Against formulation/diagnosis
Publish Date : November, 2024
Because it addresses disorders or deficits in physical entities ― physiological functions or anatomical structures ― allopathic medicine requires the practitioner to have some sense of what the problem is, in order to decide with what procedure it should be treated. This modus operandi is, from start to finish, objectivistic or instrumentalist and manipulative. The practitioner and (in a somewhat different manner) the patient both treat the disordered or deficient entity ― from a diseased liver to a broken bone ― as an object to be manipulated back into a condition of relative health or, at least, reduced discomfort. Formulation, along with probabilistic diagnosis, precedes and then governs mechanistic (instrumentalist) intervention. That is, epistemological deliberation determines procedures of application, and accordingly theory rules technique ― supposedly. This is the objectivism of what has been called “instrumental reason,” in which the object is codified and then treated in the general manner that one treats things ― from cups of coffee and laptops, to building sites and military targets.
Because of its emergence within the medical hegemony, formulation and diagnosis continue to prevail over most thinking about psychotherapy. Over the past fifty years, I have sat in countless clinical presentations in which “data” about patients in counseling or psychotherapy ― who are almost invariably absent from the proceedings of the presentation ― are discussed and deliberated by a group of practitioners. Formulations about the patients’ functioning, as well as the etiology of their supposedly “pathological” condition, are then generated. Sometimes this is undertaken in a quite unfettered manner (sometimes with a tone of serious compassion, sometimes with a tone of latently smug superiority). For example, “the family all seem to be on the spectrum … he is enmeshed with his mother … she is excessively angry at men … unquestionably borderline … there is a lot of splitting … they are hysterical about the government … he has ‘gifts’ which suggest that he is psychotic … she is confused about her gender … he is mostly in the paranoid‑schizoid position … her ego’s capacity for judgment is overridden by her poor impulse control … these children lack a strong superego figure.”
Having arrived at all these conceptualizations about the patient, what is the clinical practitioner supposed to do with them? The point I am making here is that all these theoretical propositions ― whether correct, in some sense, or not ― tell the practitioner next to nothing about what to say and how to interact when in the presence of the patient. When it comes to healing psychic life, the objectivistic mode of operation ― formulate and then manipulate ― seems misguidedly disconnected from the lived-experience of the patient (or of the practitioner in the treatment room). This is method-as-technique, theory-driven, as contrasted with method-as-praxis (see Critique and Praxis #002, September 2024).
It is true that, when psychotherapists sit with their patients, it may seem to them that their knowledge of some theory is being applied in the service of the patient’s treatment. For example, “I am now understanding the patient’s paranoid‑schizoid functioning and I am containing it interpretively so that the patient can move into a more depressive position (for instance, I am interpreting the way the patient uses splitting) … I am interpreting the patient’s compromise formations so that the patient can modify them more adaptively (for instance) I am interpreting what the patient seems to be denying) … I understand the patient to have problems with their sense of self‑coherence and self‑esteem, so I am verbally supporting their development of a more stable and positive sense of self (for instance, I am interpreting how the patient seems to discount aspects that might be construed more positively.” And so forth.
In these examples, it seems that theory is being applied ― at least tacitly, in a conversational but nevertheless instrumentalist technique ― to the object as constituted by its data or information. This is the case even when the “object” is the patient’s subjectivity or even the intersubjectivity of the therapist‑patient duo. This may be a fair characterization to the extent that psychotherapists indeed do take the patient’s functioning as an object of scrutiny and of an epistemologically‑driven treatment that drives change ― comparable to that of allopathic medicine. But in large measure this may be a misperception on the part of therapists who understand their labors in such a framework. It may seem as if theory is being applied as technique that will manipulative change the ‘object’ but, as psychoanalysis teaches, appearances can be deceiving, and this epistemological dimension may be the least significant dimension of what is actually happening.
Aside from the manipulative goals of psychotherapy, the objectivistic‑instrumentalist approach cannot possibly be an apt way to think about psychoanalysis as the discipline of free‑associative discourse, in which the processes of change are neither objectivistic nor instrumentalist. This is why it is so important to grasp the idea that psychoanalysis is praxis (which is discussed more extensively in the trilogy). The common or scientifically traditional conceptualizations of theory and technique are not pertinent to a psychoanalytic engagement. With the notion of praxis, method takes priority and is not theoretically‑driven. In this sense, psychoanalytic processes are always atheoretical.
All these considerations are part of a larger shift in our thinking, involving the realization that the genuine healing of psychic life cannot be achieved by objectivistic or instrumentalist procedures. Psychoanalysis can claim to be science, but it is ― as Freud wrote ― in conflict with “official science.” This is what we find in Rediscovering Psychoanalysis ― the healing of psychic life must be appreciated as an existential praxis, a freeing process in relation to the truthfulness of being‑becoming as a human. In this context, formulation and diagnosis have no place ― indeed, they are phenomena to be deconstructed.