Diagnosis (S01E003)

In this episode of The Subject of the Unconscious, hosts Neil Gorman and Isolda Alvarez delve into the complex topic of diagnosis within the framework of Lacanian psychoanalysis. They discuss the distinction between traditional DSM diagnoses and the Lacanian structural approach, emphasizing the unique and subjective nature of mental suffering. The conversation explores how diagnoses are used, both within and outside the psychoanalytic context, and considers the implications of labeling and over-diagnosis in contemporary mental health practices. Join Neil and Isolda as they navigate these intricate issues and set the stage for a future discussion on the concept of nonsense in psychoanalysis.

What is Subject of the Unconscious?

A podcast where there are relaxed but serious conversations about Lacanian psychoanalysis and the way it affects (and is affected by) the imaginary, the symbolic, and the real today.

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Neil: Hello and welcome to the subject of the unconscious. I am one half of the podcast. My name is Neil Gorman, and I am joined by my accomplice. My co-host Isolda Alvarez. How are you doing today, Isolda?

Isolda: Very well, Neil and you?

Neil: I'm okay. I. Feel maybe slightly nervous because we are going to talk about this gigantic topic today. Definitely not say everything there is to say about it, but maybe start to say some of the things that can be said about it. That topic is diagnosis and the way in which. That concept has, been used, I think within the context of Lacanian psychoanalysis.

So I'm gonna start by asking you a question and we'll see where this goes.

Why do you think that this would be a interesting topic for us to cover on the podcast?

Isolda: I think that it is important to clarify what [00:01:00] is the relationship to the contemporary psychoanalysis or the Lacanian orientation, to say the least, to diagnosis for two reasons. One, it doesn't mean that we are against diagnosis.

I think that needs to be clarified. And I hopefully will do something like that in today's episode. And, second I think the reason over diagnosis right now, within the mental health, spectrum or regarding when you talk about psychologies, mental health, family therapy, psychiatry, I think there's an over diagnosis.

There is a Push to diagnose and make labels about any type of suffering. And in my humble experience that doesn't, brings relief completely. Although sometimes people could feel better when, because they have a name and as we explained before, that gives meaning or purpose or helps to make sense or whatever is happening.

[00:02:00] But that doesn't mean that actually you're. Stop the suffering because you have a name or a label to grasp whatever is happening to you. So I think because of those two huge elements, I think it will be important to talk about diagnosis. And what's the position at least the one that I understand, the Lacanian orientation has, towards it

Neil: That's an awesome introduction I think. So thank you for giving that. As you were speaking, the thought that came into my mind is that like all signifiers, the word diagnosis, what it signifies can slide. It doesn't necessarily mean the same thing. And there are all sorts of different kinds of diagnoses that people can mm-hmm.

Come into contact with, be labeled with, seek out, et cetera. And the way that Lacanian psychoanalysts think about diagnosis is probably a lot more [00:03:00] simple in a way than the way that other. Disciplines. Think about diagnosis. I have no idea how many diagnoses there are in the DSM at this moment. There's a lot.

Tons and tons of different diagnoses. Yeah. And subcategories within different diagnoses and so on and so forth. And within the lacanian orientation, I can think of a handful. You have two different kinds of neurotics. You have obsessives and hysterics. You have. Triggered psychosis. untriggered psychosis sometimes also called ordinary psychosis and possibly this other category called perversion, . So that's the way that Lacanian, I would say. Those are the categories I guess, that we're working with . Do you want to add anything to those?

Isolda: Yes. I would like to add a provocative question. Maybe

Neil: I love provocative questions.

Isolda: Because, yes, there are diagnosis, but also we work with [00:04:00] these categories that you call it, thinking on more like structures. Mm-hmm. So beyond the fact that we may put together a certain phenomenon or say with this person or this object works or function, or, , embrace. Its own suffering or enjoyment in this way or the other way.

The most important thing is how the arrangements or what deals this subject is able or capable to do in order to not suffer that much. So we can say like maybe among us, psychoanalysts, we say, this is the differential diagnosis. This is white da, da da. But it's not something that is, , important or significant in the treatment when you are with the patient, which is a quite different when you talk about psychologist or a mental health or psychiatrist, because usually the diagnosis is discussed and communicated.

Quote unquote, to the patient. We don't work. [00:05:00] The same way is a guidance and orientation for us. The professionals are like listening or the one that is trying to occupy the place of the psychoanalyst, but it's not something that is discussed with the patient. Not because the patient cannot know about it, but because it doesn't help at all.

