18 Chapters
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3. The Impotence of Epistemology

Verhaeghe, Paul Karnac Books ePub

3

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.

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5. Conclusion: The Need for a Metapsychology

Verhaeghe, Paul Karnac Books ePub

5

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.

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

Verhaeghe, Paul Karnac Books ePub

10

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.

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1. Introduction: Clinical Psychodiagnostics versus Medical Diagnostics

Verhaeghe, Paul Karnac Books ePub

1

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:

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

Verhaeghe, Paul Karnac Books ePub

13

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.

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