Monday, 8 May 2017

Hate thy Neighbour – a contribution from Roger Litten

As part of the PIPOL activity, people in various countries and cities have rallied to the call to mobilise against the possibility of Marine Le Pen as president in France by writing. Today, of course, we know the result of the election, but even yesterday we were still waiting to hear whether France had followed the trend of UK and USA in lurching to the right. It is not the end of the struggle, of course, but at least there is more time to organise, speak out, write, and combat the waves of ignorance, fear and hate that continue to lap at the door.








Hate Thy Neighbour
Roger Litten
first published on PIPOL 8 site – 21 April 2017



The rise of the National Front in France and the entry of the discourse of the far right into mainstream politics is something that should concern us all.
We should not allow ourselves to be deceived by Marine Le Pen´s attempts to present the friendly face of fascism, going so far as to purge her own father from the party.
We psychoanalysts above all should be aware that the elimination of the father serves as a fundamental pivot for the transmission of a culture. But just what kind of culture is being promised to us here?
Have we forgotten that almost half a century ago Lacan was already situating the problematic of segregation as “the mark, the scar, left by the father´s disappearance”?[1] How then are we to ensure that we do not find ourselves sliding from the father to worse?
Recent events in America, England and other countries across Europe show that there is no room for complacency here. Although the circumstances may differ in various countries, what we are witnessing is a combination of populism, nationalism and xenophobia becoming the new norm of political discourse.
The result of the Brexit referendum provides ample evidence of the attraction of the appeal to nationalist and populist sentiments, the reactionary nostalgia for symbols of national sovereignty and tradition in a country that has still not come to terms with the decline of its once proud empire and its diminished place in the world.
But we should not overlook the key role played in the outcome of that referendum of an almost visceral response of repudiation and rejection, an overwhelming sense of fear and helplessness in the face of the unfolding refugee crisis in Europe, the prospect of a wave of undifferentiated immigration coming out of Syria and other areas of political and social breakdown in Africa and the Middle East.
The same island geography that underpinned the rise of Britain´s Empire off the back of naval power facilitates the seductive idea of shutting down our borders, cutting ourselves off from mainland Europe, turning our backs of the challenges of social, political and economic integration that it represents, and taking refuge in diffuse and ill-defined notions of national identity.
The vacuity of perhaps the most effective slogan of the Brexit campaign - “Take back control” - allowed it to stand proxy for the question of immigration. In response to Angela Merkel´s open hearted but politically naïve reaffirmation of the “open borders” policy of the European Union, the promise of being able to take back control of our national borders was able to over-ride any appeals to economic self-interest.
Amongst other concerns in the wake of the referendum there is one issue that has perhaps not received the media coverage that it warrants. This is the alarming rise in so-called “hate crimes” (in some areas up 100%)[2] since the referendum, a proliferation of attacks on foreigners, immigrants, minorities, anyone bearing a perceived trace of difference.
It is here that we perceive most clearly the disjunction between the empty rhetoric of national sovereignty and the cold reality of daily attacks in the street, serving as the outlet for a mindless violence, brutality and hatred that has been given new legitimacy by the outcome of the referendum.
What then can we contribute on these matters, especially those of us who look on with concern but have no direct part to play in the forthcoming French elections? The fact that we have no vote in this matter does not mean that we have nothing to say.
In the first instance, each one of us, as subjects and citizens, can be as articulate as possible about where we stand on these matters. But in our capacity as psychoanalysts we can seek to go beyond simple condemnation and moral outrage, attempting to account for something of the perverse attraction of the positions we condemn, the emotional logic that makes each one of us vulnerable, to one degree or another, to the seductive whispers of hatred and intolerance.
If nothing else, our experience as analysands can teach us something about the status of the subject, which as Jacques-Alain Miller long ago taught us, is by definition an immigrant, born of the signifiers of the Other, alienated from the country of its birth, and always to some extent an exile, a refugee from a jouissance to which we are never quite reconciled and about which we ultimately wish to know nothing.
But it is above all our experience of occupying the position of object in the clinic, incarnating the position of reject, refuse of discourse and of jouissance, that provides a unique platform for reading the co-ordinates of the libidinal logic at play in current political developments.
It is on this basis that already in the 1920s Freud was reading the rise of populism in Europe in the aftermath of the First World War. His great text from 1921, Group Psychology and the Analysis of the Ego, devoted to the logic of mass phenomena, remains today one of our fundamental references.
In this text Freud explores the libidinal and emotional factors at play in the formation of groups in the light of the psychic mechanisms of hypnosis and suggestion. His examination of the role of the leader in the formation of the group allowed him to situate the question of identification at the heart of group formations.
He demonstrated that it is the identification with the leader, not just as bearer of the insignias of prestige and the promise of an equal love for all, but also as standing in the place of the murdered father of the primal horde, that is the pivot for the horizontal identifications between members that make up the cohesion of any group.
Situating the leader in his or her position as substitute for the dead father allowed Freud to consider the other factors that can take the place of the leader in carrying out the same function as point of reference for the unifying tendencies of the group, asking whether “a common tendency, a wish in which a number of people can have a share, may not in the same way serve as a substitute”.
Crucially, Freud even highlighted here that a negative tendency of repulsion, rejection or hatred can play just the same unifying role in group formation as one of positive attraction. “The leader or the leading idea might also (…) be negative; hatred against a particular person or institution might operate in just the same unifying way, and might call up the same kind of emotional ties as positive attachment.”[3]
The Freudian problematic of the articulation between vertical and horizontal identifications in the group continues to provide us with a minimal but flexible framework for examining the interaction between nationalism and populism in contemporary politics. One of the more pressing issues today then becomes that of exploring the hybrid mutations of the articulation between these two axes in the era of accelerated decline of patriarchal authority and legitimacy.