To the suffering or oriented the patient at any point, when you're working with it. I'm not saying that in psychiatrist is not important. I'm not saying that in psychology it isn't. They obviously have their own reasons and is a different way or a different approach to deal with the suffering of the human beings.

But in the county orientation. Could be many other things to do to try to orient the subject, the patient, regarding to his or her own suffering. But we don't go there with our patients and say like, whoa, you have a neurosis and you are an obsessional patient and that's why you can't stop thinking about certain things or certain stuff.

Da da da da da. I just want to put it like. [00:06:00] And the question will be up to what extent, , if it's actually the same to say structures and diagnosis for us.

Neil: You said something there that I think is important and probably makes sense to people if they are really familiar with Lacanian psychoanalysis as a clinical practice.

But I'm gonna assume that some of the people who are listening to this are gonna be either unfamiliar or less familiar with that. And try to explore this a little bit here. So there's, you use the term differential diagnosis. Mm-hmm. And differential diagnosis. What is that? Well, I just named those different categories.

Obsessive hysteric triggered psychosis. untriggered psychosis, also sometimes called ordinary psychosis and perversions. Mm-hmm. So there's five things there. We would say that those things are kind of shortcuts, is how I think of them. Maybe you don't think of 'em this way, maybe other Lacanians don't think of them, but I think of them as shortcuts.

And what I mean by shortcuts is that if I'm going to bring a case to [00:07:00] supervision, because there's some aspect of the case that I feel unsure about and I'm gonna be bringing it to a supervisor, asking them to help me think about it in, in a way they're gonna need to know something about the case.

And they're gonna know what I can tell them. I can tell them various things about the patient. One of the things that I might say is that I suspect that this person is a hysteric, or I suspect that I have an ordinary psychosis here. Something like that. And that's a way to get them to have the start of an understanding of what's going on.

But it is not something that, as you said, is super important.

Isolda (2): Mm-hmm.

Neil: As in, okay. Because the person is this, therefore you must act in this way, or that means that they're absolutely like this or that they meet six out of 12 categories and have done so for three months. Yes, but not greater than six months or, or so.

Exactly. The way exactly it is exactly in the [00:08:00] DSM. In addition, it has absolutely nothing to do with, how we would bill, which is, uh, I think, you know, I, I wanna be careful with how I say this here. I get the impression sometimes working within the American mental health system, that diagnosis primarily operates as a billing mechanism.

And it does other things too. But that's a real big reason that I think it exists in the way that it exists, in the way that it's coded, in the ways that it's coded on official documents and whatnot. That's not what Lacanians are doing. Again, this is. These terms provide kind of a shared understanding to a point so that we can kind of discuss the case amongst ourselves, and so what we can think about the case as well, even if we're not discussing it with our colleagues, we might need something that we can use as a concept to start to think about this person.

However, of the things that I think is key is that while it is a starting point, it's something that opens up more questions than it provides answers. Yeah. Is how, what I would say, meaning that [00:09:00] if somebody you have, say you have a caseload of 10 people, and let's just say this is probably very unlikely, but let's just say that all 10 of those people are all obsessive neurotics.

Every single one of them you would describe as an obsessive neurotic. That doesn't mean that you're treating all 10 of those. Obsessive neurotics in the same way. Chances are, you're treating them all very differently because each instantiation of obsessional neurosis is the one and only totally unique instantiation of that structure

Isolda (2): Yes.

That you

Neil: will ever come across, ever. Right. It doesn't provide necessarily. A detailed like kind of GPS style map. Turn left here, go for, mm-hmm. Three miles. Turn, turn right. Stay in the middle lane. It doesn't do that again. It, it's just like, this is a thing that I can use in a sense to orient myself a little bit, but then there's the questions.

Why have I decided this person is an obsessive? How is it that maybe that structure came to be in their experience? How is it that they [00:10:00] have suffered as a result of being an obsessive? What have they tried in order to alleviate that suffering? Has it worked, has it not, so on and so forth? It's this question after question, I think, but that's the thing that you can use in a way to start it.

I think in other disciplines, the way that diagnosis structures is as an answer. This is what we are going to say this person has, and we are saying they have it in order to justify doing certain things or not doing certain things. So a kid might come to a mental health worker and they might be seeking out a diagnosis of A DHD.

