A 4-year-old child wakes up one morning with a rash. She is sweating, apathetic. The young, and therefore worried, parents call the doctor who does a quick examination, concludes it is chicken pox, reassures the parents, and prescribes an anti-itching powder.
This short sequence is a perfect illustration of medical diagnostics; incidentally, it is a perfect illustration of an implicit social relationship as well, something that we will return to later. The young patient displays a number of symptoms that are collated by the doctor so as to identify—diagnose—a distinct syndrome. This is done in accordance with an established knowledge that maintains both a notion of etiology and a clear diagnostic distinction between health and illness. In this way, the doctor makes a diagnosis, usually with the help of various instruments (thermometer, stethoscope, etc.), forms a prognosis, and suggests a treatment on the basis of her observations. The intent is to return to the status quo ante, the earlier state. The model is in fact essentially circular and can be put schematically in this way:
Symptoms are gathered together into an objectively generalized syndrome,
In accordance with an established knowledge, which includes an etiology and a clear distinction between health and illness,
The result is a diagnosis and prognosis reached by way of an instrumentally assisted diagnostic,
The aim: treatment and a return to the previous state.
A 15-year-old and his concerned parents come to a psychologist for a consultation. He has been caught joyriding by the police. The parents not only want the psychologist to diagnose him, they want rapid treatment as well. The juvenile court is threatening to take drastic measures since this was not the boy’s first time. How can the psychodiagnostic process here be compared with the medical process described above?
The first interview adds more information. The boy does not simply steal cars per se. They have to be Mercedes. Once in the driver’s seat, he drives around apparently aimlessly on his own. Each time, he leaves the car unharmed in another part of the country and hitchhikes home. The boy himself cannot give any explanation for his behavior except for the fact that he has an expressed preference for this kind of car. While the diagnosis “joyriding” remains the same—at most it could be substituted with “maladjusted behavior”—where are the symptoms that could be gathered into an objective, universalized syndrome?
In the second interview, the psychologist focuses on the family situation. The boy is an only child whose parents are undergoing a marital crisis. The mother is from a privileged background, the father is working class but has raised himself to a higher socioeconomic status. At the time, each fell in love with the other’s otherness, now they reproach one another for it—a fairly typical scenario. The mother has taken a lover, the father works himself to death and retreats from confrontation. He works himself to death for…Mercedes. And entirely coincidentally, the region where the boy leaves his cars is where his mother was born and where her last name still holds a certain prestige.
The as-yet undiagnosed symptoms now appear in a completely different light. Whose symptoms are we talking about anyway? The son is caught between his parents, his behavior clearly cannot be understood outside of its context. From a psychoanalytic perspective one would say that his behavior provides an answer to the desire of the Other, that is, his parents, with the proviso, however, that the boy himself is not, or is only barely aware of it. “The unconscious is the discourse of the Other” (Lacan). Systemic theory would say that the boy shoulders the symptoms of his family. A cognitive behavioral approach would see his behavior as learned, which leads us to the following question: From whom does one learn what, and why?
Whatever approach one takes, a common factor emerges: the diagnosis cannot be limited just to the boy. The impact of the Other is fundamental. This is the first major difference between medical diagnostics and psychodiagnostics: clinical psychodiagnostics cannot be restricted to the individual. Psychic identity, with its potential psychopathology and aberrant behaviors, must be conceived in such a way that it grants the other a place equally important as the individual’s.
A second difference has meanwhile emerged. Unlike what takes place in medical diagnostics, here one cannot similarly bind a number of isolated symptoms into an objective, universalizable syndrome that holds for just about every case. To the contrary, the more information the diagnostician acquires, the more specific the situation becomes, to the effect that generalization becomes all the more difficult. In medical diagnostics the symptoms are interpreted as signs pointing to an underlying disturbance that can be both isolated and generalized. In clinical psychodiagnostics we are confronted with signifiers that carry endlessly shifting meanings in any given interaction between the patient and the Other.1 The signifier “Mercedes” will never carry the same meaning in any other clinical situation as it does here. The universal element is missing; the clinical psychodiagnostic process results in a category in which N = 1. The clinical psychodiagnostic questions are thus not so much “What disease does this patient have?” but “To whom or what do the symptoms refer? What are their meanings and functions, and who do they relate to?” There must be an underlying and, as yet, invisible structure determining the whole that intersects in the patient.
