London Society Programme 2013/2014
Our theme of work for this year is
CARTELS: We encourage everyone to work in cartels this term and if they choose to, to present some work at specially reserved times in the programme this academic year. Please contact the Bureau if your cartel would like to book into one of the available slots on 15 February or 5 April 2014.
The Programme:
Venue: ULU, Malet St
11th January 2014 – NLS Knottings Seminar
15th February 2014 – NLS-Seminar ‘What Cannot be Said’ (2 – 5pm)
15th March 2014 – Clinical Conversation [New Format] (11am – 1pm / 3pm – 5pm)
5th April 2014 – NLS-Seminar ‘What Cannot be Said’ (2 – 5pm)
14th June 2014 – Study Day: Psychoanalysis in 21st Century Culture (Science, Law, the Social)
Other Dates in our Calendar:
16/17 November 2013 – ECF Study Day (Paris)
14-18th April 2014 – WAP Congress (Paris)
17/18 May 2014 – NLS Congress (Ghent, Belgium)
Report on the ICLO-NLS screening of “Other Voices” with Ivan Ruiz
Dublin, 5th September 2013
The opening event of the ICLO-NLS 2013/2104 programme was a particularly auspicious moment, not solely in terms of the psychoanalytic community in Ireland, but for those in the English speaking world interested in hearing something of Psychoanalysis and Autism.
On the 5th of September, 2013 in association with the Instituto Cervantes Dublin, an open screening of the world premiere in English of the documentary Other Voices – A different outlook on Autism was held.
Those in attendance were joined by the film’s maker Ivan Ruiz who spoke frankly and engagingly about his film.
Chair of ICLO-NLS Florencia F.C. Shanahan opened proceedings introducing both the film and Ivan Ruiz. She stressed the importance of the film in engaging with the world of the subjects with autism, their families and psychoanalysis, but also in bringing to the fore the other often unspoken yet crucial dimensions that surround the clinic of autism, namely those of a political nature which drive the elements of diagnosis, method of treatment, resourcing and financial assistance.
Joanne Conway made a short address, noting the relevance of this documentary as a means to transmit something to someone – that is something about the position of psychoanalysis to support and uphold for each who undergo it, their idiosyncratic way of being in the world. She then introduced the formation of a Special Interest Group within ICLO-NLS pertaining to Child and Adolescent Psychoanalysis. This group comprises practitioners in the field – not solely from the Lacanian orientation – who seek to interrogate the challenges posed by this clinic.
After the viewing of the film a discussion with the audience took place. Ivan Ruiz spoke candidly about the making of this film, and his motivation to do so being drawn from both a personal experience of autism and psychoanalysis. Another motivation for him was the risk he perceived in society in terms of a change in the conception of what it means to be human – that is how the “subject” is more and more reduced to an ideology of statistical conceptions of what it is to be human. It is a risk for all subjects, but particularly for those with autism and that is why he wished, via the medium of this film, to reach a larger public. This film is a “response to this risk of our civilisation”. He stated he was not a filmmaker, which was disputed by one speaker from the audience – who spoke of the overwhelming and moving testimony of those who spoke, which as filmmaker he unobtrusively and respectfully conveyed.
The question of diagnosis was raised from the audience stressing that whilst psychoanalysis valorises singularity – a diagnosis can be “helpful”. Ruiz responded and stated that in the film, diagnosis is indeed important – and for psychoanalysis it is a means to orient a treatment – a treatment which does not erase the subject as for psychoanalysis each subject with autism is different. Ruiz noted that while we do not yet have a diagnosis for living – it is sure to be coming! Ruiz continued that The Autism does not exist – an Autism for all does not exist and that was an important message to transmit in the film, and so he purposefully did not include any autistic child in the film as there was a risk of creating an “image of autism”. This is not a film to show anything but “to hear something”. And yet each of the children named (by parents, grandparents and analysts) in the film is vitally present – as evidenced via another question from the audience.