Once again it is the work of Lacan that provides us with the most reliable guide in addressing these questions. His linguistic formalization of the Freudian Oedipus Complex allowed him to reduce the question of identification with the leader to the logic of subjective identifications with the master signifier. At the same time his conceptualisation of the object a as residue of jouissance not reducible to the signifier, allowed him to locate more precisely the disturbing element at the heart of subjective identity and at the root of what Freud had called the discontents of civilization.
It is the articulation between the master signifier and the object a that provides us with the framework for exploring the effects of segregation that we witness increasingly as the inexorable counterpart to the contemporary politics of identification. The more conditions of group coherence are indexed on appeals to national identity, the more aggravated are the corollary tendencies towards the elimination of disruptive residues and any heterogeneous traces of difference.
It is this logic that enables us to grasp the degree to which the cremation of the Jews (Papa Le Pen´s “detail of history”) was in fact an integral corollary of the quest for Aryan purity and adherence to symbols of national identity.
It was above all in the decade following his expulsion from the IPA, finding himself the object of excommunication by the discourse of orthodoxy, that Lacan continued to refine and question the status of object a and the logic of segregation that it entails[4]. His charting of the rise of the object to the social zenith in place of the master signifier allowed him to expose the converse logic that promised the rise of ever more extreme forms of segregation played out in the real, as predicted in his words from the Proposition of 1967:
“Let me summarise by saying that what we have seen emerge from this, to our horror, represents the reaction of precursors in relation to what will unfold as a consequence of the rearranging of social groupings by science and, notably, of the universalisation science introduces into them. Our future as common markets will be balanced by an increasingly hard-line extension of the process of segregation.”
According to this revised logic, xenophobia, racism and segregation are not simply secondary byproducts of the mechanisms at play in globalization and national unification. Rather the later Lacan was able to demonstrate that signifying identifications are in fact predicated on a primary act of rejection of an inassimilable jouissance at the level of the drive.
This is the logic that is elaborated by Eric Laurent in his indispensible text entitled Racism 2.0.[5] “The founding crime is not the murder of the father but the will to murder he who embodies the jouissance that I reject.” Identification with the signifier fails to resolve the question of jouissance not simply because the signifier never entirely covers the field of jouissance, always leaving an inassimilable and destabilizing residue, but more profoundly because of a fundamental and irremediable disjunction at the heart of the articulation between signifier and jouissance.
The fragility and instability of identifications, whether at the subjective or national level, are thus indexed on a fundamental void in the knowledge of jouissance that inhabits us, “a fundamental not-knowing with respect to the jouissance that would correspond to identification.” Because “we have no knowledge of the jouissance from which we might take our orientation”, and because we can no longer rely on the symbolic co-ordinates of the Other to provide our reference, “we only know how to reject the jouissance of others”.
Eric Laurent traces out the consequences of this logic of segregative identifications founded not simply on a rejection of jouissance but also and more problematically on a complementary denial of human identity to the one whose jouissance I reject. “He who I reject for having a jouissance distinct from mine is not a man.”
It is clear that this logic opens the door to all kinds of barbarities, perpetrated precisely in the name of national identity, against those who come to embody the jouissance that I reject in myself. It also exposes the vacuity of all the secondary rationalizations invoked to justify our discrimination as well as the fundamental duplicity of the identifications built upon this rejection. “The malicious jouissance at stake in racist discourse is the failure to recognize this logic.”
To conclude we can perhaps return to another key reference on these questions, the session devoted to racism in Jacques-Alain Miller´s course from 1985-86 on Extimacy, recently published in The Lacanian Review under the title “Extimate Enemies”[6]. In this text, Jacques-Alain Miller explains why recourse to liberal ideals of universal humanism fails to resolve the issues at stake in racism and segregation:
“This humanism becomes completely disoriented when the real of the Other manifests itself.” Appeals to the rights of man or a sense of our common humanity fail to resolve the question “because the universal mode (…) encounters its limits in the strictly particular. It encounters its limits in what is neither universal nor universalisable, in what we call with Lacan the mode of jouissance.”
It is here that Miller situates the “remainder that one could call the obscure causes of racism, against which indignation is perhaps not enough”. He then goes on to indicate the questions that arise at this point, the consequences of which we are still exploring at a theoretical, social and political level:
“Putting the hatred of the Other in question is not sufficient, since this would precisely raise the question of knowing why this Other is Other. (…) The hatred of the Other is something more than aggressiveness. In this aggressiveness there is a constant that merits the name of hatred, the hatred that aims at the real in the Other. (…) What is it that makes this Other so Other that one can hate it in its very being? It is the hatred of the jouissance of the Other. This is the most general form of modern racism that we witness. It is the hatred of the particular way in which the Other enjoys. (…)
“You are willing to recognize your neighbour as Other as long as he does not live next door to you. You are willing to love your neighbour as yourself, but above all when he is at a distance, separated from you. When this Other gets a bit closer, one has to be an optimist (…) to believe that this produces an effect of solidarity, to believe that this leads straight away to mutual recognition. (…) When the Other gets a little too close, new fantasies appear that are especially concerned with the excess of the jouissance in the Other. (…)
“The essence of the matter is that the Other is unfairly subtracting from you a certain part of your jouissance. That is the constant. The question of tolerance or intolerance (…) has to be situated at another level, which is that of the tolerance or intolerance of the jouissance of the Other – of that Other inasmuch as this Other is fundamentally the one who is robbing me of my jouissance.
“For our part, we know that the fundamental status of the object is to have always been stolen by the Other. We write this theft of jouissance minus phi, the matheme of castration. If the problem appears unsolvable, it is because the Other is Other in my interior. The root of racism is the hatred of one´s own jouissance. There is no other – if the Other is in my interior in a position of extimacy, it is also hatred of myself.”
Here we find ourselves at the heart of the logic that drives the discourse of hatred and segregation. It is up to each one of us, one by one, to grasp the way this logic plays itself out in our own experience and to trace out its consequences for an ethics and a politics based in a reading of the logic at stake in contemporary events and the future that is being promised to us.





