Robert M. Young Online Writings
THE CONCEPT OF PSYCHOPATHOLOGY: A CRITIQUE
This is the first chapter of a book which will concist of five chapters exploring the concept of psychopathology.. At the risk of trying your patience, I'm spending this first chapter entirely on the term and concept. of psychopathology — I hope you'll agree with good reason. My purpose is to convey something about the historicity of ideas in psychoanalysis and how they appear to differ from how we think about concepts in natural science. In my opinion, this is both philosophically and clinically important. Concepts — including scientific and clinical ones — are part of culture and subject to contending values and interests.
I think it is relevant how I came to be thinking abut this matter. I had for some years been doing some lecturing for a psychotherapy training organization, the London Centre for Psychotherapy. However, when they rang me up the next year I could not do what they asked — for a reason I can’t recall. ‘Then would you be willing to give five lectures on ”Psychopathology”?’ I accepted, put the phone down and instantly felt that I knew nothing about the topic. Not being known for my diffidence, I thought this odd and bewildering. I’d been studying various aspects of abnormal psychology, neurology, psychiatry, psychoanalysis and psychotherapy, as well as the broader intellectual, cultural and ideological aspects of these disciplines for about four decades. Why, then, was I diffident?
My reaction was to go out and buy a copy of DSM III-R, the Diagnostic and Statistical Manual of Mental Diseases (Third Edition-Revised) (APA, 1987), which is published by the American Psychiatric Association. This is something which I had never before contemplated doing, I also bought an up-to-date textbook of Psychiatry, the UCH Textbook of Psychiatry (Wolff et al., 1990). I had not bought a textbook of psychiatry since I was a student in medical school the 1950s. I report these things because of how strikingly they convey the separation between the assumptive worlds of psychotherapy and psychiatry.
As it happens, neither book has the term ‘psychopathology’ in its index. Nor is it in the glossary of the textbook. That led me to feel that the concept may be passé. That turns out not to be right, but in order to get a handle on why this is so, it is necessary to take a long conceptual and historical detour.
What is packed into the concept of psychopathology? First, it implies a medical model. There are two central points about the juxtaposition of psyche with pathology. The first is a distinction between the normal and the abnormal or pathological. The second is an analogy between psychic processes and somatic ones. Psychopathology draws on an analogy to cellular pathology, a discipline which was only founded in the the nineteenth century in the work of Bichat, Cruveilhier and Virchow (ref), who made it possible to make diagnoses on the basis of specific observable characteristics of organs, tissues and cells. Some date modern scientific medicine from this period in which diseases were linked to highly specific lesions.
It doesn’t take much reflection to realize that there is something odd about this analogy, but when you ask what to do instead of making it, you come upon a deep feature of the legacy of the mind-body problem as bequeathed to modern thought by René Descartes (1637). He defined mind negatively as that which does not have the attributes of matter. When people have sought to think scientifically about mind, they soon discover that it has no language of its own which resonates with the scientific languages used in thinking about bodies. So they reach for analogies. You could say that these analogies provide much of the history of psychology. If you look closely at the analogies which are employed, you see a parallel to the history of the physico-chemical and biological sciences. Locke (1690) saw himself as an under-labourer to Newtonian physics. He and the other practitioners of a set of enquiries in epistemology and psychology, drew on the billiard-ball physics of the turn of the eighteenth century and offered the notion of the ‘association of ideas’. Ideas impacted on one another; memory was seen as somehow consequence of repetition of these impacts. This notion led to a model which was elaborated by Étienne Condillac (1754)and others but systematically developed by David Hartley in his Observations on Man, His Frame, His Duty and His Expectations (1749), which was the treatise which inspired the associationist tradition in empiricist psychology in the work of James Mill, John Stuart Mill, Alexander Bain and Herbert Spencer (Ribot, 1873; Warren, 1921; Young, 1970, chs. 2, 3, 5). In fact, Locke first used the association of ideas to explain wrong-headed connections, but the model soon came to be extended until it became the foundation for all thought and feelings. The major systematic psychology treatise before the advent of the theory of evolution was written by Alexander Bain and used associationism to explain The Senses and the Intellect (1855) and The Emotions and the Will (1859).