An audience member was struck by intense desire articulated by those parents interviewed. Watching the film one is witness in part to the devastation, powerlessness and loss some parents experienced in being presented with a diagnosis of autism and with it a paucity of hope of anything beyond that for their child. But then there is a terrific turn in the piece whereupon an analyst speaking about her work with autistic children emphasises the particularity of each and the fact that each child has a name. The name of course being an ultimate signifier of the desire of the Other. After she speaks each parent in turn then introduces the viewer to their child via his or her name. As each parent names their child something amazing radiates from the screen. Smiles, laughter, love, a tidal wave of desire of each parent/grandparent for each child and their particular gifts and way of being. It is a visceral moment and a radical departure from the language spoken at the beginning of the documentary. It is palpable how psychoanalysis has supported both the singularity of the child and a treatment of the Other (parents) allowing for the creation/restoration of a radical and singular relationship. Ivan Ruiz commented on the dimension of desire in terms of autism as highlighted by the questioner – how in Lacanian psychoanalysis desire is usually only articulated in terms of the neurotic yet here we clearly see the place of desire for these subjects – one only has to listen to the young man Albert and his interest (among many) in Tin Tin – an interest of his father’s originally and one his paternal grandfather also supported/encouraged via his drawings. So something in terms of desire is transmitted and accepted to an extent by the subject. Ruiz noted that the effect of psychoanalysis here is to restore desire via the speech of the parents about each of their children.
What was also evidenced in the film was the particular demand on parents and analysts alike to invent a new clinic/treatment case by case. This approach encompasses vital work with parents and child toward the possibility of opening new pathways through which the parents (and others) may enter the world of the child.
Time was forever at our heels in this event and the discussion came to a close long before it was ever near ending. In closing Florencia thanked those in attendance with particular thanks to Ivan Ruiz, and noted that the questions of the evening pointed to some controversial points in the film equally for those who were psychoanalysts and those who are not, and perhaps point to those elements we each take on ourselves to understand.
The event was a great success, evidenced in the record numbers in attendance. This film is a testament to the lives of autistic subjects and their families. A testimony of their courage to persevere and hold fast to their struggle to uphold subjectivity above all and a powerful account of how an encounter with psychoanalysis can make a difference for each. This film must be heard.
Joanne Conway (ICLO)
NLS Congress | 17th and 18th May 2014 in Ghent
What Cannot Be Said
Desire, Fantasy, Real
In my title, some of you will have recognised an echo of Wittgenstein’s formulation, the last proposition in his Tractatus: “What we cannot speak about, we must pass over in silence”[i]. Unlike the philosopher, I have cut the formulation in the middle and allowed the suspense to complete it on the basis of what Lacan proposes in Seminar VI, along with the decisive orientation that Jacques-Alain Miller gave to it in Athens.[ii]
For psychoanalytic experience invites one precisely not to be silent about what cannot be said, “which provides an opportunity to put to the test the fact that words cannot say it all”.[iii] In the course of the treatment, the aspiration to find the word that would say the thing fades, even if Lacan began by installing the Name-of-the-Father as the final word of the story. He made it into an Other of the Other, the guarantee of the established order, which he consecrated as the symbolic order. But what J.-A. Miller shows in his presentation is that in what follows and right up to the end of his teaching, Lacan systematically dismantled this pseudo-harmony of the symbolic. That is the meaning of this formulation from Seminar VI: “there is no Other of the Other”.
Free association necessarily encounters the impossible to say. It is thus at the moment when the word with which to say it is found to be lacking that the subject falters to the point of panic, there where he must, as Lacan says, face up to his existence. “At this moment which is, if one may say, a panic point, the subject must cling to something, and what he clings to is precisely the object qua object of desire.”[iv]
Wittgenstein would be right, says Jean-Claude Milner, “if only what we cannot speak about consented to be silent.”[v] The analysand would thereby conclude his analysis on the revelation of a want-to-be that constitutes the metonymy of his desire and arrive at the “forsaken horizon of being.”[vi] As J.-A. Miller notes, this version of the end of analysis turns the subject into a non-dupe, in other words, a subject founded on erring.
However, as he pointed out in Athens, the place where the end of analysis is played out is not on the side of the insubstantial being of a desire, which would be a pure signifying metonymy, but on the side of the fantasy, which is enjoying substance [substance jouissante]. Thus, “the heart of this seminar is not interpretation; it is the subject’s unconscious relation to the object in the desiring experience of the fantasy.”[vii]
What is a psychoanalysis practice that aims at the object a of the fantasy? What is at stake is not that the analysand narrates his phantasmagorias, it is a question of circumscribing what the subject’s life is structured around when he is a prisoner of his fantasy – in the singular and unconscious – just as Lacan does in his analysis of dreams or of Hamlet. There is no direct experience of the unconscious fantasy, which is why it is necessary to reconstitute it in our constructions.
