The Psychiatric Manufacturing of Identity
On the political circumstances behind rigid, brittle identity constructions.
A patient sits before me, sobbing. When I ask him if he can put words to his emotional state, he mutters: “I was hoping for a simple answer.”
I empathized with his wish to find an easy answer to the questions he had about why he had always felt out of place, and why he felt so awful at times that he wanted to kill himself. He had spent large parts of his childhood migrating from country to country with his family, mostly for economic reasons. He had experienced severe and sudden losses of people important and dear to him. In his teenage years, he increasingly withdrew from peers, mostly playing video games.
Recently, he had found answers to these questions: searching the internet and spending some time in chat rooms, he had suddenly realized that although his gender assigned at birth was female, he had always felt more like a man, and started to self-identify as trans. In addition, he had trouble focusing his attention on work, and therefore assumed he had ADHD. He had come to me, a psychiatrist with experience in both those areas, to get his answers confirmed by an objective authority.
This patient’s psychiatric assessment and clinical interviews showed heterogeneous results in respect to the question of ADHD, as is so often the case. With respect to trans identity, there really is no way for a clinician to “objectively” discern whether someone is trans—it is a self-identification first and foremost. What I am most often called upon to do, though, is to comment on whether a person should have access to means of medical transitioning. I am what is often derisively called a “gatekeeper.” It is an uncomfortable position of balancing ambivalences about wanting to empower people to make their own choices, while at the same time keeping them from self-inflicted harm. This young man was in his early twenties, and what struck me most in being with him was a feeling of fundamental uprootedness—a sense of being internally “homeless” and unconnected that became palpable in me when sitting with him. After much deliberation, I told this patient that I could not “give him” the diagnosis of ADHD, and that I would recommend a period of intensive psychotherapy to try to make sense of his life and problems so far. Although I offered to send him to an endocrinologist to start medical transitioning, I advised against this course of action before he had made a start in intensive psychotherapy.
The above fictionalized case is representative: most people who consult me wish to receive specific, narrow diagnoses, and routinely break down in my office when they do not receive them. For a while I thought that the desperation I saw in reaction to a diagnosis denied was connected to the wish for a quick fix—a medical intervention only accessible with the “right” psychiatric label. It became apparent to me over time, however, that most patients actually desired a diagnosis in order to confirm an identity. Many people I saw had constructed an identity that revolved around their self-diagnosis; they explained large parts of their biography in terms of this psychiatric marker. In these cases, a denial of diagnosis on the grounds of careful psychiatric and psychotherapeutic evaluation proved almost impossible. These patients would often break down in a state of confusion and despair, as if they were no longer able to make sense of their lives because they had been robbed of a precious resource, a signifier that contained their overwhelmingly complex experience.
Many of my colleagues share this experience. They express concern that handing out diagnoses simplifies the multifaceted predicaments in which many patients find themselves, and observe that this trend towards rigid, fetishized self-diagnosis is intensified by the bourgeoning industry of apps that lower the threshold for pronouncing oneself clinically depressed, traumatized, or lacking in concentration.
I am not primarily concerned here with arguing for or against the validity of diagnoses in individual cases. Although important in the clinical day-to-day, this line of questioning employed to analyze the emergence of clinical phenomena tends to reproduce the neoliberal paradigm of individualizing collective issues and predicaments that are born in wider social and political space. The inflationary use of diagnoses to create identities is a collective symptom of our current political, cultural, and economic moment.
This clinical phenomenon is a response to the shattering of cultural and social structures as organizing agents of individual lives, which leads to a need to rigidly define the self in terms of identity. The active destruction of large organizations like labor unions and churches, and the weakening of that core structuring entity, the nuclear family, might have been necessary to dismantle their perceived authoritarian power over the life choices of the individual. Yet this decrease in stable structures external to the individual has come at a high price. All responsibility to develop the self in its many confusing and conflicting dimensions now falls to the individual, who increasingly seems to look for a way to meet the challenge by clinging to prefabricated identities. Moreover, certain identities—for example, ADHD—come with the added benefit of offering some respite from the high functionality demanded by our current economy. In late-stage capitalism, there is little space for imperfections. The harsh demand to optimize every aspect of the self seems to be held in check only by the authoritative power of psychiatric diagnosis, offering a legitimized excuse to be less-than-perfectly functioning.