Thus we can say that medical diagnostics and clinical psychodiagnostics are exact opposites in this respect. Medical diagnostics begins with the particular (the symptom) and moves toward the general (the syndrome), based on a semiotic system that is entirely focused on the individual’s complaints. Clinical psychodiagnostics begins from the general (the incipient complaint) and proceeds toward the particular (where N = 1), based on a system of signifiers that is part of a wider relationship between the subject and the Other.
Despite its complexity, medical knowledge exhibits a relatively uniform character whose conceptions of etiology and of what constitutes health and illness can be readily identified. Clinical psychodiagnostics is completely different. Not only does it have no uniform character—there are many different theoretical perspectives, each with their own competing conceptions of how the mind functions—but it addresses quite a different question. With the exception of a restricted number of cases, we are not so much confronted with the question of whether someone is healthy, but whether she or he is normal or abnormal. In contrast to the absolutes of the medical norm (fever starts at 37 or 98.6 degrees), in psychodiagnostics we are confronted with the problems of a perpetually relative norm: What constitutes abnormal behavior within what kind of abnormal psychical identity? This will be our central question, which can be approached from three main angles.
One approach attempts to describe the difference between normality and abnormality through the lens of contemporary science, namely, through computation and quantification. Psychic normality is understood in terms of average scores, standard deviation, and modal personalities. This implies that psychic characteristics can be mathematically calculated and then presented in the famous bell-curve of normal distribution: the normal group in the middle of the graph is the largest while the left and right sides are occupied by the smaller abnormal populations.
In the clinical field, however, less emphasis is placed on quantification. Indeed, there the question is whether quantification is even possible.2 To measure something, one needs an objective unit of measurement: cm, kilos, grades, and so on. Yet in clinical praxis such an objective unit of measurement is missing. What would depression’s unit of measurement be, what would an average “depressive quotient” look like? While it is true that contemporary psychodiagnostics has a number of scales through which we try to measure anxiety, depression, and other states, in the final analysis such measurements come down to the counting of words or expressions against which patients can measure the extent of applicability to themselves.
The end result may well be of a quantitative nature. Nevertheless, such numbers invariably have a different status than those of the hard sciences because they always demand interpretation owing to the lack of an objective unit of measurement. The numerous attempts to establish such objective norms inevitably terminated with biological parameters. Aggressivity, for example, can be calculated by the objectively measurable quantity of testosterone in the blood. Nevertheless, experience shows that subjective behavior is never directly linked to these objective markers.
The saga of the so-called lie detector test is a good illustration of this. Despite objective measurements of sweat, heartbeats, and blood pressure, there is scarcely a direct correlation between the test results and the degree of truth emitted by the test subject. More broadly one can say that, in psychopathology, there is no firm link between objective, assessable parameters for a specific psychological problem and the way it is subjectively experienced and expressed (Koster van Groos 1989, p. 353; Silvestre 1981, p. 27).
The ultimate impossibility of achieving an objective quantification doesn’t prevent approaches like this from occurring in clinical practice: “A stronger than normal separation anxiety”…“a severe personality disorder”…“an excessive midlife crisis.” Such quantitative evaluations rely, at best, simply on the observer’s own clinical intuition and experience. At worst, they are based on the observer’s mirror image. The danger of such an intuitive diagnostics will be discussed in the following chapter.
Almost imperceptibly, we have come to the second approach, one that considers normality as an ideal, a utopia, which means, equally, that it doesn’t exist per se. As Freud puts it: “a normal ego of this sort is, like normality in general, an ideal fiction” (1978 [1937c], p. 235). Here we encounter ideal and, hence, ideological prescriptions of how mankind ought to be. The title of the first Western psychological manuscript (from 1590) is paradigmatic in this respect: Psychologia, hoc est de hominis perfectione (“Psychology is the study of man’s perfection”) by Goclenius of Marburg.