The Congress in Ghent will thus focus on what does not consent to be silent and makes its way through the inter-said [inter-dit]. We shall emphasize “the opposition between the closed order of the father (metaphor is always a stopping point) and what desire brings, on the contrary, of the irregular and fundamentally out of place.”[viii] The theme unfolds between what cannot be said except between the lines and what is impossible to say. It may be true that “the analyst offers himself as a support for every demand, and responds to none of them”,[ix] but it is not merely in this non-responding that the mainspring of our presence lies, as Lacan says at the end of Seminar VI. As this Seminar reveals, the true nature of the objects of the fantasy is to be real objects, “separated from the subject though they are closely related to his vital drive.”[x] The analyst makes himself into its “inexorable”[xi] support. In the different structures, the reconstitution of the fantasy as support of desire will serve as the turntable with which to articulate the relation of the subject’s desire to the desire of the Other… without Other.
Dominique Holvoet
Translated by Florencia F.C. Shanahan and Philip Dravers
[i] Ludwig Wittgenstein, Tractatus Logico-Philosophicus, 1961, trans. D.F. Pears and B.F. McGuinness, (London: Routledge, 1961), p. 89. [T.N. Or according to Ogden’s translation: “Whereof one cannot speak, thereof one must be silent” Ludwig Wittgenstein,Tractatus Logico-Philosophicus (1922) trans. C.K. Ogden (New York: Cosimo, 2007), p 27 and p 108.
[ii] J-A Miller, “The Other without Other”, closing presentation at the NLS Congress in Athens, May 2013. To be published in Mental 30 and Hurly-Burly 10. Working version available on the NLS website.
[iii] J-A Miller, “La psychanalyse, sa place dans les Sciences”, Mental, 25, p. 19.
[iv] J. Lacan, Le Séminaire, Livre VI, Le désir et son interprétation, (La Martinière et le Champ freudien editions, 2013), p. 108. (Unpublished in English).
[v] J.C. Milner, “L’oeuvre claire, Lacan, la science, la philosophie”, (Paris: Seuil, 1995), p. 169.
[vi] J. Lacan, “The Direction of the Treatment and the Principles of its Power”, Écrits. The First Complete Edition in English, (New York: W.W. Norton & Co., 2006), p 536.
[vii] J-A Miller, “The Other without Other”, op. cit., p 9.
[viii] J-A Miller, Ibid., p. 12.
[ix] J. Lacan, Le Séminaire, Livre VI, Le désir et son interprétation, (La Martinière & le Champ freudien editions, 2013), p. 572 (Unpublished in English).
[x] J. Lacan, Ibid. p.469.
[xi] J. Lacan, Ibid., p.565.
Dear colleagues,
You are kindly requested to declare your cartels on the website of the School by filling in the form that you can find by clicking on the rubric “Life of the School – Cartel - Declaration of the cartels”.
The declaration of the cartels concerns the cartels of the NLS that start this year as well as the ones from last year that will continue their work.
Attention! : Do not tick in the box “Cartel Towards the Congress”. It is reserved for the electronic cartels.
I wish you all the best with your work!
Despina AndropoulouResponsible for cartelswww.amp-nls.org
New formula of the project of the electronic cartels
Dear Colleagues,
As it was announced at the end of the report of the second round of the electronic cartels, the e-cartel project will be lightly modified the next year. These modifications aim at the reinforcement of the work within each cartel and the facilitation of the exchanges among the cartels.
Taking into account the difficulties we have noted during last year, the new formula of the e-cartel project for 2013-2014 is the following:
1st step: Constitution of the cartels as groups (4+1) or on individual basis. In the last case, it is the delegate of the cartels who, as a general rule, will be charged with the designation of the Plus-One. The Plus-Ones will send the composition of their cartel by the 15th of September to the following e-mail address: d.andropoulou@yahoo.gr
2nd step: The members of each cartel choose from the proposed cases, the vignette that will be commented upon and discussed. In order to stimulate the work by all members of the cartel, more time (about 3 months) will be allowed for the exchanges between the members of the cartel (theoretical elaboration of the case, specifications on the evolution of the case, effects of the analytical act, elaborated work on the structure of the case etc.)
3rd step: Each cartel, represented by the Plus-One, sends its elaborated vignette to the delegate of the cartels.
4th step: Redistribution of the vignettes by the delegate.
5th step: Each cartel works on the case of another cartel for 2 months. An extime participates in the discussion.
6th step: The vignettes are sent to the delegate. The delegate sends back each commented vignette to the cartel that has written it.
7th strep: The author has at their disposal a month in order to send their vignette in its final version (including the commentaries of the other cartel and/or answers to questions posed).
The deadlines of each step as well as the names of the extimes and other information will be given out during the procedure.