On the individual level, people present their personhood, their self, as unified—if necessary, with a psychiatric diagnosis to account for any supposed failure of imperfect functioning—instead of as an entity with multiple parts that are in conflict with each other. In a corresponding development, our collective understanding of the nation state has shifted: what used to be a locus of highly conflictual democratic struggle for compromises is now commonly understood as a post-political enterprise run by experts who make the necessary cuts to keep business running smoothly. In individual psychic functioning as well as on the political level, the surface presentation of non-conflictual functioning seems to serve the purpose of masking a profound dilemma: there is conflict and complexity at the core of both entities that need containing structures to allow for them to be worked through, elaborated, and brought to a livable compromise.
Psychoanalysis has been concerned since its inception with the conflicting internal forces that drive people to follow or disavow their desires and wishes, oftentimes unknown to themselves. Psychoanalytic treatment, at its best, is a radically open process with no outcome defined in advance. This process values a person´s defensive structure, the ways in which people keep from themselves their own excessive or destructive desires, while at the same time trying to dismantle the defenses enough to make the disavowed desires more accessible to conscious deliberation. Because the unconscious, the central focus of psychoanalytic treatment, is defined by its inherent unknowability, the process of analyzing its derivatives (dreams, slips of the tongue, and the general awkwardness of everyday life) is necessarily interminable. From a psychoanalytic perspective, symptoms like gender dysphoria and attention deficit or impulsivity are always overdetermined and point to latent wishes and anxieties that await further elaboration. The idea of an unconscious complicates the concept of identity to the point of absurdity. If my symptoms—which psychoanalysis sees not as physical or psychological malfunctions, but as ubiquitous compromises between the drive to live out our desires at the same time as defending against them—are always covering for a huge and messy and at least partly unconscious underbelly of conflicting wishes, how can I in good faith attach a reified label like trans or ADHD to them? Psychiatric diagnosis limits complexity in order to arrive at clinically manageable and understandable entities. It is called upon in this day and age exactly for that limiting function.
Psychoanalysis seems perfectly suited to confront the paradigm of psychiatrically-manufactured diagnoses and to promote an understanding of the underlying issues that might make the wish for a fixed identity take precedence over complexity. In the clinical situation, however, psychoanalysis has traditionally served its subversive function within a frame of multiple sessions a week to allow the patient enough space and support to be able to deal with whatever comes to light. The current clinic tends to be very different from this ideal model of day-to-day contact with the psychoanalyst. If I see a patient once a week, many of my psychiatric colleagues consider this “high frequency” psychotherapy. Many psychiatrists and even psychotherapists see patients for consultations every other week or even once a month, handing out tools for homework and recommending apps or books for further work.
In my psychoanalytic view, this way of conducting therapy misses the point. Many people I see are in deep distress. They would need the support of psychoanalytic treatment multiple times a week in order to have a secure enough frame to think about the complex meanings of their suffering, and to foster real internal change. Psychoanalysis’ most irksome demand vis-à-vis the culture of the quick fix is this focus on the importance of time and extended clinical contact to elaborate complexity in a real safe space. Psychoanalytic colleagues in private practice tell me that it is astounding how patient narratives are able to change and complexify with the move from the psychiatric clinic to the private consulting room. In trans people, for example, the “born in the wrong body” narrative that is put forward to get recognition in medical contexts can in some cases be elaborated into multilayered gendered identifications. Whether this elaboration becomes possible depends to a large part on the context. The medical apparatus tends to act in reaction to this narrative, while the psychoanalytic clinician will accept it and invite further associations. There are strong economic imperatives working against the psychoanalytic position and which favor a medical “can do” attitude. Resources are said to be tight, and the big players of capital like insurance and pharmaceutical companies have no interest in promoting a costly and time-consuming elaboration of complexity. It is one of the greatest successes of capital to sell the extreme shortage of space for exploration and personal development as liberation.
For decades, conservative and liberal political players have haggled over the recognition of traumatic experiences and self-selected identity. Political psychoanalysis, and a Left worthy of the name, should eschew this debate. A radical Left should care less whether people transition or not, whether they take Ritalin or not, whether they define their experiences as traumatic or not, and care more about the political circumstances that lead people to resort to rigid, brittle identity constructions in the first place. If we don´t get talking about the material reality of the flight from complexity and instead stay committed to try to bring about individual liberation within capitalism, the Left will remain utterly defeated, and psychoanalysis will remain an elitist venture for the well-to-do.
Sebastian Thrul is a psychiatrist and psychoanalyst in training in Switzerland and Germany. His main scientific interests are the political dimensions of psychoanalytic technique, the application of psychoanalysis to clinical work within the public healthcare system, and questions related to gender. He has lectured and written on these topics for scientific and lay audiences. He is one of the hosts of the podcast New Books in Psychoanalysis and regularly invites interesting psychoanalytic thinkers to public online conversations as part of The Free Association Lisbon´s Forward section. He can be reached at email@example.com.