In this approach, diagnosis takes a peculiar form: in affirming an ideal image of mankind, the clinician’s work is accordingly reduced to calculating the distance between the patient and this ideal. In other words, in the majority of cases, diagnosticians appear less interested in etiology than in an immediate diagnosis, one enabling them to concentrate on the desired goal. Such reasoning is clearly visible in the way psychodiagnostic tests often contain an ideal result, the difference between which and the patient’s score serves only to represent how far he or she still has to go. Also surely not coincidental is the way the diagnostician often talks about the need to “grade” certain tests. Suddenly, we have become teachers and treatment becomes a question of learning or of (re-)education through which the pupil must be brought as closely into line as possible with this ideal result. Moreover, such an approach presupposes that one can define this ideal of normality. Seeing as how we are not dealing with an objective external norm (fever starts at 37 or 98.6 degrees), but with an always relative—because socially determined—norm, such a task is far from simple and leaves the result open to further discussion.3
How one handles the treatment within such an approach is reminiscent of what we earlier described as intuitive diagnostics: it seems practical, a matter of sound judgment, of personal ethics, and so on…When, in his Ethics Seminar, Lacan (1992 [1959–1960], pp. 8–10) summed up the therapeutic ideals as human love, authenticity, and independence, many therapists nodded enthusiastically. But this assent only served to make Lacan’s subsequent rejection of these ideals all the more disconcerting. Beyond the attractiveness of their—incidentally, continually changing—contents (i.e., the ideals), the underlying formal system tends to be overlooked. This latter is nothing other than a coercive ideology, yet one more alienation imposed on contemporary homo psychologicus through which the therapist determines the client’s “good.” Meanwhile a confusion reigns between psychotherapy and (re-)education. The latter is unrealizable without ideals, while the former belongs to a different order. People frequently get into difficulties when their ideals have been shattered.4 But to spoon-feed them new ideals at such a time, albeit with therapeutic intent, resembles a detoxification treatment that replaces opium with morphine. Instead, psychotherapy must give them the chance to interrogate the hows and wherefores of these ideals, that is, their subjective history, so that certain choices can be (re-)made.5
The dangers of such a treatment, however, go beyond alienation—indeed, alienation is probably inevitable in any form of psychotherapy. Thomas Szasz glimpsed the snake in the grass most keenly (1972, p. 26): “Every rule or norm of psychological health generates a new category of mental illness.” The role of segregation in the psychopathological industry now comes into sharp relief: a certain group designates itself Normal by categorizing others as Abnormal (“I’m okay, you’re not okay, therefore everything is okay”). That people subsequently wanted such normality for others, too, lends the whole thing an altruistic shine, the same as that by which colonialization, for example, is also justified. The examples of such misuse are most clearly visible in totalitarian regimes, where psychiatry and psychodiagnostics quickly become abused for such ends.6 Because of our lack of distance, it is much harder to acknowledge the applicability of this charge closer to home. Nevertheless, we can at least give two contemporary examples. First, one of the most significant personality disorders today is that of the antisocial personality. Second, yesterday’s pervert has been rechristened the so-called paraphile, in distinction from his normal (healthy?) counterpart, the normophile.7 No further comment is necessary.
The results of regarding normality in terms of the ideal can be summarized thus: first, psychopathology and criminality become so interwoven that the knife begins to cut both ways. Criminal behavior becomes acceptable because it is explicable; psychopathological behavior becomes punishable because it is deviant. It is no coincidence, therefore, that an ever-increasing number of psychiatric patients are beginning to populate Dutch prisons (Beyaert 1987; De Ridder 1987). Second, psychiatry and clinical psychology become the judges of the social order, with the prosecutors of the pathological society at one extreme and the guardians of the public good at the other. With the latter, the practice of psychology becomes transformed into a form of social coercion and obligatory adaptation. Cautionary warnings against this are found more often in a number of the gems of world literature (see, for example, Huxley’s Brave New World and Orwell’s 1984) than in our own field. This ought to be more than enough to address the ethical aspects of clinical psychological practice. To think naively in terms of adapted or unadapted behavior, or even desired or undesired behavior, is to enter into dangerous waters. Who desires what, and in whose name?