The delegate of the cartels
Despina Andropoulou
WHAT CANNOT BE SAID
desire, fantasy, real
————————————————————-
It will be preceded, on May 16th, by a Clinical Conversation reserved to the members of the NLS, under the auspices of the WAP
Presentation at the SLP Congress in Milan, 12 May 2013
by Dominique Holvoet
When Paola Francesconi, president of the Scuola Lacaniana di psicoanalisi asked me to speak about the Cartel at the SLP, I was caught unprepared. I had just interrupted cartel work in a cartel for which I was the plus-one, supposedly due to other responsibilities, but also because of a certain malaise about which I hadn’t yet drawn the consequences. I found myself called upon to participate in this cartel, to stand in as the person who would know, and from whom a teaching is expected, without being able to correctly function as a plus-one, to occupy the right place. With regards to Paola’s proposition, I’ll add that up until then I had always thought that it was better to form cartels than talk about them! I have revised my judgment after writing this presentation: it is necessary to know the structure of the cartel in order to avoid its pitfalls. Jacques-Alain Miller speaks about cartels in terms of the four discourses: absence of production if there is a master at the starting point, free association without direction if the plus-one thought s/he occupied the position of the analyst, cartel crisis if there is only “plus-one-of-knowledge” (plus-un-de-savoir). Knowledge is only gained if the plus-one is in the place of $ (the barred subject).
Reading Lacan’s founding texts and Jacques-Alain Miller’s interventions on cartels, I revisited -after this cartel crisis- the important point that made me, thirty years ago, choose the Cause Freudienne as a School of psychoanalysis. I had, indeed, been very surprised and encouraged by the fact that analysts were taking the time to read my modest work, to listen, to comment and to help me move forward in my questions. This unique position, which I had never encountered at the university or elsewhere, gave me the desire to work and the cartel immediately seemed to me to be the best tool for reading Freud and Lacan, especially since the stimulating presence of the others is added to the support of the plus-one, which pushes the effort beyond that modesty which is always a bit fake, or coward. Because of this, the cartel has always seemed to me to be an incomparable means of controlled elaboration, and I believe that the WAP colleagues share my opinion.
Nevertheless, the Cartel never ceases to cause problems. We must in fact recognize that the cartel meets a resistance that seems to be structural. We return constantly to the question of the cartel in the Schools of the WAP, we talk about it over and over, we have to invent something to give it back its vigour. And you will notice, as I have, that just like the cartel, the “pass” keeps causing problems. One could say that the pass and the cartel are the two lungs of the School of Lacanian psychoanalysis. Without the cartel and the pass, the school would suffocate. But one could also say that the pass and the cartel are two grains of sand in the functioning of the group; two little grains of sand that Lacan placed there to jam the machine, to block the “it works” of the group, which is the other side of the discourse of the analyst; two grains of sand to make the School. As Jacques-Alain Miller has shown in his text, “The Cartel in the world”[1], the invention of the Cartel in 1964 accompanied an anti-authoritarian movement. The cartel, of course, responds to the Freudian logic of the collective, which only constitutes itself as a group thanks to a leader, responding to the logic of male sexuation. But in the cartel the place of the at-least-one, the leader, is reduced. What’s more, it is a permutative function. No at-least-one, but one-more, one-extra (un-en-plus) adding him or herself to the four to be the hysteric or Socratic agent of a provoked elaboration. The plus-one is here extimate, adding him or herself to the cartel only to incomplete it. The plus-one is the person who selects and discusses the work of each, the person who chooses the outcome to reserve for the work, writes Lacan, in the act of foundation. In short, the plus-one is the person who takes care to consider the work of others, to give to the work of each its place. But the plus-one is also the person who feminizes the cartel, making it pass from the logic of the all to that of the not-all.
Cartels in the NLS
In its relationship to the School, the cartel is thus one of its organs, that is to say, something that makes it lively, or… moribund if the organ is sick. Lacan wanted the cartel to be the place of ebullition of the School’s work. But what is “the School’s work?” Seen from the cartel, it is the elaboration that is sustained by each, an elaboration submitted to the attention and the criticism of peers in a small group, an elaboration that can know a public fate, since the plus-one looks after the outcome of the work. This is where the apparatus that was fine tuned ten years ago in the NLS by the first delegate of cartels, Gil Caroz, comes into play, an apparatus refined over the years. I’m not talking about the work of the cartels as a whole. There is the classical version of the cartels’ work whose publicity is made in the online Catalogue of Cartels on the School’s site, and then there is another version, that of the electronic intercartel. I will distinguish between the “electronic” use of the cartel and that of the intercartel per se.
