Welcome to another brief theory post, or at least as brief as I can make
it. This time I’m looking at some of the theory and debate surrounding both the
use of and the very existence of, diagnostic labels in mental health. Taken
along with these two other theory posts this should constitute a
very basic grounding in my approach. In addition, there are links to further
reading and resources in the tabs at the top of the page, although it doesn't
constitute a complete beginner's overview.
We're used to the idea of mental illness as a set of discrete
conditions, any of which a person will either have or not have at any given
point in their life. Alongside this there is the perception that, in the main,
what arguments there are in psychiatry are over whether these individual
conditions actually constitute illnesses rather than states of healthy being
that happen to differ from current societal norms. Perhaps the most famous
example here would be the classification of homosexuality, eventually removed
in its entirety from the DSM in 1986 after spending 6 years in limbo as a
disorder only if you didn't want to be
gay. As
much as anything the process by which this was changed highlights many of the
difficulties inherent in attempting to systematise scientifically within a
culturally created, political space.
In addition to these major reversals, non-academics may also be aware of
the process of shifting boundaries and diagnoses within conditions as our
knowledge of them is increasingly refined. Often this aspect of science is
hidden in popular culture in favour of the twin fallacies of 'scientific fact'
and the idea of science-as-discovery. Science as it is actually done is about
teams of people gradually refining concepts through falsification, rather than
individuals generating knowledge through genius and insight, but the shadow of
logical positivism looms large over our culture. In spite of this, an example
of this kind of change and refinement within mental health that more people
might be aware of, as it has surfaced into popular understanding, is the move
from the term 'manic-depression' to the more nuanced 'bipolar disorder',
slotting it into a larger structure of understanding about mood and mood
disorders.
This categorical method is however a relatively new way of thinking
about madness, which as surviving uses of the word attest, has long been a much
more amorphous concept. This is not to say that historically we had no concept
of differences in the ways in which people could be mad, just that previous
systems tended to view madness as a monolithic constant, the sufferers of which
displayed various symptoms depending on circumstance and constitution. In other
words, it was the fact that you were mad that was first and foremost of
importance, and the manner in which you were so that was secondary. The big
shift therefore was to separate madness into madnesses, i.e. to treat
individual illnesses or conditions as distinct on a conceptual level.
Henceforth, it was not enough to consider someone as mad and then to discern
the cause and quality of their madness, but rather a case of studying symptoms
and gauging whether they were sufficient to diagnose a specific disorder.
The concept of diagnosis is an important one, because as madness has
shifted into mental illness, (and as an important part of this work has been an
attempt to shift it from a predominantly moral to a corporeal judgement) there
has been a shift from the dismissal of those afflicted and their ostracising
from society* towards the desire of the unwell to have their specific illnesses
recognised and, in a more general sense, a desire for legitimacy. (This could
also be understood as a shift in the perception of the mad from objects to subjects.)
Diagnosis is both an emotional and a practical need. As an example, In
the USA where access to medicine is controlled by insurance companies the DSM
is** in many cases the arbiter of that access. Medicine on an industrial scale
is necessarily bureaucratic. Even without this people often find it easier to
cope with a problem that they can name than they can with one that is unknown, while
it is easier to prove to others that what you are suffering from is real when
you can point to it in a book. Despite this, the case remains that many people
still regard mental illnesses as not really real illnesses - or that they
should be possible to defeat with strength of mind alone.
I mentioned in the previous paragraph that the DSM, the American Psychiatric Association's
Diagnostic and Statistical Manual, has become, in a very practical way, the
arbiter of what is and isn't an illness. As is often the way with such tools,
through use and convention it has also become for many people the underpinning
of the thing it describes rather than a schema for understanding it, emulating
the manner in which some people approach dictionaries, positioning them as
controllers of rather than guides to, language. This mechanism of social
construction of truth can be difficult to pare away from any actual underlying
truth that may or may not exist in reality. Especially as the methodology
behind it, as delineated by Kraeplin in the 1880s, was originally directed at
classification, at finding the thing as it is rather than the thing as it
appears to be and can be usefully dealt with. (The methodology is also one
which has a currently high cultural capital for generating truth, even when
misapplied - it seems very scientific, because it is logical, but logic
requires true premises to produce truth and those are not always easy to
evaluate.)
