Home Psychology Psychiatric Diagnosis Revisited: From DSM to Clinical Case Formulation
Commotion in Psychiatry, Part II: Critical Researchers Dethrone the Psychiatric Ethos
In the 1960s and 1970s psychiatry was not only challenged by studies on the unreliability of psychiatric diagnosis. The discipline was also in crisis because researchers in the social sciences and the humanities looked at psychiatry from new and increasingly critical perspectives. Several scholars are noteworthy, such as sociologist Thomas Scheff (1966), whose work on labeling shed a new light on diagnosis, and psychiatrist Ronald D. Laing (1960), who assumed that symptoms of mental illness express concerns one cannot communicate. Nevertheless, here we focus two other scholars from fairly different research traditions: Thomas Szasz and Michel Foucault.
A first key figure who, in the 1960s and 1970s, strongly criticized the commonly accepted models of diagnosis was psychiatrist Thomas Szasz. The basic idea he put forth in his 1961 monograph The Myth of Mental Illness is that until then psychiatric thinking was too focused on
“thinking in terms of substantives.” This means that in his view, psychiatric problems were too strongly thought of as deeply ingrained conditions, while “process-thinking,” which focuses on dynamical processes, was neglected (Szasz 1961, p. 2). Process-thinking is interactional in nature, and explores how problems are constructed within contexts. Szasz suggests that as long as it is not proven that psychiatric symptoms are actually caused by underlying biological deficits, it makes no sense to interpret them as signs of medical illness. Focusing on the example of hysterical complaints, he suggests that, first and foremost, psychiatric symptoms have a communicative function. Hysterical complaints are proto-linguistic communications that follow the language of organic disease, but, as symptoms, they have to be deciphered. In his view, psychiatric symptoms should be studied in terms of people’s sign-using behavior. Starting from game theory, Szasz aimed to isolate the underlying rules that govern patterns associated with symptomatic behaviors. In order to substantiate his point, Szasz (1961) documents how different contexts, for example, nineteenth versus twentieth century, or the USA versus the former Soviet Union, entail different forms of symptomatic expression. If psychiatric symptoms were stable biologically rooted entities, this kind of contextual variation should have no substantial impact, while this impact is indeed present. He therefore concludes that “the search for the physical causation of many so-called psychological phenomena may be motivated more by the prestige-need of the investigators than by a quest of scientific clarity” (Szasz 1961, p. 81). So what is at the root of psychiatric symptoms? Szasz (1961, p. 75) believes they comprise “problems of human living - or of existence” that are communicated by proto-linguistic signs. For example, a person might be disappointed in life, and experience certain events as a “slap in the face” in the figurative sense, but instead of communicating disappointment he might start experiencing facial pain, which is then communicated to others. Facial pain expresses the disappointment, but doesn’t communicate it verbally, hence the idea that it is a primitive proto-linguistic communication: “It makes communication concerning a significant subject possible, while at the same time it helps the speaker to disown the disturbing implications of his message” (Szasz 1961, p. 124). This communicative process is largely unconscious and disturbs human interaction if not properly understood.
Indeed, on the one hand, Szasz’s book, which focuses on hysterical complaints, might be interpreted as a plea for an interaction-based relational model of psychopathology. In the DSM-II hysterical complaints are classified as psychophysiological reactions. This is one of the diagnostic categories with low inter-rater reliability in the study by Spitzer and Fleiss (1974). Szasz’s book, therefore, might be seen as an attempt to get hold of these Janus-head symptoms, but by following a relational- communicative approach instead of a biological approach. On the other hand, however, the provocative tone of this book might also be taken up as an anti-psychiatric attack on the biomedical model. He calls psychiatrists “pseudo physicians” who are “striving for prestige by aping the ‘natural scientists’”  (Szasz 1961, p. 82). In terms of Szasz’s (1961) own theory, such bold assertions are “rule-breaking communications,” which have a predictable effect: the establishment was offended and Szasz’s point was completely lost in the midst of all the commotion. Indeed, for many, his message was likely taken as pure heresy. Nevertheless, it is arguable that more than half a century later, many of the points Szasz put forward still hold true. If one accepts, as Szasz (1961) assumed, “that illness involves a deviation from the normal anatomical or physiological structure and functioning of the human body,” one could conclude, as Hanna Pickard (2009, p. 84) suggests, that this does not hold for most mental disorders.
