DSM-5 'Future of Psychiatric Diagnosis' Conference at Institute of Psychiatry, 4/5 June 2013

Conference Report: ‘DSM-5 and the Future of Psychiatric Diagnosis’, Institute of Psychiatry, King’s College London (4th-5th June 2013)

The DSM-5 has been all over the media of late, generating criticisms 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;

• from patients’ associations 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;

• 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;  

• from NIMH [National Institute of 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).

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.

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. 

Day 1 by Véronique Voruz

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 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.” 

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 task 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.

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 making children say that Ritalin had a fantastic effect on them.

Day 2 by Janet Haney

Dr Clare Gerada (Chair of Council of the Royal College of General Practitioners) opened the second day by introducing herself to the conference as a GP, adding ‘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 not married) as Professor David Clark, “the most cited psychologist of all time, more cited even than Eysenck”. This time there was no laughter – had she meant to be ironic? Eysenck had been Professor of Psychology at the IOP between 1955 and 1983 and was famous for his controversial ideas about race and intelligence. David Clark’s work hugely affects that of Gerada, she said, because he has made CBT 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 wry 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 pointed out, in a gentle yet cynical manner, that the DSM is “perhaps more interesting to psychology than to most people”, adding that “the DSM is a great help when lobbying politicians”. He went on to say “there are no RCTs of generic CBT”. Pausing only to survey the effect of this revelation on the audience, he then pressed home his advantage by presenting Powerpoint proof that CBT is more effective than counselling in almost every case. This slide was not reproduced in the conference file, and I could not see any reference to the study that produced the results. No-one laughed, who would dare?

Professor Wessely, “an epidemiologist by training”, had some very amusing slides, which the audience clearly enjoyed. One of them a Gary Larson cartoon: two almost identical men, one (the doctor) saying to the other (the patient) as he straps a rocket to the latter’s back, “You’re allergic to the environment, we’ve got to get you off the planet”; the patient is aimed for easy exit out through the window. This was so popular that a member of the audience requested that it continue to be displayed after the talk was over. Wessely’s work focuses on the very serious fact that more soldiers deployed in the Gulf War suffer from ‘mettle fatigue’ (a headline of a report by the Evening Standard) than do those involved in other recent wars. He presented results on the “number needed to offend” [laughter – this time playing on an epidemiological phrase “the number needed to treat”]: 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 the World Health Organisation) chaired the session. Vikram Patel was billed as speaking about “Why the DSM-5 matters to global mental health”, but when he stood up he said: “The DSM-5 is irrelevant and risks undermining global mental health.” The finer point that he wanted to make was that the conflicts of interest visible around the DSM-5 “threatens the growing momentum [of support] among donors and governments” in those parts of the world where psychiatry had yet to dominate. 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 the UK to say that this stuff is always situated in a particular place, time, and set of relationships, and that it means different things to different people at different times. But she also noticed the prevalence of what social scientists call ‘the male voice’ that discusses 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 DSM-5? This distinguished man of the world seemed to be genuinely confused: “You want to know if I have voices?” he asked. The laugher swelled up again.

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, Murray seemed not to care who knew his opinion of those Americans and their DSM-5 and talked openly about the shifts in psychiatric and economic power. Murray’s task was to chair a packed session, featuring professors from Germany (Klosterkötter) and the Netherlands (Van Os), as well as USA (Carpenter) and UK (McGuire). This session revolved around the controversial dropping of Attenuated Psychosis Syndrome from the DSM-5. The presentations were particularly dense and compact, as slide upon slide testified to the diligent work of researchers with access to varying levels of technology in four different countries (a neuroimaging machine won ‘hands down’ for the man from the IOP). I asked the psychologist next to me (who had popped in to the conference for this session only because it was so controversial and affected her own research) whether the loss of the label in DSM-5 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 [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!
- [much laughter].

The final ‘round table’ did what it could to re-present a solid scientific face, and to rally us back to that 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 DSM-5 would a) make things worse, b) make things better, or c) make no difference at all. Someone insisted on a time frame (a year, was proposed), but no-one asked ‘better for who? or ‘in what way?’ so the insights about finance, power and prestige were easily swept aside. More than half of the audience went for (or shall we say “expressed a wish”) for option (c).