In the course of the nineteenth century and after, analogies were also drawn between mental processes and chemistry, so that we have ideas of mental elements, mental compounds, mental chemistry. A parallel process was occurring in which further analogies were drawn from physiology, involving mental structures and functions. And then came analogies from evolution, e.g., mental development and evolution and adaptation. More recently, information theory and cybernetics have provided a fund of analogies, and much of current psychology involves cognitive modelling based on analogies to digital computing. I will return to these analogies below.
In addition to the dichotomy between the normal and the pathological and the analogy between somatic and psychic processes, there is lurking around somewhere a third feature of psychopathology, the disease-syndrome model. Specific constellations of psychopathologies lead to diagnoses of mental disorders or diseases.
To be normal is to be in physiological and psychological balance. There is also more than one ambiguity around the term ‘normal’. It can mean average, as in the case of lying within a statistical range designated as normal, e.g., normal intelligence or normal blood sugar of heart rate or pulse or height. It can mean normal according to some criterion which few meet, e.g., within healthy weight limits in a society where many or most are overweight. It can also mean ‘not deviant’, as in conformist, not rebellious, obeying norms of behaviour. This often boils down to whether or not the speaker approves of the person in question., e.g., ‘I don’t want you going out with him; people who have rings in their noses aren’t normal.’. These meanings merge into one another in everyday speech. In physiological discourse, normal usually means falling within limits which are taken to be usual in a healthy person, free of perturbation. Important physiological concepts lie behind this designation., for example, the milieu interieur or internal environment of Claude Bernard (18xx) and the concept of ‘homeostasis’ of Walter Cannon (1932). These refer to the body’s stabilising mechanisms for keeping all sorts of physiological variables within certain limits. Beyond this there are relations with the external environment, and once again there is an elision between physiological, psychological and social evaluations: healthy/adapted. adjusted.
In disease something occurs which upsets these equilibria. There are several sorts of causes: infective, invasive, degenerative, assaultive, autoimmune, genetic.
All of these concepts can be and have been applied to social phenomena. Lemert wrote a book in 1948 entitled Social Pathology . Barbara Wootton published Social Science and Social pathology in 1959. Bainton’s The Anatomy of Revolution (19xx) used anatomical concepts to write about social upheaval, while Coser wrote about The Function of Social Conflict (1956).
So, starting from the oddity of juxtaposing psyche with pathology, we have found many instances of the mixing up of mental language with biological and medical concepts. All of these are heirs to a parent tradition known as ’functionalism’ (which I examine more extensively in Young, 1981 and 1989). It is a very widespread way of thinking in the human sciences which is based on physiological models from the early nineteenth century and evolutionary ones from mid-century. Franz Joseph Gall, the founder of modern brain research and of phrenology, established a model for thinking about the mind and the brain whereby the parts of the brain were seen as separate (though interrelated) organs, and their activities were functions Young, 1968, 1970, ch. 1). This extended the organ-function paradigm from stomach/digestion and kidney/filtration to so that it could be argued that the categories of character and personality were functions of the brain. This way of thinking was taken up by enlightened figures, such as Auguste Comte , the founder of positivism (Greene, 1959), in France and G. H. Lewes, a prolific English popularise in physiology and philosophy (Ashton, 1991). For our purposes, one particular set of influences was crucial, since it was taken up by the father of evolutionary associationism in psychology, Herbert Spencer, adopted from him by the eminent neurologist, John Hughlings Jackson (Young, 1970, ch. 6), and found its way into the first book of an impecunious researcher on the nervous system who would have to give up his research at the lab bench and earn his way as a clinician in Vienna. Sigmund Freud’s first monograph, published in 1891, when he was 35, was entitled On Aphasia: a Critical Study. This book brought functional thinking into the foundations of the ideas of the person who, four years later, would co-author the first psychoanalytic book, Studies on Hysteria. (Breuer & Freud, 1895)
It would not be possible to over-emphasize the pervasiveness of the functionalist paradigm. Perhaps the most efficient way of grasping its essence is by examining a few paragraphs from Herbert Spencer. In his first book, published in 1851, with the scientistic title Social Statics, Spencer wrote:
