Saturday, 19 March 2022

diagnostic function


In a recent episode of The Life Scientific, the guest - psychologist Julia Shaw (who researches false memories, forensic psychology, and bisexuality) - talks about coming to understand that her father was schizophrenic. She'd been home-schooled by him and, when she was 14, she realised that, whilst she 'didn't have a word for it', for him all was not well. After 9/11, for example, he spoke only to her; he was clearly out drinking too much in the day; he'd come home drunk from the bar and they'd watch Mortal Kombat through and through, or do a lot of sparring. ... And then later, in one of her first clinical psychology lessons, she learns about the 'paranoid schizophrenia' diagnosis: "Oh my God", she thinks, "that's my dad! It sort of put a construct to all of his behaviour and a lot of the experiences I had growing up."

Psychologists and psychiatrists of a so-called 'critical' bent have often challenged the value of such seemingly 'baggy' constructs as make up diagnostic systems. Now - and in what follows I set aside the value of diagnoses to the diagnosed individuals themselves - Shaw herself clearly found it very useful. I don't here intend to question this utility. What I want to ask is instead what the utility consists in. For I think it too easy to quickly assume that the value consists only in possession of a new label to describe what's going on. And for 'critical' psychs to then take issue with the rather magical-seeming notion that coming into possession of a mere word can provide substantive knowledge of anything more than semantics. (Thus Shaw eagerly takes up Al-Khalili's suggestion that the illumination came because "nobody had labelled" his paranoid behaviour 'schizophrenia' before.) The question of diagnostic utility then too quickly gets corralled both into a general discussion of the benefits and disbenefits of constructs in our lives - for example, do they organise our experience in useful ways - and also into a more specific discussion of whether the principles governing one particular organisation, one particular construct (one diagnosis, that is), are reliable and valid, or are instead arbitrary, haphazard, and pseudoscientific.

George Kelly
What occurred to me, though, as Shaw was speaking, was that the value of knowing one's father to be schizophrenic may consist more in the clarity that arrives in truly knowing someone for mad. Not just mad in a loose way, either; not just 'mad' in a way which could be taken for a metaphor or a slur. But rather, mad in this, rather than that, way. It is not me; it is not the situation; it is not just another way of being human; not one way of making sense rather than another. It is instead my dad: there's something wrong with him; he's lost his reason. He's been quietly, and sometimes not so quietly, insane all these years. That this insanity has a particular form - it is schizophrenic rather than melancholic or obsessional, say - is of note here, I want to suggest, not simply because it offers some sense-making relief through the 'organisation' of one's previously disparate experience. (This constructivist trope of sense-making as organising is so central to so much psychology, from Kelly onwards that it can boggle psychologists' heads if you suggest we'd actually do better to adopt a rather more Aristotelian, rather less Kantian, anthropology.) For what matters here is, I suggest, not so much any particular organisation but rather (what I call) allocation. The diagnosis, first and foremost, enables not the provision of a 'subjective' organisation, but the recognition of an objective fact: that my dad's not in his right mind. Relational disturbances are now allocated to their proper source: they're not primarily a function of myself; they're not an irreducible function of the relationship itself; they're not a matter of the form of a particular social context; instead they're properly said to be of my father. And the provision of this, rather than that, diagnostic category - I suggest - may serve the function not primarily of further finessing the general diagnosis of insanity. Instead it validates it; it subserves it. 

An analogy may be helpful. We're struggling in one of our relationships, and come to realise that the problem lies not within ourself, nor within a systemic property of the relationship, but instead in our friend or colleague. They are, we come to realise, vicious (i.e. vice-ridden). 'Why do you say that?' your spouse says. What makes it apt to say they're being a git, and what makes it apt to say they're being a git? And now you offer the judgement that they suffer a particular form of gititude: they're always drawing attention to the faults of others whilst boasting of their own successes. This can be important to note in its own right, of course. (By analogy: think of the different treatment implications that can sometimes follow from psychiatric diagnosis.) But what may be rather more helpful, from the provision of this more fine-grained judgement of gititude, is the warrant it provides for your taking your moral attitude of condemnation to your friend or colleague. If you want to ratify your allocation of someone to a genus, then showing how they meet the mark of belonging to a particular species within that genus will tend to do it. 

To return now from morals to madness: the value of knowing one's father for schizophrenic may, I suggest, lie rather less in now knowing what treatment is indicated, or in understanding that he's one amongst others who have somewhat similar difficulties. Instead it may lie rather more in securely knowing that adopting a moral or relational approach is here inapt since he's not in his right mind. The dangers of such an allocation should be clear: that now every troubling thought or feeling or action of his is now chalked up to his insanity rather than to his situation or to oneself. But the possibility of abusing psychiatric judgement in this way is hardly grounds for avoiding it - any more than we do well to avoid moral judgement just because it may wrongly be used when instead psychiatric judgement would be more apt. Knowing him to be deeply, ongoingly, rationally awry in the way he experiences and responds to the world helps one get one's bearings, to know what's what. And we aren't forced to think of this as the provision from within ourselves, from within our language, of a scheme which we as it were 'impose' on our 'raw' experience of him. Leave those tired constructivist metaphors aside for a moment, and think instead on what it is to acknowledge morally or psychiatrically objective situations, rather than to construe some allegedly non-intrinsically psychiatric or moral situation a particular way. It's not that we're now making sense of him, if you like, but that we've now recognised what's what. Dad is mentally unwell. His behaviour isn't some version of normal of which I should be struggling harder to make sense. It's something which of its nature is not rationally intelligible. In this way he's a patient, not a rational agent. For this reason the social contract must be renegotiated. Losses must be mourned. But the relief of saying 'I shan't keep trying to play with someone who's breaking the rules', as it were - (and the 'as it were' is important unless we're to drift into unholy Szaszian libertarianism) - is palpable. I shall no longer bang my head against the cliff face of his unreason. I will no longer always try to reach shared understanding with him. There he goes - my poor dad. But here I am, freed now from the impossible obligation of, as it were, living within an impossible home. I can now carry on rationally - since I can now recognise that: he cannot.