The third perspective approaches normality in terms of a developmental process. Here, normality is regarded as something that requires long-term study, something that cannot be grasped in a single take. This seems to me, for a number of reasons, the most legitimate approach. Diagnosis, and even therapy, often entail merely a single, momentary take whose transitory nature gets forgotten. The earliest historical example is Bertha Pappenheim, better known by her pseudonym Anna O. As one of the most pathological cases in Studies on Hysteria (Freud and Breuer 1978 [1895d]) she was later rediagnosed as a schizophrenic psychotic (Bram 1965). Great was the surprise, therefore, when it was discovered that—counter to all expectations connected with such a diagnosis—she led a miraculously full and creative life in the forty years following her treatment (Freeman 1977).
This developmental notion is found in a number of writers, most often in connection with the idea that human life undergoes a number of phases, wherein each period announces a distinct problem and its accompanying potential disorders. The model for this idea is to be found in the organic somatic development of mankind, which does indeed possess quantitative criteria, deviations from which yield indications of pathological disturbance. But to transplant this idea wholesale into clinical psychology is considerably more problematic. A fair amount of developmental psychological results are as much (or more) determined by environmental factors than by nature, and hence will have different characteristics from culture to culture. What I simply wish to underline here is the way all psychological development takes place in interaction with an Other, and that the impact of such an Other must not be neglected in clinical psychodiagnostics.8
In addition, one must note how this way of thinking emphasizes a linear, chronological time-scheme. In the case of psychopathology, an alternative temporal structure can just as easily be put forward, one based on retroactivity, or Nachträglichkeit, in which elements from the past are interpreted by way of the present (Freud 1978 [1918b]). A depressive patient, for example, will stress the negative elements of his life’s story because of his depression. But to consider this negative past the cause of his depression would be to jump to a conclusion too quickly.
Beyond these remarks, it is nonetheless clear that in certain cultures an experienced clinician can quite properly make out a number of more or less typical life stages. The problem is that this observation inevitably relies on the concept of normality as an average. How long does the toddler’s negativism phase last? What is an average puberty crisis? What is a typical midlife crisis? Even if we find statistics for such things, these will also be relative, and need reinterpretation in the light of the specificity of each particular patient. The judgment ultimately depends on the clinical intuition of the individual caseworker.9
The greatest danger in such an approach is the same one facing the entire clinical psychological field. To maintain that everything must be situated in chronological terms implies that the present can be explained on the basis of the past, and that both of these determine the future. Put differently, it implies that what is actual can be entirely explained by the past, not just disorders, but normality as well. The risk, then, is that the following message is implicitly sent: anything that can be traced back to a life history is explainable, comprehensible and, hence, acceptable. The hyperbolic but logical extension of the so-called “mitigating circumstances” serves as an illustration. “He beats his wife, but what do you expect? He had an unhappy childhood.” Nevertheless, even insanity has ethical limits. Throughout this book, I will emphasize over and over again that these two fields—the field of clinical psychology and the field of jurisdiction and normativity—must be clearly separated.
By way of concluding this second point of comparison between medical and clinical psychological diagnostics, we can say that our field has far less univocal theoretical grounds. The main reason for this has to do with each field’s different objects: illness/health versus normality/abnormality. The criteria for the latter can never be of the same order as the former since the quantitative factors can never be more than a general appraisal, while the diagnostic data must be interpreted in a specific way each time. To do this, one needs a governing metapsychological theory of psychical identity and its development.
Along with measuring, the entire focus in medical diagnostics is on looking. Medical instruments can be understood more or less in terms of an ever-increasing perfection of looking at and in the body, by which certain parameters are measured and weighed according to objective criteria. In clinical psychodiagnostics, however, the focus is on listening. Indeed, psychodiagnostic tools can be regarded as an attempt to develop standardized methods of listening. The results of this process, therefore, can never have the same objective status as in medical science, and the focus is not so much on the measurements themselves, but on the interpretation of the results.