Behind the veil of this theatrical vote the shifting alliances of research and politics pin their hopes on objectively verifiable markers, preferably in the brain. Meanwhile, yesterday’s protesters and other outsiders are massing at the IOP doors, awaiting the “Maudsley Debate”: Enabling or Labelling? This House believes that psychiatric diagnosis has advanced the care of people with mental health problems. Satorius is speaking ‘for’, Callard is speaking ‘against’, and Wessley is in the chair. (PS. The vote:  For 144.  Against 109. Abstain 18.)

Put Poetry into the Jobcentres and save CBT for somewhere more fitting

Soundings, 2: Nobody heard him, the dead man, but still, he lay moaning…

June 26, 2015

There is a meeting today at 1.30pm at the Streatham Memorial Gardens. I shall be there early. The meeting will gather together a group of people, perhaps 100, maybe more judging from the Facebook page, who will then march up the road, not far, to the Streatham Job Centre. It is a mark of our varying dissatisfactions with the Government’s idea to put CBT therapists in job centres in a supposed attempt to get people ‘off the dole and back to work’.

What a beautiful day for a protest, the roses are blooming and the birds are singing. I barely have time to look at the statue with its inscription To Our Glorious Dead and the list of names inscribed below – it’s 1.15pm and already there are 12 people standing in the shade of the trees, and two are holding up a banner which the other ten are photographing. The gist of the banner is this: ‘CBT practitioners: are you a professional or a collaborator?’

 @blacbanner collective politicalart.org

 I set to work introducing myself and asking people why they have bothered to come today.

“It’s a human right to be able to refuse medical treatment. To not be made to be part of an experiment. It’s written in the UN Declaration of Human Rights.”

“I’m just gutted. Council Houses, Brixton Arches, rent increases, everything.”

“I want to support people facing cuts to their allowances. I have friends with distress who are scared by the way things work.”

“It seems a really bad idea to combine a disciplinary system with social care.”

The next person turns out to be a national spokesperson for the Green Party: “the Government is crossing a line – it’s written in their Manifesto, their intention is clear. Don’t believe them when they say there’s no coercion, it’s written in their Manifesto.”

“It’s an inappropriate setting – it is not a place to speak freely, which it should be for any therapy”.

 “It’s wrong to make a mental health service part of a sanction system.”

“To cut public spending, they are hitting the most vulnerable.”

“It’s clearly wrong.”

“Mental Health isn’t something you can flick a switch and fix”.

“The problem, in my opinion, is that we live in a system which makes us ill – unemployment, poverty. Actually I’m doing therapy, CBT, over there (points just over the main road which is throbbing with traffic fighting its way into the narrowing Streatham High Road). The services become part of the problem. They mean well, the people who work there, but it’s done in a way that, well you are made to feel uncooperative if you turn it down. And the political, social situation is not up for discussion – these are the things we really need to talk about if we are going to get better.”

“The problem with CBT is that it makes you the problem, and tries to change your attitude.”

“Debt. Struggling with debt leads to suicide.”

“I’m horrified, instead of funding mental health services in clinical settings, I had to wait six months for CBT – why not fund it more in places where people actually go to talk about their health?”

“My girlfriend is terrified, and has taken on the language of officialdom. She says that she is a ‘shirker’! She is terrified of psychiatrists, of the ways of the medical system. She feels like a terrible burden on everybody. She has been invited to go to job centres, I go with her, but she panics in waiting rooms, and she panics when she sees the security guards – it freaks her out. She was on DLA, and they said ‘would you like to work?’ and she said ‘Yes, I would like to work!’ and they said ‘we will help you to go to work’. So we went there together, I held her hand, she wanted to work, but her expectations were really unrealistic.”

“Its funny, they speak of parity don’t they, of parity between mental health and physical health. So, if you break your leg and can’t work, will they send you to the job centre to fix it?”

“It’s about dignity. My partner has worked, she has paid her National Insurance, she has contributed, but now she has taken on their vocabulary, she calls herself a burden…”

“Treatment should be voluntary. If the Job Centre should suggest that people go to the Doctor, well, are they qualified to tell people to go to the doctor? If I was working in a Job Centre I would be very uncomfortable raising it with people, because you have to be very diplomatic when you suggest to someone that they might need counselling. Even when your friend says so, you might feel offended! I mean, you have a personal relation with your job centre advisor when you are unemployed, you don’t want them prying into your personal life, do you? You have to be careful if you speak to someone about their mental health, it could be negligent to raise the question, it is a bit like the oppression we associate with Russia. When I was unemployed you had to sit in an open plan office every day for two weeks, and look for work. There were people who lectured you about looking for work. There were a lot of vulnerable there then. Imagine if you had to raise the question of mental health with someone who is clearly in distress and struggling. It could be negligent, are the people in the job centre qualified?”