There are then two main oppositional positions to the heavily
diagnostic, discrete conditions, model that from the aforementioned position
currently dominates psychiatry. First are the anti-psychiatrists, the most
prominent of whom include RD Laing and Thomas Szasz. Although they do so from
often differing positions anti-psychiatrists argue in general against the very
idea of mental illness, and more specifically against the various measures
(drug therapy and incarceration primarily) employed by psychiatry to treat
them. There are a great many flavours of anti-psychiatry, from new-age types,
magicians, natural living adherents, Scientologists, anti-pharmaceutical campaigners
and the 'common-sense' argument to Laing's stress of the beauty of and Szasz's
stress of the autonomy of all minds. The arguments here are varied but tend to
resolve down to a defence of the sanctity of minds qua minds - i.e. that to say
what is normal or correct behaviour or functioning for a mind and crucially
what is abnormal is an act of supreme arrogance.
There are certainly serious arguments in favour of these views,
especially with regards to the medicalisation of things like homosexuality, and
the way in which certain drug companies have behaved incredibly unethically
when it comes to treatments that may not actually work or that have required
new diagnoses in order to be prescribed. In addition there is the muddying
factor of psychoanalysis, which is a system that deliberately works by making
normal functions abnormal. Psychoanalysis was heavily influential on psychology
and psychiatry for a relatively short, but very public period and the fact that
many people conflate psychoanalysis with psychiatry I think overstates the
(already present, but not overwhelmingly so) tendency of the latter to
medicalise things that are actually in the realm of normal behaviour.
The other dissenting position is in some ways similar to the earlier
conception of madness I discussed briefly at the beginning (in that it views
madness as a set of interrelated states which we can fall into and out of over
the course of our lives), while in others it differs significantly. It, in
essence, holds that mental illness is real; is disruptive to people; is
measurable both physiologically and psychologically; and is demonstrably a
functioning of the mind outside of identifiable norms. However, in addition it
holds that it is subjectively experienced and crucially is located on a series
of overlapping spectra and is an emergent property of the interaction between
mind, physiology and environment.
It is from this sort of position that techniques like Cognitive
Behavioural Therapy stem, which attempt to treat the mind as a psychological
instead of a physiological entity, and as a tool rather than as the person
concurrent with that mind. Although that is not to say that an approach like
this would rule out the kind of therapies disavowed by anti-psychiatrists the
focus would rather be on treating symptoms rather than the conditions of
orthodox diagnosis. A current move by one version of this position towards
orthodoxy is described by this article, detailing the US National Institute for
Mental Health's proposals for a replacement to the DSM, the RDoC.
So there you have it - very briefly and grossly oversimplified, the
three(ish) main positions on what madness actually is and the axes on which
they differ. Crucially, they don't necessarily need to be mutually exclusive,
at least on certain dimensions. It is for example entirely possible for a rigid
diagnostic system to be both empowering and limiting at once, just as it is
possible for certain functions or behaviours of the mind to be acceptable and
normal for one person, but destructive and unpleasant for another. (I tend
towards the third position personally, which is probably apparent in the way
this post is written, as I believe it to be a more integrated approach.)
As a general bit of housekeeping, I will be referring to these concepts
and positions a fair bit in future posts. The main point to take away however
is that while on an everyday level we feel happy to refer to psychiatric
disorders in a very definitive way, similar to how we refer to physical
conditions, and while this may in fact be a necessary part of talking about,
socially constructing and understanding these concepts, it is entirely possible
that it is more complicated than all that. In addition, people's positions on
the status of diagnosis can be political, philosophical and sociological as
much as they can be a scientific opinion, while the science itself is still far
from consensus.
* Foucault, in Madness and Civilisation, talks a lot about the way
madness and leprosy were conceptually similar, with the idea of asylums for the
mentally ill developing from established mechanisms for dealing with lepers.
** Or was, as other diagnostic manuals are gaining traction in use.
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