Or they might go to a psychologist and get some testing done to see if they have PTSD and if they get these diagnoses. Sometimes what that could mean is that they now become eligible. For certain services. They might be able to get extended test time at school, or they might be able to have a support animal that they bring with them [00:11:00] to work,

Isolda (2): or,

Neil: but they need the diagnosis in order to justify doing these different things.

And so I think that's, and again, I don't think it only has to function that way in other disciplines. I, I wouldn't wanna be that reductive, but I think that that is the way it functions often in some of those other disciplines, which I think is very different. Then the way that diagnosis as this structure, this kind of way of thinking is used in the LACANIAN orientation.

So I just said too many words and I'm going to stop talking and let you say something probably smarter than what I've said.

Isolda: No, no, I think it's quite, um, quite important what you just explained because it shows the difference. The differences, um, between, uh, uh, Le Canning orientation and any other type of, like, uh, approaches related to the mental health field?

Uh, I do think that if I, I could like summarize it. I think the diagnosis in the Le Canning orientation orient us. [00:12:00] The direction of the treatment, it has nothing to do with the patient. The patient doesn't have to take care of it. We take care of it. It doesn't mean that sometimes we don't work with certain diagnosis.

We actually do, and when we work in an interdisciplinary committees. For example, with, uh, maybe another therapies or a psychiatrist, we do take into account certain diagnoses, not because that's going to resolve the problem, but most, the majority of the cases is because that gives you an orientation also, the what is the relationship with that subject, with that label, if not the same.

When someone gets to our offices and say, hi, I am. A-D-A-D-H-D person that a, I have a DHD is not exactly the same. And that brings me to the point that you made that I think is, is super important, which is the, um, this [00:13:00] idea, um, on how, how in the mental health field is used. The thing about the diagnosis, one thing is to put together a certain phenomenon and say, this is how I'm gonna call.

This. So this is it. And that helps or not to the patient to try to relieve and kind of create certain knowledge, quote unquote, about what is happening to, to himself or to herself. And another one quite different. When you say that, we can put certain things together that orient us. But it is just for us to try to orient us in our practice and the treatment.

And it is nothing to do with the idea that these diagnosis is universal at any point. It's not a standard. It's not like a, whoa, you have three obsessive five hysters and three phobics, and this what you do with all of them. It has nothing to do with that. That's what I was putting out there at the beginning, the question of the diagnosis or the [00:14:00] structure, because you have a structure kind of way in a particular way.

So you have 2, 3, 4 or five obsessive patients, but each one of those patients have a singular and unique relationship with their own suffering, and that's what we're interested in. Not as much as the diagnosis, , in as much as what are the singular ways in which this person, this object. Is related to that aspect of his or her life that bring like obstacles, consequences, make him or her suffering the things that she or he can't stop doing, although they want to stop them, that sort of thing.

I think that's very important to put it out there because sometimes I, her Neil, like around, especially in the community and mental health in the us well psychoanalysts are just against diagnosis. No, we are not. It's just a different type of use that we give to that.

I got a patient the other day that [00:15:00] came to my office and said hi, I am bipolar.

I said, okay. Uh, how is that related to the suffering that brings you to my office? So. She started explaining well, because of this, because of that, da da da da da da da da, okay.

I got another kid that was diagnosed with A DHD, and when I asked the mom and the kid, they couldn't actually identify anything related to what actually brought them to the office.

So you see there is a case in which, yes, there is something that that patient kind of identify with, and there is another one that. Might help the insurance, as you said, to bill for that, session , but has nothing to do with the concern of the mom and nothing to do with the suffering of the kid.

So you have their, like, differences there.

Neil: , I wanna try to, add some stuff to what you're saying here. At least make an attempt to do that and. I don't know if this is gonna work or [00:16:00] not. This is gonna be probably circuitous in the way that I try to make a point here.

I hope I can remember the point by the time I get to the end of what I'm trying to say. So here's, this is an opinion. I don't have any sources to back this up. This is just kind of based off of the time that I have been practicing in various mental health systems here in the United States as a psychoanalyst, and not because I wasn't always a psychoanalyst.

Mm-hmm. And the times that I've spent within , a school of social work teaching about different things like public policy and mm-hmm. And whatnot, which are things that social workers tend to be pretty interested in.