“How dare they take food away from someone, it’s against Human Rights.”

“It is a symptom of our civilisation’s discontent, and therefore, worth punctuating. It might not be necessary, never mind possible, to remove it.”

By this time there were about 60 people gathered in the Memorial Gardens, and people were holding placards and banners and other people were taking photos. I asked one man what he planned to do with his photos. It turned out he was a freelance photographer commissioned by the South London Press to cover the demo.

Two women picked up the sticks to the Alliance for Counselling and Psychotherapy banner. They were sisters, and they had another sister with a learning difficulty. They told me that they were ‘watching’ and ‘listening’ to what was happening in the country with the politics, and one said ‘we have noticed that they go for the weakest first’.

Now we start slowly to muster together and walk across the road. A bloke rolled down his lorry’s window and shouted “get outta the fucking road, go get a fucking job”.

While we edge ourselves in amongst the traffic and move slowly up the main lanes of the road, I recognise someone from my early training days. “I used to be head of psychotherapy” he said, “and I would have been raising hell against a move like this made by the management”. "Who is the head of therapy now," I asked, “A CBT guy”, he replied with a wry smile. "And is he raising hell against this new policy?" I asked; a big grin and a loud laugh was all that I could make of the reply against the roar of the traffic and the shouts of the London drivers.

Someone next to me said that she was concerned about therapy being put next to the Job Centre function, because ‘it puts fear into people’s minds,’ then added, ‘which is not desirable’. ‘It is the very thing isn’t it, fear,’ she went on, ‘this is what CBT people try to resolve, isn’t it? yet the people who might need it most, would be the one’s most vulnerable to exactly this kind of fear’. The paradox had not escaped her, so how had it escaped our civil servants and government ministers, she wonders?

People with microphones are raising our spirits with their strong voices. There is a discreet police presence up the hill, and down the hill, and the security guards in the building are checking people’s ‘tickets’ before letting any one in. Too late! An advance guard from the protest has snuck into the building and is creeping up the stairs as we listen to the man with the mic doing his best to rouse the rabble. A few people take it in turns to move the crowd through the mic, and then a cheer goes up, and everyone moves to the other side of the street and looks up at the top floor of the building. A large red banner is unfurling in the wind with the words “Back To Work Therapy Is No Therapy At All”. It is now 2.30pm.

 @blacbanner collective politicalart.org

Someone with the microphone is haranguing Ian Duncan Smith, and talking about the suicides of people who have lost their benefit, and I remember Stevie Smith’s (no relation) wonderful poem ‘Not Waving, but Drowning’: Nobody heard him, the dead man, but still he lay moaning.

Nobody heard him? We can hear him because he is not yet fully dead, only half dead, still moaning. Threatened and pushed out of the symbolic order, off the benefits, deprived of a means to live with his dignity, turned into an object, treated as any old piece of rubbish, but not yet dead. Not yet.

In April 1953 Stevie Smith wrote her poem Not Waving but Drowning. On 1 July 1953 she self-harmed in the office and her doctor decreed that she is not emotionally stable enough to go back to work. She was retired with a small pension, and dedicated her life to writing and looking after her ailing aunt. In 1957, the publication of her collection under the heading Not Waving but Drowning established her firmly as a major poet worldwide and opened a new life for her of poetry readings and broadcasts. She soon became a cult poet and is sought after by the likes of John Betjeman, Philip Larkin and Sylvia Plath.

Should we, perhaps, rather put poetry into Job Centres, and save the CBT for somewhere more fitting?

Nobody heard him, the dead man,

But still he lay moaning:

I was much further out than you thought

And not waving but drowning.

Poor chap, he always loved larking

And now he's dead

It must have been too cold for him his heart gave way,

They said.

Oh, no no no, it was too cold always

(Still the dead one lay moaning)

I was much too far out all my life

And not waving but drowning.

The odd couple - Gay Rights and State Regulation of the 'psys'

An Odd Couple: Gay Rights and State Regulation
A bill – supported (on Twitter) by the British Psychoanalytic Council – proposing the regulation of counselling and psychotherapy by the Health Professions Council [1] is awaiting its second reading [2] in Parliament on 6 June 2014. However, no sitting is expected, nor is the bill (sponsored by Labour Co-op [3] MP Geraint Davies, Swansea West) expected to become law.

