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· Resources · |
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Classification and the Treatment of the Patient Victor Barbetti
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The Rise of the DSM
American psychiatry and the field of mental health were more fragmented and diverse than they had been in 1960. The developers knew that it was impossible to organize a classification system that would satisfy multiple constituencies with different views about etiology, prognosis, structure, severity, or relevant dimensions (axes). (Kirk and Kutchins, p. 203) Faced with such pressing legitimation problems, the American Psychiatric Association set up the DSM-III Task Force in 1974 to oversee the development of a new manual. And in 1980 the DSM-III was published. The DSM-III heralded a number of important methodological changes over its predecessors, including "explicit diagnostic criteria, a multiaxial system, and a descriptive approach that attempted to be neutral with respect to theories of etiology" (DSM-IV, p. xviii). This new manual boasted of "extensive empirical work" which attempted to resolve issues of reliability and validity, and provide consistent medical nomenclature for both clinicians and researchers (DSM-IV, p. xviii).
...the term mental disorder unfortunately implies a distinction between "mental" disorders and "physical" disorders that is a reductionistic anachronism of mind/body dualism. A compelling literature documents that there is much "physical" in "mental" disorders and much "mental" in "physical" disorders. The problem raised by the term "mental" disorders has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute. (DSM-IV, p. xxi)
In the DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress ...or disability...or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior...nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as described above. (DSM-IV, p. xxi-xxii) Quite comprehensive! According to this definition, a mental disorder involves a basic dysfunction in an individual regardless of etiology . The diagnosis of a mental disorder for an individual relies upon the presentation of a marked level of impairment (distress, disability, increased risk of death, pain, etc.) or dysfunction for that individual and cannot be based upon culturally accepted or permissible patterns of behavior and/or expression. A mental disorder is a conflict in the individual person. In reference to its uses in forensic settings, the developers of DSM-IV explicitly state that "inclusion of a disorder in the Classification does not require that there be knowledge about its etiology" (DSM-IV, p. xxiii). The correspondence between diagnostic category and the individual's presenting problems (symptomatology) alone provide the ground for a diagnosis. These two fundamental premises of the definition of "mental disorder"-- that it is an individual event, and etiology is not a necessary component of the diagnosis-- is the sine qua non of our modern understanding of whole enterprise of the mental health profession. It is on this basis that both research and practice are carried out, directly affecting what is being researched and who is being treated. Conquering Reliability
In my opinion, the development of DSM-III represents a fateful point in the history of the American psychiatric profession...the judgment is in: DSM-III has already been declared a victory. There is not a textbook of psychology or psychiatry that does not use DSM-III as the organizing principle for its table of contents and for classification of psychopathology. (Kirk & Kutchins, p. 6) Klerman was not alone in his views. In the pages of The New Psychiatrists, Gerald Maxmen proclaimed: On July 1, 1980, the ascendance of scientific psychiatry became official. For on this day, the APA published a radically different system for psychiatric diagnosis called...DSM-III. By adopting the scientifically based DSM-III as its official system for diagnosis, American psychiatrists broke with a fifty year tradition of using psychoanalytically based diagnoses. Perhaps more than any other single event, the publication of DSM-III demonstrated that American Psychiatry had indeed undergone a revolution. (1985, p. 35; as quoted in Kirk & Kutchins, p. 7) With biopsychiatry making leaps and bounds in scientific journals, the publication of a diagnostic manual grounded in empirical research was surely a fresh source of enthusiasm and solidarity for psychiatry. Many psychiatrists welcomed this new nosology, for it provided an avenue for moving psychiatry closer to mainstream medicine; hence, closer to legitimacy.
Classification is, in the crudest way, a form of measurement, a method of determining whether phenomena have the particular characteristics for membership in a class. Questions about the meaningfulness of the concept of mental illness, just like questions about the substantive meaning of many relatively abstract concepts such as intelligence or anxiety, involve issues about the validity of scientific constructs. (Kirk & Kutchins, p. 29) Construct validity is concerned with questions about the nature of the phenomena under investigation. In other words, the question is: are we in fact describing what we say we are describing? For example, intelligence testing is widely regarded as a useful tool, yet scholars and researchers have yet to agree upon what is being tested-- namely, what is intelligence? There are still several camps who disagree on fundamental criteria for what is and what is not intelligence. Critics such as Szasz and Laing were addressing these fundamental issues of validity, and doing so with a force and acumen not easily dismissed by those within mainstream psychiatry. The inability of researchers and practitioners to agree upon the nature of the object of study was a very real and stultifying problem.
there is...one ironic advantage of problems of reliability: they make it possible to forget about the messy problems of validity. Preoccupation with the consistency of clinician's judgments about the presence of mental illness or about the types of mental illness in a particular group of patients has the attraction of avoiding the issue of the general conceptual definition and meaning of disorder. (Kirk & Kutchins, p. 31) In their book, The Selling of the DSM, Kirk and Kutchins suggest that the first task of the new critics was to transform the problems of diagnostic reliability into a technical difficulty requiring technical solutions (Kirk & Kutchins, p. 35). According to Kirk and Kutchins, shifting the focus from the quagmire of validity to the technical and statistical difficulties of reliability had two major advantages. First, the issue of reliability appeared to be more solvable than the problems of validity. Second, the abrupt removal of the pertinent issues into a purely technical arena made matters more complex, and thus beyond competence of clinicians and the public alike (Kirk & Kutchins, p. 35). By focusing on a problem perceived as having a greater chance of success, and by confining this work to the realm of the expert (statisticians), this new group of critics succeeded in mystifying the psychiatric profession as well as the public at large.