We commonly enough compare a nation to a living organism. We speak of ”the body politic”, of the functions of its several parts, of its growth, and of its diseases, as though it were a creature. But we usually employ these expressions as metaphors, little suspecting how close is the analogy, and how far it will bear carrying out. So completely, however, is a society organized upon the same system as an individual being, that we may almost say there is something more than analogy between them. (Spencer, 1851, p. 448)
A FUNCTION to each organ, and each organ to its own function, is the law of all organization. To do its work well, an apparatus must possess special fitness for that work; and this will amount to unfitness for any other work. The lungs cannot digest, the heart cannot respire, the stomach cannot propel blood. Each muscle and each gland must have its own particular nerve. There is not a fibre in the body but what has a channel to bring it food, a channel to take its food away, an agency for causing it to assimilate nutriment, an agency for stimulating it to perform its peculiar duty, and a mechanism to take away effete matter; not one of which can be dispensed with. Between creatures of the lowest type, and creatures of the highest, we similarly find the essential difference to be, that in the one the vital actions are severally decomposed into their component parts, and each of these parts has an agent to itself. In organizations of another order the same principle is apparent. (Spencer 1851, p. 274)
The date of Social Statics is important — seven years before the announcement of natural selection theory in the joint Darwin-Wallace paper of 1858, in which they announced the theory of organic evolution by means of natural selection. In On the Origin of Species, published a year later, Darwin had only one sentence on man, and in later editions he extended it with a tribute to Spencer: ’In the future I see open fields for far more important researches. Psychology will be securely based on the foundation already well laid by Mr. Herbert Spencer...’ (Darwin, 1872, p. xxx)
By 1860 there was no coyness about analogies or metaphors in Spencer’s writing. He discussed 'The Social Organism' in evolutionary terms, freely mixing biological and social language:
Societies slowly augment in mass; they progress in complexity of structure, at the same time their parts become more mutually dependent, their living units are removed and replaced without destroying their integrity; and the extents these peculiarities are proportionate to their vital activities.
These are traits that societies have in common with organic bodies. And these traits in which they agree with organic bodies and disagree with all other things, entirely subordinate the minor distinctions: such distinctions being scarcely greater than those which separate one half of the organic kingdom from the other. The principles of organization are the same and the differences are simply differences of application (Spencer, 1860, p. 206).
Having established the common principles, Spencer feels able to pronounce with confidence on social and economic forms — particularly the ones which were in greatest need of justification because of the effects of the industrial revolution on jobs and the social order:
The doctrine of the progressive division of labour, to which we are here introduced, is familiar to all readers. And further, the analogy between the economical division of labour and the “physiological division of labour”, is so striking as long since to have drawn the attention of scientific naturalists: so striking, indeed, that the expression “physiological division of labour”, has been suggested by it. It is not needful, therefore, to treat this part of the subject in great detail. (Spencer, 1860, pp. 211-12) .
Thinking in terms of biological and medical analogies became pervasive in the next few decades. In particular, it was central to Emile Durkheim’s thinking in The Rules of Sociological Method (1895).
Briefly, for societies, as for individuals, health is good and desirable; disease on the contrary, is bad and to be avoided. If, then, we can find an objective criterion, inherent in the facts themselves, which enables us to distinguish scientifically between health and morbidity in the various orders of social phenomena, science will be in a position to throw light on practical problems and still remain faithful to its own method (Durkheim, 1895, p. 49).
We shall call 'normal' these social conditions that are the most generally distributed, and the others 'morbid' or 'pathological'. If we designate as 'average type' that hypothetical being that is constructed by assembling in the same individual, the most frequent forms, one may say that the normal type merges with the average type, and that every deviation from this standard of health is a morbid phenomenon.... It is the function of the average organism that the physiologist studies; and the sociologist does the same (ibid., pp. 55-6).
The healthy constitutes the norm par excellence and can consequently be in no way abnormal (ibid., p. 58).
Now, it is important, from the very beginning of research, to be able to classify facts as normal and abnormal, save for the few exceptional cases, so that the proper domains can be assigned to physiology and pathology, respectively (ibid., p. 63).
The various principles we have established up to the present are, then, closely interconnected. In order that sociology may be a true science of things, the generality of phenomena must be taken as a criterion of their normality (ibid., pp. 74-75).