It is, however, expected to become a campaign issue, and indeed, it is already showing signs of gathering support. Those in the psy-therapy field who favour state regulation are hitching their wagons to it, the motor of which, you may be surprised to hear, is gay rights.

The bill proposes that Section 60 of the Health Act 1999 (Regulation of health care and associated professions) be amended to include a paragraph requiring that a code of ethics for registered counsellors, therapists and psychotherapists must include a prohibition on gay-to-straight conversion therapy. You can read the bill here – it is one page long.

Let’s look at some of the threads that hold this ‘object’ in place.

1. Davies claims that 16 per cent of therapists practise gay conversion therapy, and cites Bartlett, Smith & King (2009) [4] to support his claim. The quote from the article actually says: “Although only 55 (4%) of [1,406 surveyed] therapists reported that they would attempt to change a client’s sexual orientation [if asked] … 222 (17%) reported having assisted at least one client/patient to reduce or change his or her homosexual or lesbian feelings.”

The major organisations, including UKCP, have responded to this by banning reparative therapy, and making it “an ethical offence” to offer it “even if asked”. In practice this seems to relate only to work done by the Association of Christian Counsellors (who are not registered under the UKCP), which leaves the wider questions which are raised here apparently undiscussed.

2. The Society of Radiographers recently considered these issues with Davies and have gone on to adopt his ideas as policy. At their Annual Delegates Conference, 7-8 April 2014, they formulated their wish to campaign with the TUC to push for counselling and psychotherapy to be given to the HCPC in order to prevent practitioners from trying to convert gays to straights. “Conference notes that gay conversion therapy has recently been evidenced as an active practice within the UK psy-scene, with one in six psychiatrists, therapists and psycho-analysts admitting to having attempted to change at least one patient’s sexuality. This practice has no medical indication and is deeply rooted in the idea that homosexuality is a mental illness.” They go on:

“Psychotherapy in the UK is an unregulated practice, with practitioners free to practise out with professional bodies and their ethical statements.  With the majority of referrals coming from general practitioners, the Government is debating a Bill to regulate psychotherapy under the Health & Care Professions Council (HCPC).  However, Norman Lamb, Minister of State for Care and Support, has said that the Government has no plans to ban conversion therapy and believes that regulation of therapists is not appropriate due to the cost to registrants and taxpayers.” And finally, the Radiographers conclude: “As a regulated profession we call on the UK Council of the Society of Radiographers to: Support the Government Bill and make it clear they believe any health and social care profession should be under statutory regulation. Work with relevant gay charities, such as Stonewall and Gay Men’s Health, to ensure that vulnerable people are protected from this unregulated practice.”

This Motion was supported by the UK Council of Radiographers and passed by Conference earlier this year. In speaking for his motion, Ross McGhee quoted Freud’s letter to an American mother in 1935, which says: “Homosexuality … is nothing to be ashamed of, no vice, no degradation. It cannot be classified as an illness; …. Many highly respectable individuals of ancient and modern times have been homosexuals, several of the greatest men among them (Plato, Michelangelo, Leonardo da Vinci, etc.). It is a great injustice to persecute homosexuality as a crime, and cruelty, too.” [5] McGhee wants to know why such enlightened opinion seems not to be figuring in the current debate.

3. Another supporter of the bill is journalist Patrick Strudwick who came to prominence in February 2010 with his article in The Independent newspaper reporting his undercover assignment to ask a Christian BACP counsellor (subsequently struck off as a result of this article) to help him to “pray away the gay”. On 24 February this year, Strudwick penned another article, this time for the Guardiansupporting Davies’ bill, and concluding that: “If the government votes against this bill on Friday [6], as they have suggested they will, they will be failing every Briton – not only the one in four of us who will suffer mental ill health but everyone affected by it. They will leave you, your child, your partner, or anyone reaching out, vulnerable, scared, to quell their distress, at the mercy of the untrained, the unqualified and the unethical. This is not simply a scandal; it is an emergency.” UKCP Chief Executive David Pink wrote to the Guardian, rebutting Strudwick’s article and suggesting that the public were more at risk of harm from such simple assumptions and misleading reporting.