The question of electronic use should be the subject of a work in itself and goes beyond the cartel, for that matter — it concerns our lifestyle which has been turned upside down by chatting, email and social networks in which the temporal dimension and that of the body of the other are put on hold. The electronic cartel essentially functions through email, that is, through a written form. This is a pragmatic choice that allows people to work together despite distance. But the absence of bodies in this work is not without effect. It goes, for some, against the logic of the cartel, while others see in this work through writing a positive effect of disimaginarization. I am not convinced by these opinions. Work through writing and the absence of bodies real-ize solitude and therefore add a supplementary demand that requires of the plus-one a strong desire that confines with the not-all.
The NLS’s intercartel runs from September to May in accordance with the theme of the forthcoming annual Congress. It only takes into consideration clinical work. It is expected of the plus-one to select a clinical vignette, presented by one of the participants. This vignette is the subject of a continuous work of elaboration that begins inside the cartel. The elaborated vignette is then read by another cartel. Cartels are thus constituted in tandem. Each vignette is thus elaborated in the initial cartel, read and re-elaborated in the tandem cartel with the extime, and re-read and finalized again in the initial cartel. This finalized work is distributed to the rest of the participating cartels and only to them for reasons of confidentiality. A general public report is written by the delegate to the cartels that puts emphasis on this work, drawing theoretical and clinical conclusions from the provoked elaboration. This apparatus supposes a very active role on the part of the delegate of Cartels that animates the whole. S/he organizes the cartels that form and composes the tandems, chooses the extimes and writes two public reports a year. The result is the realization of a knotting of groups via effective and critical work. Thanks to this work, the intercartel is, with the Congress, what effectively constitutes the School in the NLS and makes it live.
Translation by Ian Curtis
Report on “DSM-5 and the Future of Psychiatric Diagnosis” conference at the Institute of Psychiatry, King’s College London (4th-5th June 2013)
Véronique Voruz and Janet Haney
The DSM-5 has been all over the media of late. Lay members of the public, service users and psy professionals have deplored the lack of scientificity of the negotiation processes leading to the inclusion of diagnoses and remarked upon the conflicts of interest playing themselves out through pressure groups, and apparent in the position of some researchers. The socio-political stakes of diagnoses, such as access to an educative or financial support for some ‘conditions’ (such as Asperger), have been made explicit. There has also been talk of the danger of overly medicalising the human condition,[1] and even of American imperialism and its exportation of psychiatric labels to the rest of the world irrespective of cultural specificities.[2] As the criticisms gathered momentum, the DSM was progressively exposed as a technology of power-knowledge in the hands of the psychiatric profession in connection with the pharmaceutical industry. It became obvious to most that the DSM was neither about the subjective experience of mental illness, nor to the direction of the treatment. Thus in the English-speaking world, criticisms came from all angles months before it was even published:
- From former DSM task force heads Robert Spitzer (DSM-III) and Allen Frances (DSM-IV), for lack of transparency and reliability (methodological flaws);
- From patients’ associations, defining themselves increasingly as ‘mental health survivors’, such as SOAP [Speak Out Against Psychiatry], Hearing Voices, or Mind, for lack of attentiveness to the subjective reality of so-called mentally ill people and for ‘naturalizing’ their suffering;
Sticker worn by the protestors outside the conference
- From ‘psy’ associations like the British Psychological Society, the Critical Psychiatry Network or Mental Health Europe, to name just a few of the hundreds of bodies that declared against DSM-5, for various reasons ranging from lack of empirical validity and insufficient emphasis on the biological causes of mental illness to lack of focus on the singular experiences of the patients. The psychiatrists of the CPN are already drawing conclusions from the multiple failings of the DSM paradigm and assert that their profession is at a turning point of its history; it is time to move beyond any existing psychiatric paradigm. They argue that psychiatry needs to re-invent itself both epistemologically and in its practices, failing which it will lose its legitimacy. “The psychic life of humans is discursive by nature”,[3] they affirm in a collective statement piece challenging the bio-medical model. Given that their orientation is, broadly speaking, Marxist, they are proposing to think mental illness as a consequence of social inequalities;
- From NIMH [National Institute for Mental Health], a division of the American Health Department and its director Thomas R. Insel, for insufficiently drawing on neuroscientific research, in a probable bid for President Obama’s Brain Initiative ($100 million allocated funds).
So the DSM is lacking in many respects… It’s hard to think what attributes it still has. Given the multiplicity of dissonant voices, and of grounds for controversy, only one thing is clear: nobody has much of a clue as to what a mental disorder is any more, and least of all as to what it could possibly mean to be mentally healthy. In the DSM anyway, the border between disorder and normality is reduced to a mere question of threshold for the same affect or symptom. Time to re-read Canguilhem (The Normal and the Pathological)!