Given that even the combined overall reliability for axes I and II did not reach the self-imposed .70 standard and that there were other reliability problems in various categories, one would expect serious concerns to have been raised about the reliability, and therefore the validity, of the classification system. But they were not. Instead, the data were interpreted liberally and inconsistently. (Kirk & Kutchins, p. 147) In addition, not only were these statistics based on field trials with very small numbers of participants, what constituted diagnostic agreement was sometimes frighteningly lenient: if one clinician judged a series of patients to be suffering from Agoraphobia with Panic Attacks and another clinician thought all the same patients suffered from Obsessive Compulsive Disorder, their diagnoses would be considered in perfect agreement on the diagnostic class of Anxiety Disorders and the kappa coefficient would be 1.0 (Kirk & Kutchins, 148) And this was considered far greater improvement in diagnostic reliability by the developers of the DSM-III! At each and every turn in their analysis, Kirk and Kutchins fail to discover the "scientific evidence" proving that the DSM-III is more reliable or valid than its antecedents I and II.
It is our belief that the major innovation of DSM-IV lies not in any of its specific content changes but rather in the systematic and explicit process by which it was constructed and documented. More than any other nomenclature of mental disorders, DSM-IV is grounded in empirical evidence. (DSM-IV, p. xvi) Classification and the Treatment of the Patient
In using the term schizophrenia, I am not referring to any condition that I suppose to be mental rather than physical, or to an illness, like pneumonia, but to a label that some people pin on other people under certain social circumstances. The "cause" of "schizophrenia" is to be found by the examination, not of the prospective diagnosee alone, but of the whole social context in which the psychiatric ceremonial is being conducted. (Laing, 1967, p. 103) It is the "whole social context" that forms the horizon within which interpersonal relations are enacted and experienced. To take the "individual" out of his or her context is, ontologically, a mistake. "Whether we exist in a close, distant, complementary, or adversarial relationship, self and other are always reciprocally constituted" (Burston, 1996, p. 178). Any attempts to isolate the individual from his/her surroundings, their context, is to neglect an entire field of meaning. There is no self without the other; the other is always implied. In Self and Others Laing writes: we cannot give an undistorted account of "a person" without giving an account of his relation with others. Even an account of one person cannot afford to forget that each person is always acting upon others and acted upon by others. The others are there also. No one acts or experiences in a vacuum. (Laing, 1961, pp. 81-82) The second problem with the current definition of "mental disorder" is its avoidance of clinical concern over etiology, or the course of the illness. This approach naturally assuages the ofttimes temperamental disputes between different theoretical factions within psychiatry (e.g. psychoanalytic vs. physiologically oriented professionals), but in so doing effaces the entire cultural, historical, and familial context from which the person emerges. It is not unlike the proverbial throwing the baby out with the bathwater. Because we cannot understand individuals outside of their context (and one's history is a very important part of one's context), ignoring the history of a particular illness is a dangerous affair. Such temerity on the part of the clinician not only promotes an alienating attitude toward the patient, it prevents the clinician from actually coming to know the patient. For Laing, this ahistorical, atomizing attitude toward the patient often resonates with the very attitudes that produced the psychological distress that drove that patient to therapy in the first place: Psychotherapy consists in the paring away of all that stands between us, the props, masks, roles, lies, defenses, anxieties, projections and introjections, in short, all the carryovers from the past, transference and countertransference, that we use by habit and collusion, wittingly or unwittingly, as our currency for relationships. It is this currency, these very media, that re-create and intensify the conditions of alienation that originally occasioned them. (Laing, 1967, pp. 46-47) But even concern for the etiology of the illness is not enough for Laing, for our modern scientific and medical model approach to mental illness is itself ontologically skewed. Laing's thought on this matter is as follows: the psychiatrist adopting his clinical stance in the presence of the pre-diagnosed person, whom he is already looking at and listening to as a patient, has too often come to believe that he is in the presence of the "fact" of "schizophrenia." He acts "as if" its existence were an established fact. He then has to discover its "cause" or multiple "aetiological factors," to assess its "prognosis," and to treat its course. The heart of the "illness," all that is the outcome of process, then resides outside the agency of the person. That is, the illness, or process, is taken to be a "fact" that the person is subject to, or undergoes, whether it is supposed to be genetic, constitutional, endogenous, exogenous, organic or psychological, or some mixture of them all. This, we submit, is a mistaken starting point. (Laing, 1964, p. 18) It is not that the medical model approach itself is mistaken, but our use of it in trying to understand the psychological landscape of suffering persons fails to bring us closer to an understanding of their world. It is, quite simply, a narrow approach. It is an approach that fails to view persons qua persons, and degrades them to the status of "objects." Such an understanding of a "mentally disordered" person precludes a deeper understanding and appreciation of a world in conflict. "It is tempting and facile to regard -- persons-- as only separate objects in space, who can be studied as any other natural objects can be studied" (Laing, 1967, p. 23).