4. Leo Abse, famously flamboyant lawyer and former Labour MP for Pontypool (and then Torfaen) from 1958 until 1987, pioneered a private member’s bill to decriminalise homosexuality. Abse’s bill was eventually passed on 28 July 1967. This important private member’s bill is apparently being prepared for spinning by the Labour Party [7] as one of its great contributions to this country, rather than the result of the personal struggle of one of its backbenchers. You can listen to a BBC interview with Leo Abse, broadcast on 20 December 1966, here.

5. The Law Commission published its report (following the consultation on the regulation of health and social care) on 2 April this year. The 465-page document can be consulted here, and you can find its analysis of issues around ‘voluntary registers’ from paragraph 5.24 on page 60, and its “Recommendation 28: The [existing] regulators’ powers to keep voluntary registers should be removed”. This means that regulators like HCPC could not also hold a voluntary register.

6. The attempt by the then HPC to capture counselling and psychotherapy was squashed by the Judicial Review hearing at the Royal Courts of Justice, 10 December 2010. Dinah Rose QC maintained that the HPC had unlawfully failed to address critical questions about whether counselling and psychotherapy should be regulated by statute, and whether the HPC is the appropriate body to administer such regulation, given the fact that many practitioners explicitly eschew a ‘medical-model’ orientation.

Despite the HPC’s attempt to have the application ‘timed out’, Mr Justice Burton also ruled that the Judicial Review had been brought without delay and was ‘clearly arguable’. Furthermore, he criticised the misleading nature of HPC statements. For example, practitioner groups had been led to believe that the HPC would fulfil its legal responsibility to report to the Department of Health on whether it had the requisite capability to regulate the field. This never happened, and the HPC proceeded as if the requirement to report on the matter did not exist, despite acknowledging it in an early-minuted meeting. Specifically, the judge questioned the HPC’s reassuring communication to the DH in December 2009 that it had completed its exercise and was ready to accommodate the talking therapies. He invited the HPC to “reword or revise” that letter. This never happened, and the HPC’s embarrassment was allowed to fade away when the new government changed the name to HCPC, gave it the social workers to register, and told it to drop its hope of capturing counselling and psychotherapy.

The questions now are whether enlightened opinion is still against state (HCPC) regulation, whether the new voluntary regulatory mechanisms under the Professional Standards Authority (put in place by the major bodies during the last few years – BACP, UCKP etc.) are widely understood and in good use, or whether the turmoil of the 21st century has left practitioners and public without the necessary bearings to think through these difficult issues.

For anyone who would prefer not to be defeated by rhetoric, babble, confusion and the wild commands of the super-ego, please do join the debate.

Since writing this post, I have editing an edition of the Psychoanalytical Notebooks (Issue 29) to bring some more detailed accounts of how psychoanalysts in the Lacanian Orientation respond to questions of sexual identity. Here is the link in case you want to follow it up. [Image by VD-collective].

@Alliance4CP

info@allianceforcandp.org

http://www.allianceforcandp.org/

Soundings, a research report for the contemporary context of psy-praxis, is written by Janet Haney, who would like to thank colleagues for their part in supplying ideas, references, information and edits. All websites were sourced: 9-11 May 2014.

[1] The Bill cites the Health Professions Council, even though this institution has recently been renamed the Health & Care Professions Council in order to take the social workers on to its register.

[2] The ‘second reading’ is the moment for the first proper debate; the ‘first reading’ is a formality to read the title of the proposed bill into the records.

[3] The British Co-operative movement stretches back to 1844 when the Rochdale pioneers invented consumer co-operatives as a response to ‘the invisible hand’ of capitalism which was funnelling profits to a few, and leaving many to struggle.

[4] Bartlett, A., G. Smith & M. King, “The response of mental health professionals to clients seeking help to change or redirect same-sex sexual orientation”, BMC Psychiatry 2009, 9:11 

[5] Freud, Sigmund, “Letter to an American mother”, American Journal of Psychiatry, 107, 1951: p. 787.

[6] In fact this ‘first reading’ in Parliament is a formality to read the title of the Bill into the records.

[7] On-line survey taken by the author this month.

13 May 2014

The Woman that does not exist and the subtle trap of rivalry

Michelle Goldberg’s careful and interesting New Yorker article What is a Woman? (August 4, 2014), collects together and traces the developments of the radical feminist argument from the early 1970s through to today. She shows how the increasing participation of transsexuals, or transgendered people, in the feminist movements have brought to light a problem in the underlying logic that increasingly leads to trouble – something that is experienced by the radfems as ‘a baffling political inversion’.