A faltering paradigm can be more fertile than a well-rehearsed discourse, so we decided to attend the DSM-5 conference (hosted by the IoP at KCL early this month) to hear what the architects and supporters of the DSM-5 had to say about the state of their project. We took our inspiration from Eric Laurent’s extremely lucid article in Lacan Quotidien n0 319: Laurent predicted the end of the psychiatric paradigm and the reconfiguration of the mental health discourse by the neurological paradigm. This reconfiguration is still in the making but is signposted by NIMH with the introduction of RDoC [Research Domain Criteria], initiating a mythical quest for objective signs of mental illness using neuroimaging, genetic markers and objectively detectable alterations in cognitive functions, in the domains of emotion, cognition and behaviour.
Scheduled to speak were DSM-5 task force head David Kupfer as well as many eminent British and American psychiatrists involved with the WHO, the ICD [International Classification of Diseases, instrument of the WHO] task force, the DSM task force, the Royal College of Psychiatrists, or again specialists of specific diagnoses such as autism, Disruptive Mood Dysregulation Disorder, or the discarded Attenuated Psychosis Syndrome. The only outsider to the medical/psychiatric professions was Nikolas Rose, a well-known critical voice in the fields of criminology, sciences of life, neuroscience and psychiatry, and to our lay ears the sole voice of sanity.
To classify
The conference started with opening remarks by Shitij Kapur, currently Dean and Head of School at the IOP. His general argument was that in the days of yore things were terrible because we did not have a classification of mental disorders; in fact we had to make do with a mere three categories (hysteria, psychosis, other disorders). Thankfully in the 1920s American psychiatrists came up with a statistical manual sorting the asylum population into 22 disorders, and by the mid-20th century psychiatric classifications began to include all mental disorders. The premise of Professor Kapur’s talk was basically that the main problem besetting psychiatry was unsatisfactory classification, hence the thrust of the APA [American Psychiatric Association] in ceaselessly adjusting its classification manual.
These opening remarks were followed by a historical talk by Professor Horwitz who recounted how prior to WWII psychiatric classification concentrated on asylum populations, with 21 of the 22 recognised disorders referring to psychotic conditions. But after WWII returning soldiers presented different types of disorders that could not be ascribed to biological or genetic factors since they had been carefully screened before being sent out to fight. Further, their disorders were clearly circumstantial (war neuroses, shell-shock etc.); they also could not be treated through the asylum system. Thus the DSM-I was born, in 1952, but unfortunately it was heavily influenced by psychoanalytic psychiatry and differential diagnosis, and focused on neurotic conditions. The DSM-I was very theoretical, and Professor Horwitz deplored that it was a manual for clinicians, not for researchers.
Indeed, it became very clear in the course of the conference that the main point of the DSM-5 was to allow psychiatrists to 1) accurately fill in assessment forms; 2) bid for research funding on certain conditions; 3) publish accredited articles furthering their careers. There was hardly any mention at all of treatment, at best the patient re-appeared from the perspective of symptom management. Otherwise the whole conference was spent discussing accuracy of classification, items on diagnostic instruments, and whether a particular diagnosis was the same as another using ‘sophisticated’ statistical tools.
Professor Horwitz rejoiced that the DSM gradually moved away from being a clinician’s tool to being a researcher’s one. That was because psychiatry, in order to re-assert its waning professional dominance in the face of alternative disciplines such as psychology and psychoanalysis, started to rely on the medical methodology of controlled trials and statistical evidence instead of case studies. Robert Spitzer’s DSM-III waged a successful war on the psychoanalytic framework and introduced symptom-based, objective and measurable conditions. The result was an a-theoretical manual, which Professor Horwitz specified as being agnostic as to etiology: in other words, anyone with the symptoms has the disorder, and the need for etiology goes “out of the window”.
The DSM-III met with instant success for reasons that had little to do with the efficacy of treatment: it proved useful in organizing re-imbursement structures, it provided professional legitimation to psychiatrists, it was endorsed by NIMH and became the framework for research funding: for a time in the US it was impossible to get funding without relying on a DSM category. It also proved successful with parents, who were fed up with being held responsible for their children’s disorders. Last but not least, pharmaceutical companies loved it because they could target their drugs to specific diagnoses. The DSM-IV and 5 (the roman numerals were abandoned to signal the modernity of the new DSM…) represent attempts at overcoming issues of co-morbidity and incorporating biological findings. But the outcome is not as successful as the DSM-III, with a proliferation of diagnoses often said to include all of the population (157 diagnoses, themselves divided into subsets…).