By the 1930s the leading figure in social anthropology, A. R. Radcliffe-Brown, who had taught in many academic centres, including holding the chair at Oxford, was applying concepts from evolutionary theory and physiology directly to societies and advocating this model as foundational for social science. Radcliffe-Brown drew his idea of social evolution directly from Spencer and his ideas of social process, structure and function directly from physiology. I mean this quite unequivocally. He wrote in the Introduction to Structure and Function in Primitive Society (1952),
In reference to social systems and their theoretical understanding one way of using the concept of functions is the same as its scientific use in physiology. It can be used too refer to the interconnection between the social structure and the process of social life. It is this use of the word function that seems to me to make it a useful term in comparative sociology. The three concepts of process, structure and function are thus components of a single theory as a scheme of interpretation of human social systems. These three concepts are logically interconnected, since “function” is used to refer to the relations of process and structure. The theory is one that we can apply to the study both of continuity in forms of social life and also to processes of change in those forms (p. 12).
In his highly influential essay, ‘On the Concept of Structure in Social Science’ Radcliffe-Brown begins, ‘The concept of function applied to human societies is based on an analogy between social life and organic life’ (p. 178). The task of social science is to see social life as a functional unity and to seek out the functional role of any phenomenon as a contribution to that unity (p. 185).
By the definition here offered “function” is the contribution which a partial activity makes to the total activity of which it is a part. The function of a particular social usage is the contribution it makes to the total social life as the functioning of the total social system. Such a view implies that a social system (the total social structure of a society together with the totality of social usages to which that structure appears and on which it depends for its continued existence) has a certain kind of unity, which we may speak of as functional unity. We may define it as a condition in which all parts of the social system work together with a sufficient degree of harmony or internal consistency, i.e., without producing persistent conflicts which can neither be resolved nor regulated (p. 181).
Functionalists in America supplemented this rhetoric with ideas drawn from the research of eminent scientists at Harvard, Lawrence J. Henderson, who wrote on The Fitness of the Environment (1913), and Walter B. Cannon, author of The Wisdom of the Body (1932).. Both emphasized equilibrium, both intermixed social and physiological concepts and both fed the widening stream which became the functionalist tradition. Their physiological writings were routinely quoted by social scientists, and Henderson later wrote both as a physiological and as a social scientist (Henderson, 1970; Cross & Albury, 1987)). It has been pointed out in a remarkable piece of scholarly research that a circle of scholars to which he was central was the cradle of much of the influence of functionalism in American social science (Heyl, 1968). Functionalist thinking became pervasive in psychology, sociology, anthropology, architecture, town planning, economics, history and sociology of science and systems theory. It remained so until the 1970s (Martindale, 1965; Demerath & Peterson, 1967; Gouldner, 1971).
Functionalism has certain noteworthy features. It takes the organismic and holistic points of view as given. It is therefore practically impossible to think in revolutionary terms within this framework of ideas. Everything is expressed in terms of parts and wholes, the contribution of the part to the whole, equilibria and self-correcting mechanisms (Russett, 1966). There is no place for contradictions or dialectical thinking. It is a philosophy for the slowly evolving status quo, palliative in its view of conflict. Fundamental social change of the mode of production is almost literally unthinkable (Mils, 1964, 1970; Gouldner, 1971; Young, 1981).
The spread of this way of thinking was not random. It became quite explicitly the preferred approach of the Rockefeller charities, the funding agency which paved the way for national government support for research (Kohler, 1991). It led to the founding of great institutions: Yale’s Institute of Human Relations, London’s Tavistock Institute of Human Relations, The London School of Hygiene and Tropical Medicine (Brown, 1979a, 1979b). There were similar institutions at Harvard, in France, in China. Rockefeller money founded sociobiology and supported x-ray crystallography. James Watson was on a Rockefeller fellowship when he co-discovered the structure of DNA. This approach reduced the human to the physiological and the physiological to the biochemical and the molecular. The breadth and depth of this tradition, along with the ideological forces which evoked and constituted it are most clearly made apparent in Donna Haraway’s. All of this approaches human nature and society in ways which are in contrast to prose, narrative, stories, humanism, yarns.