The logic of the 'radfem' problem is stripped down to show itself as follows: if you have the bad luck to be born with a body like this (female), then society will force you into the position of a serf, a secondary, an inferior: so, unite and fight for freedom. If you are lucky enough to be born with a body like that (male), then you are privileged, whether you like it or not: prepare to eat dust (ie we shall attack you for your privilege). Members of the 'radfem' group have imagined that they are on the trail of a kind of racism, that their position is righteous ipso fact. They are, therefore, very surprised when they find themselves caught up in the position of the oppressor and the subject of as much hatred in return. This is what happens when trans people show up and want to identify as women.

Goldberg’s thoughtful article helps to show how the logic slips along an unstable dichotomy which leads to oscillation and conflict – participants have unwittingly stepped onto the imaginary plane (see Lacan, especially his early work) of a––a’. Even though many of today’s feminists would want to argue for a more sophisticated or ironic understanding (see for example Lucy Mangan’s humorous 'weekend column' in the Guardian, August 2014), the underlying logic of the argument goes on reproducing itself. 

Only a couple of years ago in the UK the storm blew up when journalist Julie Birchill jumped in to defend her friend Suzanne Moore from ‘a bunch of dicks in chicks clothing’ and found herself attacked in return. Moore had bemoaned the fact that she could never be as gorgeous as a ‘Brazilian Transsexual’, and was surprised to find herself the target of a twitter attack from the trans movement and its supporters. The logic that underpins these positions swings back and forth between oppressor and oppressed, bodies like this, and bodies like that: and as Lacan predicted, hatred and rivalry prove themselves very difficult to avoid.

The argument is replaying itself again now, as Caitlyn Jenner appears on the cover of Vanity Fair, and once more begs the question, is being a woman simply a matter of perfecting a body image, or manufacturing/relying on a certain kind of genital. For some decades now, we have had the possibility to think about the problem in three registers - symbolic, imaginary, and real. Feminity might better be thought as a subjective position, or perhaps, a work of art. For each, it is a question of how to bring 'woman' or feminity to life when there is no pre-written programme to inform you in your nature.

4 Sep 2014

Like an Open Sky

This review was first published in the Psychoanalytical Notebooks No. 28 on The Child, by the London Society of the New Lacanian School.

We screened this film at a community space in south London in March – it was the first public screening in the UK, and, at the time it seemed likely that it could also be the last public screening because no UK distributor had stepped up to buy the rights.

It was a Saturday night, fifty people came, and another ten people were there as volunteers: preparing the space, running the box office, serving at the bar, or managing the ambiance and the technology. Most people stayed for a discussion after the film. 

As I waited for the room to fill up, and the show time to approach, I prepared a few lines in order to introduce the film. I remembered another film, made for TV, and shown in 2011. I'm sure you will remember it. It made a big splash in the news, and resulted in jail sentences for several of the staff that had been filmed. It was the Panorama 'secret camera' exposé of the tragedy that was unfolding at Winterbourne View care home in Bristol. Could there be two more different films about such similar work? 

Like An Open Sky is a two hour documentary in which everyone speaks French (of course, there are subtitles). The film maker, Mariana Otero, spent a year at Le Courtil, an institution that is to be found on the border between Belgium and France, before strapping on her camera and making her film. This period of preparation pays off as the staff and children in the film are clearly at ease in front of the camera, and some of the children can be seen actively making use of the camera as part of their experience of care.

But even before that, Mariana had spent a long time visiting institutions looking for a place to make her film. She said that she wanted to make a film about people who are 'offbeat, out of phase, people who have a radically different relationship with the world, with language, and with their bodies'. These children might more typically be called 'mentally handicapped', 'children with learning difficulties', 'mad' or even, as in the Panorama documentary, 'dangerous, disturbed, and challenging patients'. Mariana stopped her search when she found Le Courtil, an institution that was established 30 years ago, and which she had never heard of before. There was something different going on here, and she wanted to stay and to know more. 