A second key figure in critical discussions on psychiatry was French philosopher and historian Michel Foucault. In his 1965 book Madness and Civilization: A History of Insanity in the Age of Reason7 Foucault analyzes how society dealt with insanity throughout history, focusing on the Renaissance, the seventeenth and eighteenth centuries, and modern times. The point he makes is that whereas in the Middle Ages the so- called madman was a figure inside society, subsequent epochs defined him as an outsider. From then on, the insane person was an outcast that must be confined; a sick individual that should be studied and treated as
a medical object. Key to this historical evolution was the creation of asylums at the end of the eighteenth century, for instance, by Pinel, where the madman was treated by a new category of medical doctors, namely, alienists, who above all functioned as authority figures. At first this subjection was explicit in the practice of moral treatment, which subjected the unreasonable insane to the discipline of the reasonable medical doctor. In the late eighteenth century, as positivism imposed itself upon medicine and psychiatry, this disciplinary power relation became less visible. It was still present but veiled under a naturalizing discourse that was henceforth used to explain madness (Kirsher 2009).
As a consequence, in Foucault’s (1965, p. 276) view madness is not so much a natural kind, that is, an entity governed by natural laws, but what he calls “a reification of a magical nature.” In his view, psychiatry did not arise because medical doctors had suddenly discovered an underlying biomedical reality that could be linked to the behaviors of the so-called insane. On the contrary, psychiatry came into existence as it brought its own object into being: disciplinary practices first delineated a group of outcasts that were amenable for adaptation to society, and later defined them as proper objects for scientific study: “What we call psychiatric practice is a certain moral tactic contemporary with the end of the eighteenth century, preserved in the rites of asylum life, and overlaid by the myths of positivism” (Foucault 1965, p. 267). By qualifying madness as a reification Foucault stresses that the early alienists, just like modern psychiatrists, turned their concept into an object. As a consequence “madness” was no longer treated as an abstraction that can be used to make sense of the world, but as a biological or psychological reality that simply awaits clinical detection and scientific discovery. Such reification is a direct effect of adopting psychiatric discourse. Through the use of specific language, the concept under discussion is materialized, or as Friedrich Nietzsche (1887, p. 122) put it: “it is enough to create new names and estimations and probabilities in order to create in the long run new ‘things.’”
Meanwhile this notion of reification slowly became recognized as a problem in psychiatry. What is more, DSM-based diagnosis in particular was at last accused of promulgating such reification (Nieweg 2005), thus giving rise to what Steven Hyman (2010, p. 157), a former president of the US National Institute of Mental Health, calls “an unintended epis- temic prison.” Indeed, while the diagnostic categories of the DSM are nothing but conventional groupings of symptoms or “heuristics that have proven extremely useful in clinical practice and research” (Hyman 2010, p. 156), people still tend to think of them as real entities. For example, reification is evident when people think of “ADHD” or “schizophrenia” as underlying diseases that give rise to characteristic symptoms, while in fact these labels are nothing but descriptive umbrella terms used to designate a collection of symptoms that make up particular syndromes. Reification produces the added problem of the so-called disorders being understood as quasi-material conditions that cause symptoms, while in fact they only indicate that a (certain) minimal number of category- specific symptoms have been observed in an individual. In other words, DSM diagnoses do not explain anything beyond this idle descriptive classification, yet people tend to invest belief in them as real entities, which is clearly absurd. While they didn’t use the concept, the effect of reification that is associated with labeling psychiatric disorders also seems the point Karl Menninger et al. (1958, p. 6) had in mind when arguing that names for illnesses only comfort the doctors and impress the relatives: labels set in motion a process of causal attribution, and trigger sets of beliefs people eagerly make use upon confrontations with mental distress.
In research and clinical practice, professionals often think of diagnostic categories as realities, which create the so-called epistemic prison in the mind (Hyman 2010, p. 157): professionals think of psychological disorders as if they were discrete entities, thus obfuscating overarching and often obvious contextual influences. Disorders are seen as realities that need to be treated, or as observable surface phenomena that correspond with specific neurobiological disturbances. Research meanwhile teaches us that it is most unlikely that corresponding neurobiological patterns will ever be found for the numerous discrete disorder categories outlined in the DSM. For example, genetic studies demonstrate that no single gene variant, genomic locus, or mutation is strictly linked to any of the common mental disorders, and that particular genetic variants are often found across different disorders (Hyman 2010). Nevertheless, many professionals seem to believe that yet hidden disorder-related entities (genes, brain-related components), which are presumed to give rise to disorder-specific characteristics, do in fact exist. Such reifying belief bears witness to a cognitive bias called genetic essentialism or neuroessential- ism (Dar-Nimrod and Heine 2011; Haslam 2011). Such bias narrows clinicians’ and researchers’ minds: “Perception of the genetic foundation as a fundamental cause leads people to devalue the role of ontogenetic, environmental, or experiential factors” (Dar-Nimrod and Heine 2011, p. 802). Interesting in this context is the plea by the Dutch psychiatrist Jim Van Os (2016, p.2) to stop using the categorical schizophrenia construct, and instead start thinking of psychosis as a mixed continuum with “extreme heterogeneity, both between and within people, in psychopathology, treatment response, and outcome.” The schizophrenia concept triggers diverse fixed essentialist beliefs in professionals, thus neglecting the actual heterogeneity between patients, like the idea that schizophrenia is a highly heritable chronic brain disorder with predominantly genetic risk factors. Indeed, within such view mental disorders are seen as fixed underlying entities or essences (see also Chap. 3) that give rise to problems. Evidence, by contrast, indicates that non-essential factors like the context one lives in or life history have a serious impact on the causation of schizophrenic pathology, implicating that it is a truly biopsychosocial problem (Van Os et al. 2010, 2014). Moreover, till now no single diagnostic brain marker of schizophrenia has been found.