Any diagnosis that uses psychological testing, even with today’s computerized renditions, always yields relative results. This relativity has as much to do with the fact that the results need to be evaluated against a representative group to which the tested person belongs, as with the fact that the parameters for measurement themselves can never be exact. As I said before, there is no precise unity of measurement for anxiety, for neurosis, and other states. This is the classic problem of reliability and validity (as discussed below). Consequently, the results still require interpretation, and it is at this point that the experimental field proper is left behind. Interpretation—assuming we are dealing with valid and reliable instruments—must be performed by the diagnostician according to the principles of the theory she or he has chosen. Without interpretation, the results remain largely useless for their specific clinical psychological application, and can be employed, at best, only from sociological and epidemiological perspectives. Again, this is an argument for focusing not simply on methodology but, first and foremost, on an overarching metapsychological theory of clinical psychological diagnostics.
It is striking to observe how, in test-based diagnostics, such a metapsychology is virtually absent from most handbooks. The history of test-based diagnostics shows a clear shift in emphasis toward the theory of test construction, itself both important and necessary but insufficient for actual interpretation and clinical application. To the extent that tests do make use of a grounding theory of psychology in the construction process, they rely on an elementary functional psychology. The basic idea is as follows: psychological functioning can be divided into separate component functions—memory, intelligence, attention, emotion…—for which individual instruments of measurement can be developed. Again, the classic example is the intelligence test.
The history of the intelligence test shows the limitations of such an approach. While intelligence was originally studied as a completely isolated function, it rapidly became clear that this view was far too restricted.10 The final outcome contradicts the basic assumptions of functional psychology: intelligence cannot be isolated, but forms part of the global psychological functioning. For example, in a Rorschach session we can easily observe how someone’s intelligence functions, just as, similarly, in a typical intelligence test we might be faced with how the test subject copes with anxiety and authority.
The practical effects of this are twofold. First of all, a psychodiagnostic examination always needs to call on a variety of instruments to get ahold of the complexity of psychic functioning in its totality. The concept of independently measurable psychic functions is simply not applicable from a clinical psychological perspective. Secondly, the exam’s utility will be ascertained by the interpretation of the results. To put it differently, the quantitative factors gain their function and signification only by way of qualitative factors.
A decision regarding next steps will be made on the basis of the foregoing diagnostic elements. From a medical perspective, treatment typically comes next. The ideal goal is to cure, that is, to return to the state prior to the illness, with as complete a removal as possible of the symptoms. It is striking how in this context the two processes—diagnosis and treatment—can be neatly separated. As a result, they need not be performed by the same person. Indeed, with the increasing specialization of medical practice, this is becoming less and less the case.
In our profession, however, things are a little different. First and foremost, diagnosis and treatment are less visibly separated. It is by no means exceptional if, during the treatment, a diagnosis is changed due to emergent additional information. Indeed, research shows that additional information may change the diagnosis considerably (Dingemans, cited in Van Lieshout et al. 1987). Moreover, the diagnostic process itself inevitably entails some element of treatment. The great majority of recent studies of psychotherapeutic efficacy indicate that the most important operative factor is the therapeutic relationship, and this is established right from the first interview, even if that has a merely diagnostic aim. As a result, it is far from self-evident that the diagnostician and the therapist need be two different people. When this does occur, a predictable enough scenario ensues. Often, the therapist regards the first interview as a rapid recapitulation of what already occurred in the diagnostic examination, while the patient complains that she or he “has to say it all over again.”
The second difference is potentially even more significant. The goal of medical diagnostics is to indicate the correct treatment for eliminating the illness. Earlier, we noted how psychic symptoms carry meanings and have a function that transcends the individual. Now we can go a step further and say that psychic symptoms invariably come down to a patient’s economic attempt at a solution for an underlying, structurally determined problem. “Economic” here signifies an accounting paradigm of loss and gain. By “structural” I mean to indicate that the problem is not limited to the individual, but must be understood from within the terms of a relation with significant others. The teenager’s joyriding, for example, was his solution to the problematic position he adopted toward his parents and their own relationship. To put it briefly, let us simply recall that classic argument of psychoanalysis: psychic symptoms are the patient’s attempts at recovery.