I would say that in the United States, one of the things that happened is that we had medical problems that people experienced, and when they had a medical problem with their physical body, say they are having stomach pain.

Mm-hmm. And it really hurts really bad. And it hurts so bad. They go to the emergency room. When they get to the emergency room, they're gonna [00:17:00] do different things and they're gonna provide a diagnosis, let's just say, to make this easy, that the diagnosis ends up being appendicitis.

Isolda (2): That's

Neil: what brought the person into the emergency room.

You're suffering, you're in pain. We identify what the pain is coming from. It's , a problem with your appendix. What do we do? Well, we do surgery to take your appendix out, right? And so they'll bring the person into surgery and, you know, hopefully all goes well. They'll remove the appendix, they'll stitch the person up, and then they will basically say.

After a while, are you still experiencing that suffering? Probably the person will say, no, I'm not. I have some discomfort from the surgery, but that will, diminish as time goes on. And then they'll have a couple of follow ups with their surgeon and they'll go back to feeling pretty normal like they did before they had this problem.

And that means that the treatment was a success, right? Yes. There was a problem. You went to the people who knew how to fix the problem. They figured out what the problem was, they did their things, and now you don't have that problem anymore. Yay. And that's a really great way probably to [00:18:00] handle.

Physical medicine, if I fall, , and now my arm hurts really bad and I can't move it, and I bring it in and they x-ray and they go, you have a fractured bone. What we're gonna do is we're gonna set that, we're gonna put a cast on there, leave it on there for a while, we're gonna take the cast off eventually, see how it is, and, maybe you, you've lost some strength and stuff because it wasn't a cast, but you do your physical therapy or occupational therapy and you get back to where you were again.

Great way to fix a problem that has occurred in a person's life. Well, my opinion here, again, underlying opinion is that style was taken out of physical medicine and applied to mental health practices.

Isolda (2): Mm-hmm. That

Neil: when people have suffering, that is what we could call mental or emotional or a combination of those things that will treat it the same way we do a physical ailment.

We'll diagnose it, we'll perform a series of operations. Do different interventions , and attempt to fix that. If that [00:19:00] works, great, we, I'm using my fingers to do the air quote thing, terminate therapy. Mm-hmm. Send the person on their way and that's what.

The medical insurance companies wanted. That's sometimes what the patients want. There's lots of people who probably want it to be that way, and that's kind of how the diagnosis was functioning in medicine. And then I, according to my argument, the way that some mental health practitioners and institutions attempted to copy, and I think in psychoanalysis and Lacanian psychoanalysis, we do not work in this way because.

And there's a lot of reasons for this. So this is a pretty brutal summary. Maybe there are certain things that a person may speak about in their psychoanalysis, and through speaking about them and hearing certain things that the analyst may say in response, they may experience what we'd call therapeutic effects.

Hmm. Certain problems that they come in with will stop being problems as a result of going through this however. [00:20:00] There are other problems, other forms of suffering that people bring to us that are not going to go away. You don't get to mm-hmm. Fix that. Mm-hmm. You don't get to the cure does not mean that that thing is no longer a problem in your life.

However, the relationship that people have to their suffering to what uniquely makes them suffer is something that can change. The person has to be the one to change it. The analyst can't be the one to change it. The person is the one who does that. They have to figure out and create and then maybe maintain or modify the ways in which they are relating to the suffering that comes from just being a person in the world.

This isn't something that there is a definite. Kind of cure, fix to, it doesn't work that way in psychoanalysis. So that was the first thing. The second thing here that I'll say, and then I'll be done, is that the way that this orients my clinical practice, and I [00:21:00] think I even said something about this in our last episode, is that when a patient comes into my office, my assumption is that they are the expert.

I am not. They know their life. I do not, they know their suffering, not me. They're the expert and. What I'm thinking diagnostically , in a way, what I think I'm trying to do is learn something from them about their subjectivity, about their suffering, about their history, about their mode of jouissance. All of this stuff.

They know that I don't, and I'm hoping that they'll teach me something about it, and then I ask them things or I say to them, this is what you've taught me. And then they might respond to that by saying like, well, that's. Exactly what I was hoping to teach. Or they might say, well, that's completely wrong.

I can't believe you would think that. And then we try again. Right? But this is the way that it works. And. I'll draw a conclusion like, based off of how that's going, that this person is probably a psychotic or a neurotic, and then the [00:22:00] different subcategories that exist within those two things, and so on and so forth.