Interestingly, without explicit reference to Foucault, detailed studies of how psychiatrists actually dialogue with patients make clear that through concrete interactions, reification indeed takes shape. Close examination of ways in which diagnosticians ask questions makes clear that they often just check the diagnostic criteria of specific DSM disorders, thus framing patient experiences as if they were discrete categories (Ziolkowska 2012). While in daily life specific experiences have a process-like character, and are embedded in broader sets of mental representations, life histories, and interactional contexts, in diagnostic contexts they are frequently treated as isolated states with an object-like character. Linguistically this is expressed in the use of nouns instead of verbs when questioning experiences (“Sleep is like what?”; “are there thoughts about death” see: Ziolkowska 2012, p. 298). Along this way patients are constructed as passive recipients of experiences, who, from a meta-perspective, should observe disorder traits within themselves, and are invited to identify with these. This installs reification: individuals are invited to think of symptoms and disorders as discrete entities. What thus remains unacknowledged is how specific experiences, like frequent lingering on the issue of death, always take shape in idiosyncratic ways, which cannot simply be generalized from one individual to the other.
This brings us to the serious problem of laypersons embracing psy- language and adopting diagnoses in themselves or applying them to others. Even more so than professionals, laypersons tend to think of psychiatric disorders as medical diseases with known etiology or pathophysiology (Hyman 2010, p. 156). By ascribing to the language of DSM diagnoses, they too materialize diagnoses into fixed essentialist conditions thought to govern the body and/or mind. Such attributions engender stigma and blind everybody from developmental, socio-cultural and idiosyncratic interpretative factors that may be associated with a given condition; the net result is unsurprising—instead of facilitating therapeutic progress, the diagnosis itself actually might hinder change (Batstra and Thoutenhoofd 2012; Ben-Zeev et al. 2010; Mukolo et al. 2010).
Yet, in Foucault’s view, reification not only creates an epistemic problem, it above all installs power-related regimes, thus creating social relations in which the patient gets stigmatized. In his 1973-1974 lectures at the College de France, he returned to the issue of psychiatric power and sharpened some of his former criticisms. There he specified that power mechanisms at work in psychiatry are far from obvious, but, on the contrary, are quite subtle in character: “disciplinary power is a discrete, distributed power; it is a power which functions through networks and the visibility of which is only found in the obedience and submission of those on whom it is silently exercised” (Foucault 1973-1974, p. 22). The kind of power that Foucault points to is not personal, but relational: it is a force embedded in the doctor-patient relationship.
Detailed conversation analytic studies make clear that moral power over patient experiences are usually installed in most subtle ways (Bergmann 1992). When questioning patients diagnosticians usually apply specific rhetorical strategies. Often they refer to the uncertain status of their knowledge (e.g., “the nurse told me that you wanted to commit suicide”), allude to experiences by referring to the opposite (“it seems that you don’t feel so well”), or use mitigators and euphemistic descriptions when referring to distress (“you are kind of irritated a bit today”). This way of speaking invites patients to confess and disclose, and protects professionals from being perceived as too direct or intrusive. On the one hand such language use might be seen as considerate and affiliating in nature: the patient is invited to engage in a helping dialogue. On the other hand, as Bergmann (1992) makes clear, such speech might also be seen as a discreet intrusion in the patient’s private sphere. In a subtle manner the diagnostician sets the agenda, pointing to behaviors that are seen as deviant, and thus engaging the patient to tell about personal events she perhaps didn’t want to talk about. Along this way morality enters the dialogue: the patient is asked to report about what is “bad” in her life. While some patients will experience such questioning as helping and inviting, others will see it as a subtle exercise of power, against which they protest, for example, by an explicit non-collaborative attitude, or through oppositional actions.