The consequences of this view are far reaching. For instance, it implies that certain symptoms can yield more gains than losses and that, as a consequence, there can be something like a “successful” symptom. More often than not, in the course of the first clinical interview the diagnostician concludes that the client has suffered under the complaint for several months, perhaps even years. Why had there been no previous call for help? Something must have changed in the balance sheet wherein the loss has finally become too big, leading to the consultation. An important psychodiagnostic question therefore is: Why has he or she come now, what caused the change in the balance of gains and losses? Moreover, it is likely that certain symptoms, within their own defining structure, will always produce more gains than losses and, for that reason, rarely offer themselves up for analysis. Exemplary in this respect is what is involved in the fear of failure. This fear must always be understood from a structural perspective: one fails (or doesn’t fail) in relation to someone else, as determined by the underlying context. The complement of this is the compulsion to succeed: one succeeds (or doesn’t succeed) in relation to someone else, again within a structurally determined context. The latter symptom is rarely presented for consultation, except in contemporary cases of burnout.
The implications for treatment are radical. The patient’s implicit demand almost invariably boils down to a demand for the restoration of the previous economic balance, rather than for the removal of the symptom itself. We will encounter this later on under the appellation of the “flight into health.” Nevertheless, a psychotherapeutic approach ought rather to be directed toward the underlying structure. Should the therapist forget this, she unwittingly collaborates in restoring the symptom’s economic gain. It is in such a way that “revolving-door” patients are made who, with each subsequent swing in the balance, knock once more at our door. Ideally, psychotherapy should not focus on the elimination of symptomatic behavior. The most important aim of the treatment is rather to effect change within the underlying, structurally determined relation with the Other through which the symptoms originally materialized. The implication, then, is that it is expressly upon this relationship that the psychodiagnostic process needs to focus.
A comparison of medical and clinical psychological diagnostic procedures reveals a number of significant differences.11 Central to medical diagnostics is the gaze, whose focus is on detecting signs that point toward objective, measurable parameters. In contrast, in clinical psychological diagnostics the focus is laid primarily on listening to signifiers that remain open to interpretation. Medical signs pertain to an illness scenario; signifiers, on the other hand, derive their meaning and function from a specific relation with an Other. The distinction between illness and health can be measured and generalized, but psychic normality and abnormality are always relative and, hence, particular. Moreover, certain psychic symptoms can best be understood as attempts at a solution for a particular structural relation with the Other.
Consequently, any data resulting from a psychodiagnostic examination must invariably be interpreted. The basis for such interpretation must be a governing grounding theory, combining quantitative, experimental-diagnostic results on the one hand, with a clinical psychological theory of the development of psychic identity on the other. In clinical practice, we frequently encounter an intuitive diagnostic that fails to take the previously discussed limitations into account. Such a diagnostic practice is best described as an exercise in naming, evoking the Biblical injunction to “go and name the things.” It is this practice that is the subject of the first part of this book. The second part offers an elaboration of a metapsychology that forms the basis for clinical psychodiagnostics proper. The third part discusses the differential diagnostics itself based on this model.
1. A sign always points to a fixed meaning: a red traffic light means stop. A signifier refers to an underlying, ever-changing signified, with the result that it is impossible to talk about a fixed meaning. Meanings are determined by the larger linguistic and sociocultural context in which this particular signifier is used. (Compare the difference of the signifier “sheaf” in these two quotations: “His sheaf was neither miserly nor spiteful” and “Alas! How many would sooner steal their brother’s whole shock than add to it a single sheaf!”). See the structural linguistics of de Saussure (1976).
2. Even the measurement of intelligence has long been contested. It is also not clear whether there are objective external parameters. Hence today’s cautious definition: intelligence is that which intelligence testing tests.