And that'll just aid my thinking, but that's the way that it's working. So again, that was a long, kinda circuitous path. I don't know if there's anything in there that you think is interesting enough to respond to, but, if there is respond and if not, go off in some new direction.

Isolda: I do think it's interesting because you put out there.

If I take it with my own words, something that I think sometimes people , don't have in mind, which is from where this model was taken, it's true. It was taken for the physical model, which is medicine, and the body works in a very special way. You don't ask the stomach what interpretation has about the pain that it has.

The stomach is not interpreted anything. It just like functioning or doesn't functioning. That's it. There's no questions asked. What I think is important in this line of thought that you introduced here, Neil is that how subjective suffering is not linear.

I'm saying that right. It's not like a line

Isolda (2): linear.

Isolda: It's not like you go [00:23:00] like 0.1, 0.2, 0.3 and that's it, because ups and downs. Then you discover something and then you go back to that and then you, uh, overcome that issue. And then the same issue jump from another side, another point of view that you didn't thought before or you haven't been able to see it that way.

So it's not linear, it's not a line. That you go like with the treatment for appendicitis. I mean, you do. You take this, you go to surgery, then you take this medicine, then you eat this, and that's it, period. It's fixed. I don't think there's nothing to fix when is about subjectivity, and that is something that I think we discussed I think it was the first episode when we talk about the standards and the principles.

So ethical principles. One of our major ethical principles actually is that we take each case is in its own like unique. You don't know at that point I'd agree with you. I don't know what I have in front of me until the person start like talking and is speaking about his [00:24:00] own issues. I might know how to orient the suffering or I might know maybe what point to try to extract.

Or the questions that I'm gonna ask, but I'm not the expert or I don't have, I don't pretend to have any universal standard knowledge about how this person is gonna feel better or worse, or what decision this person has to make Among many of the things, because subjective suffering is just. Not linear.

It is not like chronological time. It has certain logic. Yes. And in the speech and the narrative is precisely what I think we try to, highlight and kind of say, but wait a second. You say this and now you want this, but how you gonna get to these if these other things are not paying attention to? And maybe the patient will go, oh.

Wait, I didn't think about it in that way. So you kind of introduce another perspective, [00:25:00] serving yourself from the inconsistencies of the speech or from the contradictions of the speech of the patient or even the same questions that the patient is asking you, which we know is not.

Those are no question that the patient wants us to respond. It's just a way to questioning him or herself. So I think this idea that there's nothing to fix and that subjective suffering is not linear as might be certain treatments, and that when we're talking about physical. Stuff is very important to put it out there on that regard.

And I'll finish my comment with that. Belgium, like. 10 years ago was asking questions and putting questions out there about how can we measure and distinguish, physical pain from subjective pain. And one of their argument was like, usually. With physical pain. Everybody goes oh my God, yes, we understand that and we can measure it [00:26:00] and we can put it out there, and everybody's going to understand how much you pain you have.

And then they go and say like, why don't we take like that subjective pain? Why subjective pain? Usually it's not taking as seriously as. Physical pain and they actually put out there an answer. Say, well first, because maybe we can measure it the same way

we have certain things in scales and tests that we can use in psychiatry that gives you. Sort of quote unquote a scale or number, but it is subjective. It is untangible. You can like touch it, you can say and actually see if an organ is working or not. But when someone is making poor decisions, you can't measure that.

Psychology tries to and put a lot of efforts on it, which is quite respectable, but it's not the orientation that we get , in Lacanian psychoanalysis at least, among many other things because we're not paying attention to the [00:27:00] morality of the choices. It's more a problem of ethic, for example. What is the ethical.

Principles that made that person make this choice or not. The other one, if you identify with a diagnosis, that's why though that's functioning for you, what use are you giving to it and not as much as well that's what you are. So that's my comment. I don't know if you would like to jump on it or not.

Neil: Yes. Just one quick clarifying question. When you say subjective pain, would it be fair to say that another way to describe that would be emotional pain?

Isolda: Yes. The problem with the emotional word or signifier is usually, people relate emotions with, sadness, love, anger. And it's not just that.

It's when you can't stop thinking about something or when you don't know what. Choice to make or when you don't. That's what I was referring to when I says subjective, kind of related to your psychic, your mind, not [00:28:00] just like, uh, the physical aspect of Right. The human being.