[1] Lacan, J., “Note on the Father”, The Lacanian Review, No. 3, 2017.
[2] Sharman, J., and Jones, I., “Hate crimes rise by 100%”, The Independent, 15th February, 2017.
[3] Freud, S., “Group Psychology and the Analysis of the Ego”, Standard Edition, 18. (1921)
[4] Cf., Lacan, J., The Seminar Book XI, The Four Fundamental Concepts of Psychoanalysis, (Chs. 1 and 25); “Proposition of 9 October 1967”, in Analysis, No. 6, 1995; “Address on Child Psychosis”, Hurly-Burly, No. 8, 2012; “Preface” to Lemaire, A., Jacques Lacan, Routledge, 1977; “Television”, Television/A Challenge to the Psychoanalytical Establishment, Norton, 1990.
[5] Laurent, E., “LQ in English: Racism 2.0”, available online: http://ampblog2006.blogspot.com.es
[6] Miller, J.-A., “Extimate Enemies”, The Lacanian Review, No. 3, 2017.

Sunday, 7 May 2017

Getting Real: EuroFederation of Psychoanalysis at PIPOL 8, Brussels, July 2017

Since last autumn (2016), as part of a team across Europe, I have been helping to prepare short texts in readiness for a meeting in Brussels in July. These meetings happen every two years and present a mixture of practical work (based on the work we do with people who come to consult us as psychoanalysts – that is, people who are suffering in some way, and who want to know something about why things go wrong), and also work which aims to interpret and intervene in the current social dimensions of our fast-changing world. 