Natural scientific investigations are conducted on objects, or things, or the patterns of relations between things, or on systems of "events." Persons are distinguished from things in that persons experience the world, whereas things behave in the world. Thing-events do not experience. Personal events are experiential. Natural scientism is the error of turning persons into things by a process of reification that is not itself part of true natural scientific method. (Laing, 1959, p. 62) The psychiatrist who approaches his "subject" from an "objective" perspective ("natural scientism") fails to understand his/her own involvement or relationship with the "who" under investigation. This mode of depersonalization, or objectification, Laing suggests, "although conducted in the name of science, . . --yields false knowledge. " (Laing, p. 24). In neglecting to see the uniquely human relationship between doctor and patient, between an I and a Thou, the traditional models can only view a person's behavior as "signs" of a "disease" and, more important, forego the possibility of seeing such "behaviour as expressive of his existence" (Laing, p. 31).
We believe that the shift of point of view that these descriptions [of families of schizophrenics] both embody and demand has a historical significance no less radical than the shift from a demonological to a clinical viewpoint three hundred years ago. (Laing, 1964, p. 27) Laing knew that his work with schizophrenic families, which had an existential-phenomenological orientation, required a radical shift in our conceptualization of the human being. Ontologically speaking, one's relation to oneself is an ambiguous situation. There is a sense in which I can recognize my identity, yet at the same time I am not who/ what I say I am. Following Heidegger, Laing would say that our being is always in question, that it is always at issue. These ontological themes were the focus of both Sartre's Being and Nothingness and Martin Heidegger's Being and Time , two classics of existentialism, and both influenced Laing's own theoretical orientation.
There are therapists-- whether they're Freudian or Jungians, or whether they call themselves one thing or another, or simply psychotherapists-- who don't treat people as objects and as things, and who don't feel it is their job to impose their numbers and their scenarios and their values on the patient, but rather see therapy as a reciprocal undertaking and just don't have that impulse to depersonalize and reify the patient. (Charlesworth, 32) But how does Laing understand persons who are traditionally labeled with a "mental disorder?" We have to decide whether to use old terms in a new way, or abandon them to the dustbin of history. There is no such "condition" as "schizophrenia," but the label is a social fact and the social fact a political event. (Laing, 1967, p.121) Most of Laing's published work dealt with so-called "schizophrenics." This raises the question of whether or not Laing's critique can be applied to diagnostic categories as a whole (i.e. our current nosology). Once again, at this point in our consideration, history can be of some service. Recall that for over one hundred years the classification of mental illness as a discrete entity and the clinical practice of psychiatry and psychology were two separate enterprises. Classification, properly understood, was viewed primarily as an administrative duty, not an edict of what does or does not constitute proper treatment. This is a crucial distinction to bear in mind, for it brings to light key differences between the two approaches. In classification we seek to concentrate or group data according to similarities. In caring for another person, we seek to open up a world that is already all too constricted and indifferent to their individuality. With one we sharpen our focus and induce structures, with the other we look for freedom where it appears there is little or none. Classification systems such as the DSM are the products of political and historical processes. These processes valorize tacit prescriptions for what is or is not considered "sane" or "normal." Such global prescriptions and categories become literally of no use for a clinician sitting face-to-face with a person whose history, present situation, and future are entirely unique and, perforce, ambiguous. Again, recalling the observations of Kirk and Kutchins, the work of creating, maintaining, and perfecting a classification system has at no time in our history been initiated by working clinicians. Why? Because good clinicians are aware that no matter how many diagnostic categories one can hang around the neck of a patient, healing takes place in a realm without judgments, in a forum in which the clinician comes to simply understand the patient. It is in this forum that persons get better, and lives are changed.
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References American Psychiatric Association: Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC, American Psychiatric Association, 1994. Burston, D. (1996). The wing of madness: the life and work of R. D. Laing. Harvard University Press: Campbridge, MA. Charlesworth, M. (1980, 1993). Sartre, Laing, and Freud. In Sartre and psychology, Ed. Hoeller, K. Humanities Press: NJ. Kirk, S.A., & Kutchins, H. (1992). The selling of the DSM: The rhetoric of science in psychiatry. Aldine de Gruyer: New York. Kirk, S.A., & Kutchins, H. (1997). Making us crazy: The psychiatric bible and the creation of mental disorders. Free Press: New York. Laing, R.D. (1959). The divided self. Penguin Books: New York. Laing, R.D. (1961). Self and others. Penguin Books: New York. Laing, R.D. (1964). Sanity, madness, and the family. Penguin Books: New York. Laing, R.D. (1967). The politics of experience. Ballantine Books: New York. Laing, R.D. (1976). The facts of life. Pantheon Books: NY. |
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