What the Misunderstandings Look Like When Distress Is Treated Asocially: The DSM
The Social Perspectives Network (SPN) is a UK-based coalition of mental health service users/survivors, carers, policy makers, academics, students and practitioners who are interested in how social factors both contribute to people becoming distressed and play a crucial part in promoting people’s recovery. In their Spring 2013 newsletter, the SPN21 launched a ‘no more psychiatric labels’ campaign which joined the International Critical Psychiatry Network in calling for an abolition of psychiatric diagnoses. They suggested that psychiatric diagnoses are not valid. That is, they don’t actually represent coherent, discernible disorders. The SPN say that the use of such labels increases stigma for those who are experiencing misery and that they don’t actually help with decisions over treatment. So the question is, are they right?
The first psychiatric taxonomies were developed by Kraepelin and Salmon in 1893,22 and if the reader in 2016 were to glance at what these looked like, they might be quite interested to see what were, at that time, considered to be psychological illnesses. For instance, just over 100 years ago medics may well have referred to such disorders as ‘masturbatory insanity’. Kellogg, a zealous medical advocate of abstaining from masturbation, warned of masturbation-related deaths that could cause cancer of the womb, urinary diseases, nocturnal emissions, impotence, epilepsy, insanity, and mental and physical debility.23 Aside from the obvious observation that few adolescents would live through their teens were such a diagnoses to carry any medical weight, a key thing to note is that this is not, in 2016, accepted as a psychological disorder. Nor indeed is hysteria, the third most common diagnosis in 1975 but which had fallen into obscurity by the mid-1980s.20 Or indeed homosexuality, a mental disorder until 1973, or Drapetomania, a mental illness proposed by the physician Samuel A. Cartwright in 1851 that caused black slaves to flee captivity and which is now understood as little more than pseudoscientific racism.
The point being made here about diagnoses is not to mock previous generations in their attempts to map out historically contingent ways of understanding distressed people, but to make the point that any attempts to transform human distress into psychiatric illnesses will entail a process of disease mongering. It is axiomatic that viewing complex attempts to maintain personal survival and integrity in the face of current or past trauma are understood, using the conceptual apparatus that is popular at the time, as symptoms of underlying illnesses, is critically problematic. This is why you can almost guarantee that those with an interest in misery in 100 years’ time will look back on what we called schizophrenia, depression, personality disorders and the like, with a bemused fascination for the quaint, unusual and laughable conceptual apparatuses that we use.
The point here is that over the years the profession of psychiatry has developed categories that have come to define thoughts, deeds and indeed whole people as in some sense deviant.24 But what counts as deviant thoughts, deeds and people changes over time. And the radical nature of this change over the last 100 years is perhaps the most profound challenge to advocates of the biomedical disease model of mental distress. What goes missing in the diagnostic process of eliciting symptoms is the biographically situated meaning of what the person is experiencing, and it is quite possible for two patients with no first-rank ‘symptoms’ in common to receive the same diagnosis.25
It might be helpful to understand suffering less as a condition and more as an event within the context of a larger surrounding plot.26 This plot is both unique to individual people, and in many senses shared with others, as the outcome of preceding acts. If we think like this, it is difficult to avoid understanding acts of diagnoses as little more than professionally legitimised social fictions (albeit quite convincing ones). Suffering and misery are incredibly difficult things to grasp, often idiosyncratic to individual people with very particular life histories and given expression through whatever ideas and discourses are popular at a given time in history. This is why we do such a bad job of it when we try. Suffering and misery are not natural biological entities but types of social status that we extend or withhold depending on what is popular at a given time.26 In one generation this might include such channels for suffering as mas- turbatory psychosis and hysteria; in another it may be oppositional defiant disorder of narcissistic personality disorder. And while the organised attempts to give validity to these rituals of language through generations of psy professionals reinforce the status of their institutions in society at a given time, it is difficult to avoid the conclusion that they very rarely provide value for ‘patients’ or ‘clients’ who experience forms of patholo- gisation and infantilisation.27
With this in mind, it is perhaps not surprising that these acts of diagnoses are plagued by problems of reliability over time, validity and prognostic value.28 The DSMs, in their various incarnations, are collections of often overlapping symptoms that each exist in their own conceptual vacuums. This book, often termed the ‘psychiatric bible’,29 offers no attempts to explain why people experience the misery that they do. For those who adhere to an understanding of ‘misery as social response’, this is deeply problematic. This is not to say that these forms of misery are not real, or painful or utterly destructive to people’s quality of life. Nor is it to say that professionals who engage in these systems of naming and treating misery do so through a series of intentional practices that harm people and control people. Indeed, they very often provide experiences of amelioration, comfort and beneficence to those with whom they come into contact. Rather it is simply to say that the conceptual frameworks through which they name and make sense of misery are redundant.
DSM-V, published in 2013, is perhaps the greatest example of what Whitely30 calls ‘disease mongering’—where normal human behaviours are conceptualised as diseased or deviant, where the strategies that people use to survive, resist and make sense of their world are increasingly formulated as symptoms of illness and pathology.31 The example of the broadening of the ADHD criteria as contrary to the process of defining legitimate diseases has resulted in children who are too active, not active enough or inattentive being rendered neurobiologically deficient;31 between 1994 and 2003, stimulant prescriptions rose from 6000 to 345,000 cases.24
The DSM is a deeply entrenched enterprise where the professionals whose role it is to construct these categories are frequently funded by the pharmaceutical industry.32 Fifty-six per cent of DSM panel members who decide what is, and is not, a mental disorder have one or more financial associations with companies in the pharmaceutical industry.32 And 100 % of the members of the panels on ‘Mood Disorders’ and ‘Schizophrenia and Other Psychotic Disorders’ had financial ties to drug companies. The DSM enterprise is profitable to the tune of $5bn a year.33 This raises pertinent questions as to the degree to which the process is potentially compromised.
An idea that is commonly found traversing the machinery of academic and practitioner psychiatry and psychology is the need to increase the mental health awareness of the public. It is perhaps time to ask whether it is those mental health professionals, who have strict adherence to meaningless and problematic disorder criteria and who are institutionalised into wholly reductionist models of human experience, who need further educating.34 Rather than allow diagnostic techniques to continue to maul the fragile core of misery, some35 have suggested a need to nourish ambiguity, whether or not we like that ambiguity. To peel back the layers of bureaucratic talk which has muffled the voices of people in pain rather. Diagnoses are not facts but networks of simplistic assumptions that fail to do justice to complex realities.1