Indeed, psychiatric diagnosis is only one way in which power manifests, and in Foucault’s view the exercise of power in diagnosis is mediated by a search for truth. When an individual receives a diagnosis, he enters a so-called regime of truth: by being labeled in terms of a nosological classification system, the individual receives a definition of “who he is,” or “what he has.” The diagnosis provides a name for what a given individual is living through in terms of a hidden disease-thing or -process, and it invites the individual to acknowledge what the doctor proclaims. Since psychiatric diagnosis is given in the name of truth, truth that resides in psychiatric expertise, the patient is subject to the discourse of the psy- professional. It pins the individual down to an “administrative identity in which one must recognize oneself” (Foucault 1973-1974, p. 161). Thus considered, psychiatric diagnosis has an alienating effect: a diagnosis is made up of bits of psychiatric knowledge that are imposed upon an individual from without. For example, when an individual believes that he suffers from “ADHD,” as indicated by his doctor, alienation is at play: alien criteria dictate what is going on with this person, and bring about conclusions as to whether he has a disorder or not. As the criteria used for making the diagnosis are believed to match how the individual feels and behaves, these criteria obtain a status of truth.
Foucault’s historical critique came in an age where diagnosis was already under fire. He suggested that underlying the noble ethos of psychiatry, that is, curing and taking care of the mentally ill, power mechanisms and strategies of social re-adaptation were silently at work. In his view, the medicalized gaze of the physician is nothing but a pastiche that conceals the true penchant for discipline and social normalization, and this permeates the psychiatric discourse. As I will further explain in this chapter, the neo-Kraepelinian restoration movement of the 1970s consisted of a loud reconfirmation of the importance of the medical model for understanding psychopathology. Rather than addressing the fundaments of Foucault’s criticisms, contemporary biomedicalization (Schomerus et al. 2012) appears to have relegated these criticisms as irrelevant. As a consequence, important questions, including the question of how psychiatric diagnosis is influenced by shifting social norms, what this shift might tell us about the nature of diagnosis, or the question of the impact diagnosis has on an individual’s subjective beliefs, have remained largely unaddressed. Nonetheless, it is quite obvious that the act of characterizing individuals by means of psychiatric terminology triggers a network of beliefs and societal practices; the latter is inevitable when a discourse becomes dominant and is simply taken for granted. In other words, the discourse diagnosed individuals are imbedded in determine the way in which they are evaluated by others, as well as how they look at themselves. For example, meta-analytic research shows that biomedical explanations of mental disorders usually reduce feelings of blame and responsibility about having psychological problems, but also significantly increase pessimism about the prognosis of a disorder, and nourish the belief that individuals with mental health problems are unpredictable and dangerous (Angermeyer et al. 2011; Kvaale et al. 2013). Indeed, contrary to what many expected, biological accounts of mental disorder don’t reduce prejudice and stigma toward psychiatric patients, but rather are associated with rejection: essentialist thinking about mental health problems “deepens social divides, making differences appear large, unbridgeable, inevitable, unchangeable, and ordained by nature” and “promotes division, segregation, and separation” (Haslam
2011, p. 819). Biogenetic accounts of mental disorders may be effective in reducing stigma in individuals who already have an accepting attitude toward mental health patients, but have far less effect—or even increase stigma—among individuals that hold already negative prejudice (Kvaale and Haslam 2016).
While it makes no doubt that psychiatric labels and reification might engender stigma, some traditional illness categories started functioning as identity categories as well, which opens up possibilities for emancipation from dominant power dynamics in society. Perhaps the best-known example is homosexuality. In the context of Western society homosexuality was long seen as a psychiatric condition, but since the 1970s it progressively got accepted as just a variety of sexual orientation. The gradual acceptance of gay marriage, which was first legally recognized in 2001 in the Netherlands, illustrates this change in attitude. Similar dynamics might now be operative for other psychiatric categories. For example, this might be the case for autism. Many autism advocates make the plea that their particular way of functioning should not be seen as indicative of disease, for which a cure or prevention strategies need to be invented, but as just a variant of human functioning, which has particular strengths and weaknesses (e.g., Grandin 2013). Guided by the idea of neurodiversity it is often indicated that autism implies certain disabilities when individuals are required to interact, which is why support is often needed, yet, it is not a malfunctioning biological condition that needs to be healed. As the self-advocacy group Aspies for Freedom formulate on their blog: “To ‘cure’ someone of autism would be to take away the person they are, and to replace them with someone else.”9 As a matter of fact, in his book Far from the Tree Andrew Solomon (2012) convincingly documents that suggestions for therapies often come across as indicative of how people without autism fail to accept peculiarities of their neighbors with autism. Self-advocacy groups like Aspies for Freedom or the Autistic Self Advocacy Network actively resist such depreciations, and want their disabilities and differences to get respected. Active identification with autism as an identity category might indeed help in getting differences respected, and in fighting prejudice. Yet, a major risk involved is stereotyping, whereby, just like is often the case with other minority groups, polarized ideas about autism make up a narrow perspective starting from which outsiders interpret most aspects of how an individual with autism functions. Such stereotyping might be especially problematic in people who are not actively involved with individuals with autism.