Neil: I was asking that just be because that's an important distinction . As you were saying, if somebody. Has a physical ailment, like a broken bone, yes. That's gonna be understandable, to people much more so than somebody saying they're depressed or somebody saying they have anxiety

Isolda: or grief. The grieving process. Sure. I receive a lot of patients saying I'm depressed and I've been depressed for like four months.

And then I start asking, well, what happened? And like, you know, four months before, well my dad passed away. So wait a second. Maybe it's not depression. Maybe it's a grief process. That's very subjective. That's quite intimate and singular. Not everybody confronts a loss of the of loved one in the same way, or take exactly the same time. So that, I think that's a really good example in how to differentiate if it's actually a depression or [00:29:00] if it's just sad.

Neil: Yeah, I mean, that makes me think about.

The, there's people have written about this, I can't think of anybody off the top of my head, but I'm sure that this concept will be understandable for everybody hearing this. There can be people who, two kids who grow up in the same family, go to the same schools, have the same parents, so on and so forth, a lot of similarity between their two experiences.

And then their parents could get divorced. Right? One of these two kids, maybe has some trouble dealing with that. But they're basically what we would call, okay. Right. They don't have any major disturbances in their life that they attribute back to that divorce or that other people attribute back to that divorce.

They live their life largely without issue. And there can be the other kid in the same family, like I said, with all the same stuff who dwells on it and really, you know, suffers because of that. Well, why does one kid suffer and the other kid not?

Isolda (2): Mm-hmm.

Neil: Right. [00:30:00] This is a, an excellent question. To, to bring up.

I think, and this kind of brings me back to the point that I was trying to make earlier, and I hope I succeeded in making at least a little bit here, that the patient is always the expert here. And I think that's important because it seems to me that maybe I'm not sure about this. This is a real big difference between the psychoanalytic.

Style and other styles. When I go to an eye doctor, I expect the eye doctor to be an expert on eyes and to be able to know things about my eyes that I can't know about them, and to tell me things about my eyes, like what kind of prescription I need for my glasses. To tell me if I have glaucoma or not, right?

I can't, I don't know that, I don't know how to, how to figure that out, but they do, and I want them to use their knowledge to tell me something, and I don't think there's anything wrong with that. I don't think there's anything wrong with people going to doctors seeking concrete answers to certain medical problems that they're having.

I think that's a very understandable thing to do. [00:31:00] However, when it comes to what I think you're calling subjective suffering, it can't work that way. I don't think, I don't think that you or me or any of the other psychoanalytic people who we know can be the expert on another person's subjective experience.

They cannot do that. They have to say to the person who comes to their office as a client or a patient, or an analysand, and please tell me about your suffering. Teach me about what is going on with you. Teach me about. What has happened that has led you to this place, so on and so forth. They are the expert, not me.

Now, it's not to say that I don't know things or that you don't know things or that psychoanalyst don't know things. We do know things, absolutely. And yes, we can use our knowledge and the work that we do, but when it comes to the way that we're working, I think with other people and their suffering, that's something that [00:32:00] exists outside of our knowledge and so we need them to tell us.

What's going on? We need them to tell us the answers to the questions. We bring the questions, I think more so than the answers. So that's one of the things that I wanted to say. Then I wanted to kinda give two examples and see what you think about both of these e examples

Imagine the two following things. These are not, I don't have anybody specific in mind when I say this. I'm truly spit balling this. There's. Somebody who comes to your office and they come in and , , you're learning about them. They're telling you all the maybe typical stuff that people say in a first session.

And one of the things that they say is, I have been diagnosed with, and they put something in there. Right. I have been diagnosed with clinical depression. I have been diagnosed with ADHD, I have been diagnosed with borderline personality disorder, whatever.

Isolda (2): Mm-hmm.

Neil: A lot of times when it happens to me, they're saying it in such a definitive way.

Mm-hmm. As if this is so important. And my way of responding to that is to say, [00:33:00] tell me about why. You're telling me this. Tell me why that is important to you. Tell me, why it is , that you sought out that diagnosis or somebody, gave you that diagnosis without your consent.

I wanna know about that. Right. I don't assume that tells me much. About it and we'll discuss that diagnosis sometimes in those sessions. The second example I want to give you, and this goes back to something you said very early on in this podcast, that we often don't discuss the structure with people.