This regular work of editing, translating and writing little bits with my colleagues helps me to get to know them, their work, the literature, and something about the countries where they live and work, and vice versa. This creates a great opportunity to get a fresh perspective on what would otherwise be too familiar. I can make use of my colleagues abroad to see my own situation via their points of view. 

By publishing some of this work here on this blog I hope to open up this work to other people who might not come across it otherwise. Some of you might be interested enough to go to the main website of the PIPOL 8 Congress. Who knows, you may even come to Brussels for PIPOL 8. 

In this first piece Brussels-based psychoanalyst Patricia Bosquin-Caroz  gives a quick introduction and invites you into the theme (translated by my colleague Raphael, from the Dublin-based group, ICLO).  The second paragraph (translated by me and John) kicks off with a reference to Ken Loach's latest film (I, Daniel Blake). This film, as I think you will know, demonstrates the problem rather well. The bureaucratic machinery of the modern state presents a formidable obstacle to real human beings, or 'speaking beings' (parlêtres – a new word invented by Lacan by bring two other words together, parle and être) as we say.  Loach describes the highly machine like way that the 'government + business agency' operates and how this results in a double disguise to the cynical strategy of deterring people from claiming rather than facing up to the truth and doing something about it.

If, like me, you are looking for ways to resist this transformation of modern life into a grinding and thoughtless machine that mashes up truth and produces ever more lies, then you could do a lot worse than read a few short articles that are being produced outside of this machinery, that is, outside of all norms. I'll be posting a few more pieces every week leading up to the meeting in July, and interspersing them with other pieces that relate more directly to the UK. 

Janet Haney, practising analyst member of the New Lacanian School, and representative for London for the EuroFederation of Psychoanalysis



My Way n°1


My Way, the Newsletter of PIPOL 8, follow us - Patricia Bosquin-Caroz

On the 1st and 2nd of July 2017, PIPOL 8, the 4th Congress of the EuroFederation of Psychoanalysis, will take place in the heart of the capital of the institutions of Europe: Brussels. Its theme, “A Non-Standard Clinical Practice”, is one which is in-phase with the era of the push to the generalised norm, not by way of promoting this, but to make a hole it. Currently in Belgium and France, and tomorrow throughout Europe, the bureaucracy of the health services imposes its standardised managerial logic onto the field of mental health; this imposition is founded on a single norm: Evidenced Based Practice. The aim of the Congress, as well as the preparation towards it, is intended to be both political and clinical. It seeks to assert the dimension of the symptom which is outside the norm and which runs counter to the modern ideal of the normal man. It will demonstrate how psychoanalytic practice, in its orientation within the various institutions of the medico-psychosocial field, forges a place for the invention, uniqueness, singularity and incomparability of each one. Not without the dimension of the transference, the only institution at stake in the analytic experience. Each week, My Way will speak to you about norms and that which is with-out norm [hors-les-normes]. In each issue you will find no more than four or five concise texts, along with photos and videos etc. These will be progressively rolled out and arranged under the various rubrics of the blog: Contemporary Erotica - Child and Adolescent - Autism - European Politics - The Normal Delinquent - A Practice of the Body – Parenting – Segregation - etc. There are sixteen in total, the content of which will originate from colleagues throughout the many regions of the EuroFederation. All the articles will be available on the blog, which you can visit at www.pipol8.eu.

Check-in each week for the work in progress towards PIPOL 8!
Patricia Bosquin-Caroz, Director of the 4th Congress of the EuroFederation.
Translated by Raphael Montague


My Way 1, by Céline Aulit (9 November 2016)

Ken Loach’s latest film hit the screens a few days ago. This time the director, who specialises in portraying those forgotten by the system, depicts, with a certain sarcasm, the contemporary absurdity that bars the way of the singularity of the subject – something that ultimately profits the protocols of health care and the classifications in the DSM. This is the ground that Valérie Pera-Guillot covers in this first issue of the Blog. The emergence of the singularity is, as Annaëlle Lebovits-Quenehen nicely sums up, precisely what the analytic discourse aims at. Singularity is our bastion of resistance! The more the subject is smoothed out and has his or her jouissance eradicated, the more that jouissance makes itself heard. Neus Carbonell underlines this in the context of the clinic of autism. The Pipol 8 Blog is now in business, and in it you’ll find snappy, sparkling testimonies, little nuggets of outside-the-norm, which, at the invitation of Philippe Hellebois, evoke the ambiguity of language, itself a powerful argument against the discourse of the master.

Translated by Janet Haney and John Haney

Wednesday, 29 July 2015

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.)