Professor Horwitz’s talk was followed by an intervention by David Kupfer, head of DSM-5 task force. Kupfer emphasized that the thrust of the task force had been to incorporate as much research and empirical data into the DSM-5 in order to improve its reliability and the validity of its diagnoses. For this purpose, the task force received input from researchers from 13 countries, from psychologists, added input from neuroscience and so forth. Basically Kupfer tried to defend the DSM-5 by showing that everything had been done to improve its classificatory reliability. Professor Rutter continued the morning session by outlining why the psychiatric community needed a classification: 1) to communicate between ourselves; 2) to regroup different types of individuals; 3) to direct treatment.
After the first three morning sessions it had become apparent that the main purpose of the DSM-5 was to legitimize the psychiatric profession in its research and funding activities, and the debate at the IOP would never challenge the idea that classification was the way to go. Meanwhile, outside the IOP a demonstration was going on, organized by people who saw themselves as survivors of psychiatry. There were, even, representatives of the Citizens Commission on Human Rights [CCHR], gathering information on ‘psychiatric damage’, or damage caused by psychiatric treatment. Overheard conversation between two psychiatrists: “I don’t understand why they are so angry at us. We are only trying to help them.”
A ‘survivor of psychiatry’ protesting outside the carefully guarded IoP.
‘Outsider’
Nikolas Rose then took over, with a very measured sociological intervention pointing out that diagnoses had above all social functions: sick leave, eligibility for treatment, disability benefit, involuntary detention, epidemiology, research, predictive tools, insurance, identification, cultural significance, biopolitical importance, management of the disorderly, grouping of the heterogeneous, and so forth. Given the huge relevance of the social functions of diagnoses, Professor Rose underlined the responsibility of the people who take on the responsibility of creating diagnostic categories. He drew attention to the epistemological consequences of the unifying gaze of the DSM-5: one third of the adult population are now said to suffer from a mental disorder in any one year in Europe. The result of such a medicalization of the human experience is the reduction of etiology to pathophysiology. Yet there is no biological substrate to mental illness, and no boundary between ill/well-being. The DSM method is to look at clinical phenomena and seek to correlate them to neurobiological underpinnings. RDoC suggests to look at the brain and link brain patterns to clinical phenomena – these two models fail to address the definitional issue of 1) mental health; 2) mental disease. They also focus on research at the expense of practice. He concluded by supporting the position of the BPS: one should start with the specific experiences of the patient rather than with the diagnosis.
Professor Nikolas Rose, Head of Department of Social Sciences, Health and Medicine at KCL
Despite Professor Rose’s well-calculated intervention, the afternoon proceeded with a discussion of specific diagnostic categories such as the autistic spectrum disorder, the Disruptive Mood Disregulation Disorder and whether it was the same as ADHD, and finally some very dodgy research from an ethicist (!) making children say that Ritalin had a fantastic effect on them, showing their drawings – no doubt as visual proofs.
To laugh or to cry?
Dr Clare Gerada opened the second day by introducing herself to the conference as a GP, adding quickly ‘forgive me for that’ (laughter). She then declared her ‘conflict of interest:’ she was married to one of the speakers (laughter). She introduced the first speaker (to whom she is definitely not married) as: Professor David Clark, ‘the most cited psychologist of all time, more even than Eysenck’. This time there was no laughter – had she meant to be ironic? If so, there was no sign of it (Eysenck had been Professor of Psychology at the IoP between 1955 and 1983). David Clark’s work hugely affects that of Gerada, because he has made CBT and IAPT available for her patients. He is currently Professor of Experimental Psychology at the University of Oxford and Visiting Professor of Psychology at the Institute of Psychiatry and is a leading figure behind the ‘success’ of the IAPT programme.
“For those of you who read the Observer” he said with a knowing smile, “you will know that the BPS has come out with a rather strident notice against the DSM”. The statement criticises the DSM as not scientific, but as created through the efforts of committees and consensus”. Professor Clark points out, in a gentle, quietly assured manner, that the DSM is “perhaps more interesting to psychology than to most people”, adding “the DSM is a great help when lobbying politicians”. He went on to acknowledge that “There are no RCTs of generic CBT, they are all of specialized CBT with specific foci and procedures”. Brushing aside the problems arising from that, Clark went on to present power-point proof that CBT is, generically, more effective than counselling in almost every case.