Le Courtil got off the ground by offering to accept any child into its care that other institutions had given up trying to help. A second, and vital part of the deal was that the child would have to actually ask to come in. Is this not a contradiction? someone asked at our discussion after the screening. If the children have been 'expelled' from the other places, would they ask to come to this one? It is something that is managed by the process of induction, which can go on over a period of time. For example, I heard an anecdote from Alexandre Stevens (the founder and long time director of Le Courtil), when he came to London in January this year. Alexandre spoke of a boy who could not stop hitting people who came within his reach. When asked about this, he had replied, it is not me who hits, but my left arm. It was explained to him that he wouldn't be able to remain at Le Courtil unless he could find a solution to this problem, and he went back home for a period of time. Soon, however, he contacted Le Courtil, and asked if he could come back in. Have you found a solution to the hitting? they asked him, "yes", he replied, "what have you come up with" they demanded, "I have discovered that I can use my right arm to prevent my left arm from hitting people" he said. And in this way he was welcomed to enter Le Courtil, and to continue on his journey of invention.

Invention from day to day is the motto of the institution, and this goes for the staff as much as the children. What the film shows is the adults and the children trying to find different ways to allow the child to find their own solutions to the difficulties they face. The camera follows four children in particular amongst several others who make up the backdrop. One of these is Alyson, a teenage girl who is, amongst other things, struggling to fend off the urge to touch her genitals. We see her at several different moments in the film: in the kitchen, cooking; in the garden, scraping at the ground and finding things that are buried; in the 'lets pretend' workshop; or in her bedroom explaining to Marie, the worker, why she is worried about being a bridesmaid at a forthcoming family wedding. When Paul (another worker) is around, Alyson's speech seems to become more sexualised and she appears to swing between childish pleasure at saying these words and a kind of perplexed, perhaps fearful expression that haunts her in the quiet moments afterwards. In our discussion after the film one of the audience members ventured to ask whether this sexualised behaviour and speech belied a sexual abuse from the family. A second audience member, herself a therapist, said that she would have a duty to follow up on the suspicion with the family in case there had been an abuse.

This aspect of suspicion and the duty to seek out a possible crime is completely absent from the film, yet nowhere is negligence in evidence. Alyson is accompanied as she struggles to work out how to deal with her body and with sexuality, and with the compulsion to say these words and to touch herself. No-one makes a fuss about it, or draws attention to it, and no-one turns it into a joke or worse, into a family tragedy, but the various different routines and patterns of daily life continue in which Alyson, together with the various workers, learns to find ways to come to terms with her experiences and the business of becoming a woman.

We see only a aspect of the work at Le Courtil in this film, and only a small segment of the institution. There are many other children in other places, and places where parents are also welcomed to come with their concerns and their difficulties, what is absent is a sense that the institution is making use of any of the people that we see. It is an institution that remains dedicated to supporting the work that is done. 

Don't they have targets to meet? Asked another audience member at our south London screening. Perhaps they do, but what is clear from the film, is that the staff make sure that these demands don't interfere with the course of their work. In the little book* that was written by the film-maker after the film had been released I found a short comment from the current director of Le Courtil. Sometimes, he says, we are asked to tick boxes and make lists, and if the insistence is strong, we do it. Then we put the list in the filing cabinet, and forget about it.

This aspect of institutional work – the bureaucracy, the regulation, the governance, the administrative overview – was conspicuous by its absence. What the film showed us was a group of people who are focused and enthusiastic about their work. At one point, the camera follows a staff member into the office on the night shift, and we hear Mariana's voice asking about the theory that supports the work. In his reply, the staff explains why they are careful not to make demands on the children, why they don't have one staff member become key for any child, and why they are careful to show themselves as being submitted to a big Other and so avoid becoming too powerful in relation to any particular child. From here you can begin to grasp the ideas that allow this institution to operate with care and actively protect the work space thus preventing the children from becoming objects of enjoyment of the big Other of theory, of bureaucracy, or of any particular person who might fancy himself as The One.  

Why is this film not getting shown in the UK? It deserves to be watched, and we deserve to watch it. Enough already with the disasters and the sensational documentaries, the tragedies and the abuses, lets get interested in something that actually makes things better.

If you want to arrange a public screening for a group that you are connected with, then please email Hannah Horner at Doc&Film. If you want to buy a copy of the DVD for private view, then go to Blaqout, if you want to read the book that accompanies the film, you can buy it at Karnac Books, and if you want to watch the trailer, it is here on youtube. More information about this movie is in English here, also.

* Like an Open Sky, Interviews. Le Courtil, Invention from day to day. By Mariana Otero and Marie Brémond, translated by A. R. Price, and published by Buddy Movies, Paris 2014.