on. In so doing, we run the risk of bypassing a ubiquitous clinical reality, namely, that every psychopathology, indeed every psyche, centers around this question of guilt. To sum up, the central theme in Sophocles’ Oedipus Rex is not so much the well-known murder and incest story; that is already history when the tragedy begins. The central question is the quest for the culprit, and its irony is that he who searches is himself the guilty party. Immediately following on from this comes the well-known rule of thumb: the patient with a sense of illness is neurotic; the psychotic is the one in whom this is missing; the pervert is the one who denies it. Retranslated this means: the one who displays a sense of guilt is neurotic—as with Oedipus; the one who doesn't is psychotic; the one who denies guilt is perverse.

 

6. Identity as a Relational Structure

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One of the classic criticisms of Freud is that he sexualizes everything. What this tends to overlook is the fact that, even as early as the “Project” (1978 [1950a (1895)]), Freud had already come up with a theory of the development of psychological functioning, long before there was any discussion of gender differentiation. For his theory of development, he employs a principle borrowed from psychophysics that will later become known as the pleasure principle, but which was originally called the unpleasure principle.1 This designation is not coincidental, to the contrary in fact. Life is seen as being directed toward the experience of as little unpleasure, that is to say, tension, as possible—hence the idea of the unpleasure principle. A couple of decades later, the same idea will be used as the basis for behavioral psychology and, still later, as the foundation for learning psychology.

Freud's argument in the “Project” is as follows. The starting point for human development is an original experience of unpleasure, called pain (Schmerz), which is the consequence of an internal need whose prototypes are hunger and thirst.2 Freud understands this pain as an accumulation of tension, resulting in a breakthrough of the stimuli through the so-called protective shields (Reizschutz), just as in cases of physical injury (Freud 1978 [1950a (1895)], pp. 298–307).3 Because the stimuli are internal, defense is virtually impossible; running away won't help.4 The child's reaction to this unpleasurable situation is prototypical and provides the foundation for all subsequent intersubjective relationships. The helpless baby turns to the other by crying. The other is supposed to take care of the “specific actions” that will relieve the inner tension (Freud 1978 [1950a (1895)], pp. 317–321; Freud 1978 [1926d], pp. 169–172). Such an intervention will always consist of a combination of acts and words, indicating to the child that the Other has understood the demand and tried to respond to it. Note that this prototypical foundation thus indissolubly links an originally somatic pain and tension with the Other. In other words, the somatic drive has an intersubjective dimension right from the very beginning.

 

7. Defense in Double Time: A Linear Model

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Both psychotherapy and psychodiagnostics typically focus on the subject's speech and behavior. But far too often this overlooks the way both speech and behavior take place inside a double dialectic: between the subject and the body and between the subject and the Other. In the developmental model described in the previous chapter, we saw how the subject constructs a defense against the experience of un-pleasurable tension right from the outset. This defense is always an attempt to master the drive by means of the Other, principally through the Other's representation of it. At the same time, this defense against and attempted mastery of what Lacan calls (a) is transformed into a defense against and attempted mastery of the Other. In what follows, I will develop this idea of the double defense.

The primary defense lies on the border between the verbal and what is preverbal, and determines the structure of the subject. Such a defense is, in the first instance, directed against something in the subject's own body, that is to say, against an internal arousal that breaks through the homeostasis. This defense makes an appeal to the other. The secondary defense takes place entirely verbally and lays the groundwork for symptom development. This defense implies an important shift: from that moment on, the internal problem is warded off in and through the Other, and its internal aspect becomes almost unrecognizable.

 

8. From a Linear to a Circular Model: On Becoming a Subject

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The post-Freudian reading of Freud interprets his theory as a description of linearly occurring, intrasubjective processes that feature just a single central anxiety. One speaks of an initial primary defense, followed by a second, both defensive processes taking place within a single psyche. The impact of the other is negligible and the classic psychoanalytic framework is considered to belong to an “individual” model.