I dare say you may feel that I have taken you down a long side-track, but I have not. The concept of psychopathology only makes sense in the context of the functionalist tradition. The easy linkage of the psychological with the pathological requires that it be commonplace to juxtapose mental (I almost write ‘mental functioning’) with physiological, and mental distress (‘dysfunction’) with disease (’pathology’),
Let us now turn to psychopathology per se. Its literal etymology is knowledge (logos) of the suffering (pathein) of the psyche. As Levin puts it in a most interesting essay, it is all the ways of hiding, manifesting, communicating, sharing and, in brief, living out the mind’s experience of worldly suffering (p. 2). The term came into English as a transliteration of a German text by Baron Ernst von Feuchsterleben in 1847. Such analogies were rife. Thomas Mayo write on The Pathology of the Human Mind in 1838 and used the concept ‘mental pathology’. Henry Holland wrote a book on Mental Physiology in 1852, and Henry Maudsley (after whom the London hospital is named) wrote Physiology and Pathology of Mind in 1867. From Gall’s idea that thought is a function of the brain, and the brain is the organ of mind, there was a progressive movement of this paradigm throughout the nervous system and outwards into the psychological and social sciences. Freud was heir to this tradition and adopted the concept of psychophysical parallelism as his own approach to the mind-body problem, which meant that there was no need to translate between mental and physical. Indeed, functionalist thinking made them appear so nearly identical that one hardly felt the need.
I trust that you will grant by now that quite a lot is tucked away into this term. Here is a definition from a 1901 Dictionary of Philosophy and Psychology:
the general study of diseased mental conditions; a synonym of psychiatry and abnormal psychology, but rather more comprehensive that either, because it emphasizes the general scientific study of all forms of mental aberration. Its more precise synonym is mental pathology.. {Note the presence here of the concepts of disease, abnormality, pathology.] The term psychopathist is sometimes used as a synonym for psychiatrist (Baldwin, vol. 2, pp. 391-92).
Janet and Dunn founded a French journal of abnormal and pathological psychology in 1903. A lectureship in psychopathology was established in Cambridge in 1923. Hart says in 1927 that psychopathology is not a mere description but an attempt to explain disorders in terms of psychological processes (Berrios, .p. 233). William McDougall, the most eminent polymath in the human sciences of his era, quotes Bleuler with approval in 1926: ‘one of the most important, if not the most important, of all paths to a knowledge of the human soul is by way of psychopathology’ (Berrios, p,. 235). A decade later it is scientized by Malamud: ‘a science that deals with the recognition, description, classification and understanding of phenomena of mental activity’ (Berrios, p. 237).
This brings us to a fourth main feature to put alongside the distinction between the normal and the pathological, the analogy to somatic medicine and the disease/syndrome model: classification or nosology, the search for a natural classification. Science seeks types, pigeon-holes, lists, differential diagnoses. That’s what DSM III-R is, but there are things to be learned from the fact that it is an evolving one. The first edition appeared in 1952; the second was in 1968 and was based on the eighth edition of the International Classification of Diseases. The third edition appeared in 1979, was revised in 1987, and the fourth edition was published in 1994. You might say that reflects a lot of accumulated knowledge, but the history of such compendiums is more complex and interesting than that. It is not just that knowledge accumulates. Another process is going on as well: the terms of reference of the classification are historically relative and mutate.
A helpful analogy is the history of encyclopaedias. I am a collector of The Encyclopaedia Britannica. I have the seventh, eighth, ninth, tenth, eleventh and fourteenth editions. You may think this excessively pack-rattish of me, but I have a good reason. I am, among other things, a scholar of ideas abut nature and human nature in the nineteenth century. The last volumes of the eighth edition went to press in 1859. It contained a large article entitled ‘Deluge’, in which the history of discoveries in geology were spelled out in Biblical terms (Anon., 1854). The ninth edition has no article on the Biblical Deluge, but it has a long two-part article on ‘Evolution’: ‘Evolution in Biology’, penned by T. H. Huxley (Darwin’s loyal publicist), and on ’Evolution in Philosophy’ by James Sully (Huxley, 1979; Sully, 1979). Knowledge does not just accumulate: the parameters of knowledge change. Indeed, a whole volume of introductory essays taking an overview of changing fields of knowledge had been a feature of successive editions of the Britannica for some time.