3. A simple example. Ernest Jones (1931) identified three ideals as the goal of analysis: “happiness,” understood as a state free from anxiety; “efficiency,” that is, “the full utilization of the person’s potential,” and “adaptation to reality” especially in “relation to one’s fellows.” With Bettelheim (1979), we can say that someone who is completely free of anxiety will never realize anything at all, because anxiety is the human driving force par excellence. This idea was given a genetic and species-specific basis by Monod (1970). The second criterion, “the full utilization of a person’s potential,” is in complete contradiction with the first, as well as appearing somewhat exhausting. The third criterion became Hartmann’s (1939) cardinal question, for which we can immediately offer an example, from only a slightly later date, of a man by the name of Eichmann as someone who was perfectly adapted to his social reality.
4. A contemporary example of this, occurring among counsellors, is burnout syndrome (Vanheule, 2001a–c).
5. This is impossible with certain patients due to a combination of biological, psychological and social factors. At such moments, one leaves the field of psychotherapy proper to work from a much more forceful angle.
6. This has been easy to recognize in the history of the “free west.” One need only look at this segregation in the example of Benjamin Rush, father of American psychiatry. Following the American civil war (itself fought over the issue of segregation), this scientist discovered two new forms of mental illness, Anarchia and Revolutiona, both all but incurable disorders, demanding radical “medical” treatment. This keen observer later laid claim to another great discovery regarding the “breakdown in the belief principle or the power to believe.” This intellectual power is subject to disturbance or illness, leading to an inability to believe in things that are manifestly obvious to belief itself. The most significant subcategory of this dangerous disorder concerns “people who refuse to believe in the benefit of medicine.” Anyone at all familiar with the structuration of the hysterical clinic and the relationship between the Hysteric’s and Master’s discourses might readily recognize a number of things here.
7. “Normophilia: a condition of being erotosexually in conformity with the standards as dictated by customary, religious, or legal authority” (Money 1988, p. 214). Paraphilia, hence, is being not “in conformity.”
8. The Lacanian term “Other” indicates the totality of the typically human elements present in the concept of nurture (education, culture, teaching, media, etc.). These elements exert themselves in every individual through language and, hence, through the Other, particularly during development. We will return to this in detail later on.
9. The drama usually begins with the second generation, with the pupils’ application of the theory. The phases that originally were deduced from a large number of nuanced and hence valuable clinical experiences, and which, as a result, present only a standardized picture, are frequently adopted by the second generation as a straitjacket. The classic example is found in the idea of libidinal organization as developed by Abraham and Freud, in which a specific function is considered every time in relation to the castration complex. Fifty years later, this nuanced and difficult theory served as a chapter in practically every training course for pediatric nurses, who learned that a child must first go through the oral phase, following which he or she enters the anal phase, only to arrive finally in the genital paradise. Woe to the 3-month-old playing with his willy, he is too early (must be precocious)! A less familiar and more poignant example concerns support for the dying. From the Kübler-Ross studies, we know that the process of dying can pass through a number of phases that appear in a certain sequence. I myself have witnessed a case in a university hospital where a dying patient was obliged to follow the “right” sequence of these phases by the well-meaning psychologist in order to die in the “right” manner (i.e., “shock and denial, anger, bargaining, depression, acceptance”—Kübler-Ross 1969).
10. Binet’s initially relative definition rapidly became, despite his protestations, an absolute law for Terman and his colleagues to the extent that IQ became the indication of a presupposed, tangible, measurable entity “somewhere in the cortex” (Konner 1982, pp. 441–444). It is nonetheless striking how the impasse of such a line of reasoning has given rise to an ever-growing expansion of the concept. Beginning from a theory involving dual factors to one of multiple factors, and toward even further partitioning (including, with the latter, the monstrosity of “emotional intelligence”). Ultimately, it seems that “intelligence” has become a synonym for practically the entire psyche (Jansz 1986, pp. 60–61, 80–81).
11. In this account I have reduced medical diagnostics to a purely mechanical-biological matter. Contemporary medical practice is, fortunately, taking more and more psychological factors into account.