Monday, 30 September 2013

On Categorisations and Diagnoses

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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