Professor Wessely, ‘an epidemiologist by training’, had some very funny slides, which the audience clearly enjoyed. One of them, a Gary Larson (two almost identical fat men, one, the GP, saying to the other, the patient, as he straps a rocket to his back: you’re allergic to the environment, we’ve got to get you off the planet: the window is in front of the patient) was so popular that a member of the audience requested that it continue to be displayed after the talk is over. Wessely’s work focuses on the very serious fact that more soldiers in the gulf war suffer from ‘mettle fatigue’ (a joke courtesy of the Evening Standard) than in other recent wars. He presented results on the ‘number needed to offend’ (laughter): the tricky business of finding names for disorders that real men won’t baulk at (don’t even think of using hysteria, he advised).
After the coffee break Norman Sartorius (former Director of the Division of Mental Health of WHO) chaired a most interesting session. Vikram Patel was billed as speaking about ‘Why the DMS5 matter to global mental health’. He stood up and said: “the DSM5 is irrelevant and risks undermining global mental health”. Patel is Professor of International Mental Health at the London School of Hygiene and Tropical Medicine.
Felicity Callard, a historian and sociologist at Durham university used her personal experience of being diagnosed in both the USA and UK to say that this stuff is always situated in a particular place, time, and set of relationships, it means different things to different people at different times. She also noticed the prevalence of what she called ‘the male voice’ in and around the DSM. A woman in the audience (also with personal experience of psychiatric diagnosis) asked Sartorius if he would like to comment on the male voices speaking about the DSM5? This distinguished man of the world seemed to be genuinely confused: you want to know if I have voices, he asked. The laugher in the auditorium compounded the confusion, and might have precipitated the conference, just for a moment, into a rather more interesting place.
After lunch Robin Murray (knighted in 2011, but appearing without his title) took the chair with much gusto. Professor of Psychiatric Research at the IoP, Robin seemed not to care who knew his opinion about the Americans and their DSM5 and talked openly about the changes in psychiatric and economic power. Murray’s task was to chair a particularly interesting session, not only because it contained professors from Germany and Switzerland, but also because it represented a controversy thrown up by the DSM5: Attenuated Psychosis Syndrome – forming the base of two out of the four presentations – has been dropped by the DSM5. The presentations were particularly dense and compacted, as slide upon slide testified to the diligent work of countless researchers in four different countries. I asked the woman sitting next to me (who had popped in only for this session, as it was so controversial) whether the loss of the diagnosis in DSM5 would mean loss of funding for the unfortunate researchers. No she said, because they are in Europe. Had they been based in the USA, the story would have been different.
Meanwhile, a Kiwi psychiatrist (ripple of laughter) was asking: ‘but does the APS have validity’. Murray replied:
– ‘Hamburgers exist, but they have no validity’. Much laughter, and then everyone joined in:
– So what should I write in my paperwork?
– Something vague and descriptive.
– So the DSM categories are subjective?
– Of course!
– That’s why you need so many entries in the manual!
– So you can choose the best fit …
– And everyone can get hold of some money!
– [ever so very much laughter].
The final ‘round table’ did what it could to re-present a solid scientific face to the world, and to rally us back to ‘the cause’. Then it fell to the local chief, Professor Shitij Kapur, to appeal to the audience to put it all back together. He invited us to vote on whether the DSM5 would a) make things worse, b) make things better, or c) make no difference at all. A little more than half of the audience expressed a wish for (c).
Cynicism
Behind the veil of this theatrical vote, we could see the reconfiguration of new alliances between research and politics taking shape. The psychiatric profession, in its vast majority, is re-orienting it research towards the objectively verifiable markers of mental illness, preferably those that are in the brain. The DSM-5 is already obsolete. The British psychiatrists present at the IoP openly stated that they only used the DSM to fill in the required forms, choosing the diagnoses that will allow them to do what they feel is appropriate in the circumstances. The conference brought a real cynicism to light: diagnostic classification is used to fill in evaluation forms, apply for research funding, and publish the peer-reviewed articles necessary to promotion. During these two days, no one mentioned the question of treatment, except from the perspective of symptom management.
Janet Haney and Véronique Voruz
10 June 2013
[1] De-Medicalizing Misery: Psychiatry, Psychology and the Human Condition, Rapley M., Moncrieff J. and Dillon J. eds., Palgrave Macmillan 2011.
[2] Crazy like Us: The Globalization of the American Psyche, Ethan Watters 2011.
[3] Bracken P. et al “Beyond the Current Paradigm”, The British Journal of Psychiatry [2012] 201: 430-434, p. 432 pour la citation.
Français <http://www.congresamp2014.com/fr/Whats-up/WhatsUp_004.pdf> –
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