It is the same with psychiatric diagnosis. There is a rich and growing literature on the historicity of psychiatric disease categories. One of the best studies is Elaine Showalter’s (1985) careful exploration of the rise of hysteria: The Female Malady: Women, Madness and English Culture, 1830-1980. She points out that the World War I diagnosis of ’Shell shock was the male counterpart of hysteria, a discourse of masculinity addressed to patriarchal thought‘ and adds, ‘but it was scarcely possible for either male patients or male psychiatrists, themselves deeply implicated in patriarchal structures, to see its meanings (Showalter, 1987, p. 194). Allen Young has written a work of searching scholarship on Post-Traumatic Stress Disorder (PTSD), a diagnosis which, in an immediate sense, grew out of the Vietnam War and which has since become the basis of a burgeoning industry of publication and treatment. The main roots of PTSD included the self-same story of World War I psychoneuroses, in particular shell shock and related disorders emanating from that dreadful conflict where people were daily blown to pieces in their thousands. He entitles his study The Harmony of Illusions, with the subtitle, Inventing Post-Traumatic Stress Disorder (A. Young, 1995). The first phrase was used by another scholar to point to the illusiveness of facts, while the second starkly alludes to the social construction of disease categories. They are no less real, but the sense in which they are true remains unclear (A, Young, 1995, pp. 9-10). A third diagnosis which has undergone extensive study as an historical and cultural phenomenon is Multiple Personality Disorder (MPD), which has benefited from the philosophical ruminations of Ian Hacking (1992, 1995) and from the anthropological contextualisation of Roland Littlewood (1966, 1998).
.There are other examples of this historicity and relativity. Homosexuality was a mental disease in the 1960s; then it disappeared from DSM. Actually ego-syntonic (at peace with one’s self) disappeared. Ego-dystonic homosexuality remains (Abelove, 1986). I have a whole volume in which the validity of the concept of ‘borderline disorder’ is debated (silver & Rosenbleuth, 1992). It includes a chapter wherein Alex Tarnopolsky says that this concept is not much used in Britain, and he claims that the Kleinian concept of ‘pathological organisation’ does a better job of accounting for the phenomena usually called ‘borderline’ (Tarnopolsky, 1992, 1992a).
We are faced here with the relativity and the historicity of disease concepts. Homosexuality ceased to be classified as a disease because of changing social values and political agitation. You may think this feature which distinguishes diagnoses in psychiatry from those in somatic medicine, but you’d be wrong. In a fascinating series of papers, Karl Figlio has shown that disease categories in somatic medicine come and go. He traces the rise of two disorders, chlorisis (a fainting disorder common in housemaids) and miners’ nystagmus (a jerking of the eyes commonly seen in miners). They appear, wax, wane, get re-classified as functional nervous disorders and quietly disappear from the textbooks of somatic medicine Figlio, 1978. 1982, 1985). If we take seriously the historicity and cultural relativity of disease entities, then the idea that the classifications could tell us about natural kinds, as the classifications of elementary particles in physics, the Periodic Table of Elements in chemistry and the taxonomy of species in biological taxonomy claim to do, we will be disappointed. Then what is the status of the categories of psychopathology? I shall argue that they are rabbit/ducks, i.e., gestalt-switch figures which in this case look like one thing when viewed clinically and another when viewed nosologically. A binocular approach strikes me as the best way of thinking about the phenomena we call psychopathological, and I shall argue that we are better at our jobs as therapists when we think in dynamic terms rather than in the static terms the classifiers have been prone to employ.
Let’s take a quick tour of some recent literature. My textbook of psychiatry when I was a medical student had one reference to psychopathology in its index - to page one: ‘that branch of science that deals with the principles of abnormal behavior, or... the science of disordered functioning of the personality’ (Noyes & Kolb, 1958). One reference covers the lot. A text from the same period had psychopathology as a main entry, followed by ‘of-’ and lists every disorder (Ewalt et al., 1957).. A comprehensive dictionary of the same period designates psychopathology as the science, with respect to which clinical psychology and psychiatry are technologies (English & English, 1958). Something similar happens in Harold Searles’ classic collection on Countertransference (1979). One entry refers the reader to borderline patients, neuroses, psychoses, schizophrenia. In Greenberg and Mitchell’s excellent Object Relations in Psychoanalytic Theory (1983) psychopathology is a main index entry, touching on all the theorists discussed. The interdigitation of the physiological and the psychological is quite explicit and still in use. Taylor’s Psychopathology, published in 1966, includes the phrase ‘physiology of mind’.