I find that sometimes people, especially if they're very interested in Lacan, we'll come in for an initial session of psychoanalysis and in that initial session or one of the first few sessions, they will say, I think I'm a hysteric. Or, , I'm pretty sure that I'm an obsessive, or this happens more often lately, I'm really worried that I might be psychotic.

They'll use that vocabulary themselves and they'll want to talk about it. And it's interesting 'cause I don't think there's, it's very [00:34:00] contingent on how it gets brought up and the person bringing it up and stuff. Sometimes it gets discussed, sometimes it doesn't.

But sometimes I will discuss that with the person and I'll discuss it in those terms. So I Wanted to toss those two examples out to you to see what you thought about either of them, because in both, I think you're kind of discussing the diagnosis in a way, either the DSM style diagnosis or the more structural Lacanian style differential diagnosis.

Isolda: Okay, Neil, here we go. As here we go. As we said before, each psychoanalyst has its own style, right? So within my style, there's one thing that I want, those things that I wanna say that I quite related to what you just said. They might be the experts, but with all due respect based on the conception of the unconscious, I think they don't know.

They don't know how much like expertise they might have or not about , the suffering that they have. Why? Because usually the patients [00:35:00] ask, but tell me what to do, or tell me how can I stop this or tell me it's true that our position is more like, well, you tell me. What do you think?

But I think they might be the experts, but they don't know that they are. And part of our invitation, or at least my invitation is like let's. Elaborate about it. What can you say about these or that specifically, an example that you gave? Well, I'm bipolar. I've been diagnosed with this.

Usually I don't go there that much. I said okay. does that, diagnosed has anything to do with what brought you to my office today? What does that mean for you? Yes, that's the diagnosis that you have in the DSM, but what you can say about it? And the second point is that sometimes, especially with those that are.

Interested in psychoanalysis that they decide to pursue a psychoanalytic treatment, and they get to the office and say the big [00:36:00] question, which is trending right now, am I psychotic or not psychotic or neurotic or hysteria? Oh my God, I don't know. I'm obsessive. I think it's a trap. I think it's precisely the point in which the patient's showing you how they don't wanna know about the actually what's happening, because the name is not gonna solve anything and it might be like the tangent?

Tangent is how you say. Do you go like around whatever you got going around or whatever you have to actually trying to avoid to pinpoint or talk about, because the theory in the couch doesn't work for anything. When you are in a session, you can talk about this, da, da, da, da, but what is actually important, and it makes important changes, is precisely when you put your subjectivity there.

And yes, I understand that my, the question that someone or my people have about the structure that they have, the diagnosis [00:37:00] that they might have is telling a lot about their own subjectivity. Yes. But in my own style, I usually don't go there because I think if they're asking that they're trying to avoid, to ask another type of questions that are more related with their own singularity and it's just kind of, um, seduction.

Oh, you are a psychoanalyst. I'm gonna talk about psychoanalysis. Yeah, welcome. But I'm not interested on that. I can talk about psychoanalysis with my colleagues and you can talk about it if you want to. Why don't you try to talk about yourself, especially the thing that you don't understand about yourself.

So, uh, that's kind of my take on that. I don't know if you wanna say something about it or not. Neil.

Neil: Oh, I do, I wanna say a few different things. I hope I can remember them all. The first thing that I wanna say here is, , my question will be, what do you think about this?[00:38:00]

So in the patients who come with a DSM style diagnosis

Isolda (2): mm-hmm.

Neil: I think that. In many though, not all of the cases where that happens, the person wants to use that diagnosis as an excuse for, I'm gonna do a very nons, psychoanalytic thing here. And Moralize, they use it as an excuse for bad behavior.

Right. Like I just, I'll put some specifics on that real quick. Or at least attempt to, somebody comes and they're just like, Hey, I'm an addict. You know, like, because I'm an addict, I can't help myself. Like some people are born addict, some people aren't. I was born an addict, and so therefore, this is how I am.

It's the like . The story about the frog bringing the scorpion across the pond and the scorpion stings the frog. Hey man, I was a scorpion. What did you expect? They're, they're using the diagnosis in that way, and sometimes they want you to help them do that. I think that's more [00:39:00] often the case than having the expecting me to maybe refute that or call that into question in some way, which is usually what I attempt to do is to question it, which is not to say yes or no.

I find, right. Like it's, it's just to question why that diagnosis is important to them or how it is that they're using it. Mm-hmm. And why they might wanna use it that way. So on and so forth. So that's the first thing I wanna say. And then with the people who come in, who, are your graduate students reading a lot of Lacan.