Subsequent analysis nevertheless shows that these three characteristics can and must be given further development in Freud's theory. The aspect of linearity is overcome by his focus on the retroactive nature of meaning and by the discovery that there is no time in the unconscious. The emphasis on the intrapsychic disappears once we realize that his theory of the oedipal structure, with its identifications and repressions, entails a dialectic between a subject and an Other that will later be repeated through the transference. The most difficult point remains his theory of anxiety, where he obstinately maintains his emphasis on castration anxiety. Nevertheless, this doesn't take anything away from the fact that he distinguishes between two different forms of anxiety, each possessing a different foundation.1

 

9. Etiology and Evolution: Nature, Nurture, and the Theory of the Drive

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The central argument of this book so far has been that identity and pathology are developed in the relation between the subject and the Other in the confrontation with (a); consequently they must be diagnosed and treated within this relation as well. The leading processes are alienation and separation, each expressing an opposite tendency. The first process is directed toward merging with the other, while the second aims to realize autonomy. The accompanying anxieties are thus diametrically opposite. In the first, we encounter separation anxiety; in the second, anxiety about being reduced to a passive object of the other. The unavoidable question now has to do with the underlying motives.

Contemporary science is steeped in evolutionary and neo-Darwinist thought and empirical evidence confirming its veracity continues to mount. With the exception of evolutionary psychology, psychology has yet to take any of this on board. The former has been the object of severe criticism, and the academy, particularly in the United States, has tended to have cold feet about it, largely because of the looming specter of political correctness. But beyond this typically obsessional superego symptom, we can discern the following problems: How can one identify an evolutionarily grounded purposiveness in human behavior? How can the answer be read in the light of our overarching metapsychology, particularly with regard to the nature–nurture debate?

 

10. Conclusion: The Subject';s Position in Relation to Anxiety, Guilt, and Depression

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In the previous chapter we discussed the question of etiology in terms of the bigger picture. Were we to ask the same question at the level of the subject, we would inevitably come up against the problem of guilt, as we already saw in the conclusion to Part 1. By way of concluding Part II, we here take up the question of guilt again, this time in the light of our metapsychology. As we will see, it has everything to do with two central clinical phenomena: anxiety and depression.

The importance of these phenomena in the contemporary clinic scarcely needs stating. At the end of the day, one finds no form of psy-chopathology without some feelings of depression and/or anxiety. Before the hype of the personality disorders, it seemed as if the DSM diagnostic would almost exclusively be based on these feelings. While anxiety has always been at the center of clinical work, depression seems to have recently increased exponentially to become a “sign of the times” (Roudinesco 1999). This ubiquity requires us to comprehend these two phenomena both from a global perspective and as differentiated within the different pathologies.

 

11. The Actualpathological Position: Panic Disorder and Somatization

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Our metapsychological discussion of identity formation has enabled us to distinguish a position of the subject in relation to (a) and the Other where the secondary defense and psychological processing have not taken place. The initial problem—which is simultaneously the motive for identity formation—remains focused on the body, that is to say, on the demand arising out of the real body and the impotence of the Other to answer it.

Should such a subject position be empirically verifiable, the consequences would be the following. First, in the psychodiagnostic field, the differential diagnostic becomes relatively simple. For such a subject position, there will be no symptoms a fortiori, that is, no signifying constructions in the Symbolico-Imaginary. The accent will remain on the starting point of the development, namely, on certain somatic phenomena and their accompanying (un-)pleasure and anxiety. Still within the context of diagnosis, this implies that such patients today will initially find themselves in the medical field and only later in a clinical psychological setting. Secondly, at the level of treatment we are confronted with a problem that is structurally different from our customary psychopathology, the latter having already undergone secondary processing. The usual psychotherapeutic treatment will be of little use here, and the potential psychotherapeutic approach to such problems must also be completely reconsidered in the light of the structural diagnostic.