Taking into account Foucault’s criticism requires an open-minded critical evaluation of how, beyond any explicit wish to exercise control, power infiltrates ordinary well-intended relationships with people with mental health problems. After all, power enters care-giving practices through the very discourse one uses. In a study of Foucault’s concept of psychiatric power, Valerie Harwood (2010) argues that diagnostic labeling tends to create what she calls a mobile asylum: a setting in which one is locked up but that, above all, exists in the minds of those involved. While researching attention deficit hyperactivity disorder (ADHD) among children living in disadvantaged neighborhoods, Harwood (2010) observed that out of well-intended concerns, professionals tend to hastily diagnose children in crises. These diagnoses draw the attention away from difficulties they experience in their practical living contexts, that is, the family, the neighborhood, or school. Diagnoses function as truth-claims that focus on the individual, guide myriad decisions, and mobilize coercive mechanisms, which ultimately have a profound impact on the child’s development. Thus considered diagnostic labeling catches the child in a series of verdicts from which they have no possible escape. In order to deal with such a mobile asylum, the potentially negative effects of diagnosis should be studied in greater detail: “to argue for the mobile asylum is to argue for the need to be alert for and recognise power and the frightening effects that certain practices, regardless of their intent, can engender” (Harwood 2010, p. 448). However, addressing implicit power dynamics requires explicit reflection on the implicit assumptions that guide diagnosis, as well as on the social interests that influence diagnostic practices. Strict belief in certain models of the mind hinder such reflection as it impedes questioning of that which seems self-evident.
Another more recent elaboration of Foucault’s point of departure can be found in the works of Nikolas Rose (1996, 1999). Rose (1999, p. 7) critically appraised how psychological diagnoses and tests provide “a mechanism for rendering subjectivity into thought as a calculable force.” In his view, psychological assessment and evaluation practices provide a technology, starting from which contemporary man inspects and perfects himself, and likewise scrutinizes and manages the selves of others. Through the lens of psychology, we began to think of ourselves as manageable machinery. Tests and assessments map individual differences, appraise them in terms of statistical or other social norms, and engender “techniques for the disciplining of human difference” (Rose 1996, p. 19). With reference to Gilles Deleuze, Rose argues that psychological technologies created a “fold in the soul.” Indeed, by applying psychological technologies we made a problem of our own inner life: “The fold indicates a relation without an essential interior, one in which what is ‘inside’ is merely an infolding of an exterior” (Rose 1996, p. 37). Within this view the psy-disciplines did not so much get hold of the “essence” of psychological life, which they (as would-be natural sciences) would like to catch, but merely installed a discourse through which we attempt to predict, adapt, and govern the self. This trend toward self-government is directed by social ideals with which the individual identifies and takes as his ideal-ego. In our contemporary neo-liberal society, success, in all its varieties (beauty, performance, health, etc.), is the ideal against which the individual is measured; it is the objective in line with which the individual refines his own functioning, and in line with which he is managed by others: “In the new domain of consumption, individuals will want to be healthy, experts will instruct them on how to be so, and entrepreneurs will exploit and enhance this market for health” (Rose 1996, p. 162).
Indeed, researchers like Maurice Temerlin, Paul Meehl, David Rosenhan, and Robert Spitzer, and critical academics, like Thomas Szasz or Michel Foucault, arguably challenged psychiatric practice at its very core. Through their criticism, a number of fundamental problems were highlighted and research in psychopathology had to deal with these problems (i.e., the issue of reification in diagnosis; the neglect of processthinking when diagnoses are seen as real-life entities; the naivety of having diagnoses function as lenses through which all behaviors are seen; the issue of power in well-intended care relations; and finally, the stigma that spawns in every direction from so-called diagnostic truth-claims). However, while explicit critiques of diagnostic unreliability strongly guided the revisions that led to the criterion-based DSM diagnosis, evaluations made by critical scholars in psychiatry have largely been ignored. Indeed, in the past decades many psychiatric researchers appear to have a minimal interest in the problems that critical researchers have consistently brought to the fore. As a result, the problems outlined remain as challenging as ever before.
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