The index in The Standard Edition of the Complete Psychological Works of Sigmund Freud has only one entry - to Freud’s first paper on psychopathology, the implication being that the rest are on it, too. It also forms the middle of the three portions of his 1895 ‘Project for a Scientific Psychology’, based on neuroanatomy, which he abandoned when he turned to exclusive reference to the psychic side of his psychophysical parallelism. Yet the concept does not appear n Winnicott’s works, nor in Laplanche and Pontalis’ definitive dictionary of orthodox psychoanalysis or Hinshelwood’s on Kleinian theory or in Masserman’s classic text (or its glossary) or Fenichel’s. Indeed, if you plow through the forty-three pages of references in DSM III-R, you will find only four references to it. It is not in Peter Gay’s excellent biography of Freud, except to refer to The Psychopathology of Everyday Life (Freud’s only title employing the term).
So — it is something between everything and nothing. We have functioning — normal and disordered. Disordered is psychopathology. Thinking in terms of this dichotomy keeps coming up. Although most say that the line is hard to draw, they are looking for it.
Where does psychopathology come from? Eric Rayner says it comes from ’repression’ (Rayner, 1991, p. 24), but it gets more complicated later on. The British Independent psychoanalysts root it in external object relations, Bowlby and Alice Miller attribute it to real traumatic experiences, Kleinians to the conflict between impulses derived from the life and death instincts. Greenberg and Mitchell (1983, pp. 135-6) say that Klein attributes the main causation of psychopathology to factors arising primarily in the internal world. It is clear that when we seek to fathom aetiology, we are quickly up to our necks in controversy.
I am trying to convey something about the conceptual language of psychoanalysis, psychiatry and the human sciences generally. German Berrios, who has devoted considerable efforts to tracing the history of concepts in psychopathology, opines that the persistence of ‘psychopathology’ in British psychiatry can be attributed to the empiricist false consciousness seeking theory-neutral statements. The effort to describe and classify frees one from understanding, process, dynamics and aetiology (Berrios, 1991, pp. 241-42). Indeed, if you look at the aetiologies of mental disorders as listed in DSM III-R, you will find that most are ‘unknown (APA, 1987, pp. xxii-xxiii). Once again, the syndromes listed in this compendium are presented as if they were natural kinds, but we can easily see that they are nothing of the sort. They are inside history and inside culture. During the nineteenth century in America there was a mental disease in the textbooks called ‘dropitomania’, defined as the compulsive need on the part of mentally deranged slaves to run away. When I first worked in a mental hospital in Arizona in 1955, some patients; charts listed as diagnoses ‘priapism’ and ‘nymphomania’, patterns of behaviour which were relatively valued just over a decade later.
Diagnoses which are contentious from a commonsense point of view have not disappeared from psychiatric classification. Here are the diagnostic criteria for ‘Self-Defeating Personality Disorder’:
A. A pervasive pattern of self-defeating behavior, beginning by early adulthood and present in a variety of contexts. The person may often avoid or undermine pleasurable experiences, be drawn to situations or relationships in which he or she will suffer, and prevent others from helping him or her, as indicated by at least five of the following:
(1) chooses people and situations that lead to disappointment, failure, or mistreatment even when better options are clearly available
(2) rejects or renders ineffective the attempts of others to help him or her
(3) following positive personal events (e.g., new achievement), responds with depression, guilt, or a behavior that produces pain (e.g., an accident)
(4) incites angry or rejecting responses from others and then feels hurt, defeated, or humiliated (e.g., makes fun of spouse in public, provoking an angry retort, then feels devastated)
(5) rejects opportunities for pleasure, or is reluctant to acknowledge enjoying himself or herself (despite having adequate social skills and the capacity for pleasure)
(6) fails to accomplish tasks crucial to his or her personal objectives despite demonstrated ability to do so, e.g., helps fellow students write papers, but is unable to write his or her own
(7) is uninterested in or rejects people who consistently treat him or her well, e.g., is unattracted to caring sexual partners
(8) engages in excessive self-sacrifice that is unsolicited by the intended recipients of the sacrifice
B. The behaviors in A do not occur exclusively in response to, or in anticipation of, being physically, sexually, or psychologically abused.