I agree with you that this is a way to not know something about themselves. It's a way of zeroing in on what they think they can know, what they think they can describe, formulate, articulate, construct, all those things.

And, that's where their attention goes. I'm gonna pay attention to, I'm gonna focus on formulating my own case that I am an obsessive, and because I'm an obsessive [00:40:00] da, da, da. Things follow from that. And in those cases, it's the same thing. It's like, well, all right. Why are you so sure?

Is the question that I ask people? Usually asked as a question. Occasionally I might say, don't be so sure period and say that as more of a statement. But that's the idea. That's tends to be what I do when I think I'm working well, is I call into question the diagnosis.

Either the DSM diagnosis or the structural Lacanian style diagnosis with the person as a way of. Trying to get them to stop knowing something and open themselves up to not knowing something, which I think of as the path that opens up desire and that's an important thing to do in a psychoanalytic experience.

So that's , my response. I'm curious what you have to say about any of that.

Isolda: Okay. I think in both, cases, having in mind that we're not trying to generalize this, right. Each case , is a singular case and each person will [00:41:00] do whatever they have to do to deal with their own suffering.

But I think in both cases, long story short, , we're talking about the same. They're trying to bring certain meaning to something that makes no sense for them. A suffering, something that they can stop doing or a sadness that can go away, or a repetition or a pattern that they don't know how to stop.

So they try to bring some sense and some meaning to something that has no meaning whatsoever. That makes no sense for them whatsoever. That could be useful sometime, and that could be a huge obstacle for the treatment in another, cases, but I think it's kind of the same. And now I got an idea, Neil, and you'll tell me if you agree with it or not, that might be a really interesting topic for our next episode.

How do we work with the nonsense? What is related to that? Because we have in one side the desire that you just. Name it. And we kind of say the other day we [00:42:00] wanna work on it too, eventually. And the other like big, huge , word that some people that like super caught up, which is jouissance, which is quite related to the nonsense and what doesn't make any sense.

I think it's important that all these efforts are related to try to create a meaning about something that is happening that doesn't make any sense whatsoever.

Neil: I think that's a great idea I think it'll be really useful to talk about this because earlier I alluded to therapeutic effects. I'm not sure if about this, I'm having this thought now in real time, but I think a lot of times therapeutic effects come from the production of meaning.

That people can get from psychoanalysis. Like new meaning can be created or meaning can be reconfigured in ways that have effects for people. , And that can be nice when it happens. But there's gonna be a point if people stick with psychoanalysis for long enough where what meaning can do is gonna kind of fall off.

It's not gonna be able to help. [00:43:00] Right. And it's not to say that you shouldn't do it, or that meaning is just dumb. And we don't care about meaning. I don't think that's true. I think sometimes people might portray Lacanians that way. That we're obsessed with the jouissance, with the nonsense with that which cannot be made sense of, with the real, which is outside both the imaginary and then symbolic and can't even be thought and so on and so forth.

And, and I think that we are interested in that stuff, but that's not all right. We're interested in desire and meaning. We're interested in nonsense and how a person, uh. I guess encounters that moment, that thing that is nonsensical in their own experience and how they might react to that and if that reaction is causing suffering and how they might, earlier I made this, I claim about how people can change their relationship to their suffering.

Another way to say that might be that they could change their relationship to that which is nonsensical in their lives, and instead of trying to just demand that it makes sense. So that could be a really [00:44:00] interesting topic, I think for us to take up in a future episode.

I think it'd be very worthwhile. I'd be interested in it.

Isolda: Yeah. How to make peace or up to what extent can you make peace with your own nonsense.

Neil: . Okay. Well maybe that's where we will stop talking about this. We've said some things and stuff about diagnosis. I don't think we've said everything that there is to say about it.

Certainly. Maybe we'll come back and talk about it again. Sometime do deeper dives on some of the specific structures or something like that. Who knows? We don't know what's gonna happen here, but next time we will try to talk about nonsense. We can say that. So this has been the subject of the unconscious.

Thank you for having us in your ears. You have been running on the treadmill or folding laundry or walking your dog or doing something else. I have no idea what you're doing, but whatever you're doing, I hope that you're having a great time, and thank you for listening to us.

Isolda: Thank you very much. Thank you, Neil.

Neil: Yep, take care.