 

12. Between Actualpathology and Psychopathology: Post-Traumatic Stress Disorder and Borderline

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The diagnosis of post-traumatic stress disorder (PTSD) is becoming increasingly common today, suggesting that the clinic has returned to its original starting point (Freud and Breuer 1978 [1895d]). Associated with this is the success of the concept of borderline personality disorder, whose link with a traumatic history is becoming progressively clearer (Herman 1992b). The argument of this chapter will be that both can be understood as situated between the actual-pathology and the psychopathology positions, albeit with a very clear stress on actualpathology.

At first—naive—sight, the diagnosis of PTSD doesn't present too many problems. It is one of the few DSM diagnoses that has an etiology. The underlying logic is this: Trauma is an actual, but thankfully relatively uncommon event, and the psychological confusion (that is, disturbance) it causes is not only foreseeable but above all entirely comprehensible. Treatment ought to follow as soon as possible afterward, and the victim will automatically request help.

 

13. The Psychopathological Position of the Subject: Hysteria and Obsessional Neurosis

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As we saw, subject-formation emerges out of the relation between the subject's own body and the Other. An originally internal, somatic drive arousal gives rise to a demand for an answer from the Other after which the processing of the Real can begin within the Symbolico-Imaginary. At the same time, both the subject and the Other acquire specific contents and an accompanying relation toward each other, and toward desire and jouissance.

Actualpathology has been characterized as that group of disorders where the subject remains stuck in primary development: the Other doesn't answer, or failed to answer sufficiently. As a result, the initial (un)pleasure and anxiety, together with their somatic anxiety equivalents, persist in an unelaborated form. The resulting disorder centers on somatization and anxiety, accompanied by reactive avoidance behavior. No processing occurs in the representational order, hence the absence of a fundamental fantasy and symptoms. An important differential diagnostic effect of this is that such patients often initially address themselves to the medical clinical setting, and only later come for psychological consultation. For the characteristics and complaints of this group I have coined the term actualpathological phenomena, in order to distinguish them from symptoms, which as Symbolico-Imaginary constructions are secondary processings and can only appear in the psychopathological position.

 

14. Perverse Structure versus Perverse Traits

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Perversion is unquestionably one of the most difficult of the clinical categories as far as both research and treatment are concerned.1 A recent survey of the relevant literature (Gijs 2002) concludes that contemporary etiological theories (mainly from bio-psycho-social and feminist perspectives) have little meaning for clinical praxis. Before anything useful can be said about perversion, we must first clear up a lot of misconceptions—particularly if it is the perverse structure that is at issue. As I see it, there are three main problems. One, the ubiquitous, and in most cases explicit moral judgment attending perversion. Two, the omnipresence of the masculine gaze, meaning in most cases a phallic gaze that hinders most studies of perversion. Three, the problem of the differential diagnosis of the quintessentially human polymorphously perverse sexuality on the one hand, and perversion as a subjective structure alongside psychotic and neurotic structures on the other.

Let us begin with the moral judgment or, better, condemnation. While there is such a thing as a “good neurotic” (Zetzel 1968), and probably even a “good psychotic,” the idea of a “good pervert” is a contradiction in terms. The sympathy one has for the victim implies a moral rejection of the perpetrator. The result is not only that it becomes impossible to see anything differently, but also to treat both “perpetrators” and “victims,” in the proper sense of the word “treatment.” Clinical praxis isn't that black-and-white.

 

15. The Psychotic Structure of the Subject

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Neurosis mirrors, perversion fascinates and terrifies, psychosis confronts us with an uncanny riddle. While in the old days people used to listen to the psychotic patient, nowadays the whole focus is on pharmacological and neurobiological solutions and we risk losing the rich clinical knowledge of former times.

In the previous chapters, we understood the various pathologies in terms of a certain structural relation of the subject with the Other. By this, the Other was understood both as language and as first and second Others; however, we have not yet focused directly on this coincidence of Other and language. This means that an important aspect of the subjective structure has received too little emphasis: each pathology, understood as a certain characteristic relation toward the Other, simultaneously implies that each subjective structure possesses a certain way of being-in-language. This is unquestionably the clearest in psychosis, which is why I have reserved discussion of it for this chapter.

 

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