C. The behaviors in A do not occur only when the person is depressed (APA, 1987, pp. 373-74).
There is an uneasy atmosphere in my seminars whenever I read out these diagnostic criteria. Most students feel that they are candidates for this diagnosis. I do. I should add that this syndrome appears in DSM III-R in ’Appendix A: Proposed Diagnostic Categories Needing Further Study’ A sign of things perhaps to come. ‘Trichotillomania’ or persistent fiddling with one’s hair and ‘Factitious Disorder’— symptoms intentionally produced or feigned — are established diagnoses, as are Impulse Disorders.
I have produced these examples at the trailing edge of established psychiatric diagnostic classification to make it clear, once again, that we are dealing with the history of the delineation of deviance in some of these instances, just as much as we are with clinically worrying phenomena.
I want now to turn once again to the concepts of normal and pathological in their original medical context. They, too, are inside history, and we are fortunate that as distinguished an historian of science as Georges Canguilhem has written a classic study of them, in which he argues that the ideas of the normal and the pathological, ‘far from being scientifically or statistically determined, are rather concepts of value deeply imbued with political, economic and technological imperatives’ (cover blurb). If this is true of the bedrock of medical concepts, by analogy to which we construct our psychopathological categories, the same adjectives must surely apply in the psychic realm: value-laden, imbued with political, economic and technological, in short, with ideological imperatives.
I shall be offering an alternative model as we go along, but I shall offer a taste of it here. The concept of psychopathology implies a fairly sharp dichotomy, a model of the mind in which the rational is the desirable state, and the irrational is kept at bay by defence mechanisms, through which intense emotions break from time to time and sometimes for long periods. But what if intense primitive mentation is normal? According to Kleinian psychoanalysis, there is a warrant in Freud for considering primitive processes and distortions of experience which are usually considered to be psychotic as part of everyday experience. Joan Riviere appeals to Freud's hypothesis that the psyche is always interpreting the reality of its experiences — 'or rather, misinterpreting them — in a subjective manner that increases its pleasure and preserves it from pain' (Riviere, 1952, p. 41). Freud calls this process 'hallucination; and it forms the foundation of what we mean by phantasy-life. The phantasy-life of the individual is thus the form in which the real internal and external sensations and perceptions are interpreted and represented to himself in his mind under the influence of the pleasure-pain principle'. Riviere adds that 'this primitive and elementary function of his psyche — to misinterpret his perceptions for his own satisfaction and to do so to a degree which it is appropriate to call hallucination — still retains the upper hand in the minds of the great majority of even civilised adults' (p. 41). This general function for phantasy is repeated in Susan Isaacs' definition. ’The "mental expression" of instinct is unconscious phantasy... There is no impulse, no instinctual urge or response which is not experienced as unconscious phantasy' (Isaacs, 1952, p. 83).
The first mental processes... are to be regarded as the earliest beginnings of phantasies. In the mental development of the infant, however, phantasy soon becomes also a means of defence against anxieties, a means of inhibiting and controlling instinctual urges and an expression of reparative wishes as well... All impulses, all feelings, all modes of defence are experienced in phantasies which give them mental life and show their direction and purpose (ibid.).
Donald Meltzer makes a similar point when he reviews the development of Melanie Klein’s ideas of the paranoid-schizoid and depressive positions. She first put them forward as fixation points from which subsequent psychoses developed. She next characterised them as developmental stages. In her later writings they became positions, characteristic of all of us, part of the warp and woof of everyday unconscious thinking (Meltzer, 1978, part 3, p. 22).
These examples from Riviere, Isaacs and Meltzer are expressions of a position which I shall develop as we examine classical psychiatric nosology, and then Freudian defence mechanisms and move on to look more carefully at Kleinian psychodynamics. In the concluding chapter, offer a worked example of a syndrome characterised in a dynamic way.
If this way of seeing the inner world is persuasive, then what is left of the concept of psychopathology? In some we will find ourselves left with less that we began with and in other ways quite a lot more.
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