Some Unarticulated Premises in the Rhetorical Construction of DSM Categories
Theodore R. Sarbin University of California, Santa Cruz
and James C. Mancuso University at Albany
Introduction
The practice of revising DSM every few years reflects an obsessive preoccupation with diagnosis. This preoccupation flows from the medical profession's long-standing formula for managing sickness: first diagnosis, then treatment
Psychiatrists have uncritically adopted this formula for managing unwanted conduct. The Manuals are supposed to provide unequivocal criteria for diagnosis, the first step in the formula.
We submit that the developers of these Manuals have unwittingly been guided by 19th century mechanistic science, the goal of which is the discovery and utilization of cause and effect relationships. We say "unwittingly" because the promoters of DSM appear to be unaware that they operate under the influence of a particular ideology: a set of beliefs based on the root-metaphor of the transmission of forces. One cannot question the success with which this root metaphor has guided research in the physical sciences.
The successful achievements of the physical sciences have justified the ideological premises. The authors of the Manuals have taken advantage of the resulting epistemic power granted to the mechanistic ideology. As a result, DSM diagnosticians feel no need publicly to declare their credo. An unarticulated ideology directs the rhetoric that frames the diagnosis of unwanted behaviors -- a rhetoric that prompts speakers and listeners to surround the diagnostic system with a halo of scientism.
Such textbooks shape the beliefs of thousands of students who accept the rhetorically driven DSM categories as scientifically established Truth. In turn, these young people enter professions -- law, social work, education, medicine, etc. -- in which they may employ these premises in formulating questionable social policies and action programs.
In our 1980 book (Sarbin and Mancuso, 1980) we identified nine ideological premises as superordinate constructions that maintain the rhetorical context in which unwanted conduct is transfigured to medically-inspired diagnoses. In this brief presentation, we elaborate three of these premises:
Research has high positive value. The rhetoric of science features the search for cause-and-effect relations on the order of those developed by practitioners of the physical sciences with its attendant dependence on quantification and on the publication of research findings. Those who use the diagnostic manuals quickly become immersed in the ideological traditions. They gain certification as scientists by publishing their own research. The research journals place a high value on prediction.
In the psychiatric and psychological journals, the tedious research reports on patients diagnosed as schizophrenic are presented as if the prediction criterion had been satisfied.
In fact, the reports show only degrees of association between dependent and independent variables. The rhetoric of science, however, influences the investigator and the reader of the research reports to glide from a legitimate claim of association to an illegitimate claim of causality.
The typical research report attempts to establish a particular instance of conduct as a "symptom" that signifies a particular diagnosis. Golden and Meehl (1979), for example, assert that persons of "a particular genetic constitution" (a cause) have some "liability for schizophrenia" (an effect) ( p. 217). The authors then proceed to lay out more specific exemplars of the cause-and-effect formulations that buttress the epistemic strategies of mechanistic science.
They assert that "The effects of a history of social learning upon schizotaxic individuals results in a personality organization ... called schizotypy" (pp.223-4,emphasis ours). Reading further into Golden and Meehl's text, the reader is to infer the causes for the schizotypic person becoming clinically schizophrenic -- constitutional weaknesses, a history of social learning influenced by schizophrenogenic mothers, etc.
Using the rhetoric of implying causal connections, Golden and Meehl's report could influence the reader to the fallacious conclusion that the presence of schizotypy would be the determinate cause for a specific detail of action, such as responding affirmatively to the MMPI item, "I have not lived the right kind of life" (p. 225).
Without the tacit rhetorical buttressing of the causality theorem of mechanistic science, DSM systems would gain little support from the plethora of research reports like that of Golden and Meehl. If the supporting rhetoric were eliminated, the implied claim to prediction would lose its awesome status. Scholars could then compete for journal space to propose alternative explanations of unwanted behaviors -- explanations based on epistemic values other than pseudo-demonstrations of mechanistic causality; for example, internal cohesion, external consistency, parsimony, or range of convenience.
"Mind" and "emotion" refer to body functions. An elaborate set of assumptions supports the ideology grounded in the general view that "mind" and "emotion" function as quasi-organs of the body. Having generated social constructions of mind and emotion as corporeal entities, society willingly allocates to medical professionals the enterprise of "curing" disordered minds and adjusting inappropriate emotions. The Cartesian concept of mind as an entity analogous to an organ of the body has infiltrated the common sense of the culture so that metaphors such as "mental illness" and "sound mind" are treated as if they had existent referents rather than being treated as evaluative judgments.
The concept of mind is a prime example of a socio-linguistic process known as the metaphor-to- myth transformation (Chun and Sarbin, 1970). Originally a verb for talking about such functions as thinking, perceiving, remembering, and so on, "mind" became the preferred metaphor, later to be reified as a quasi organ. Being an organ, "mind" could be split, hence the obfuscating Greek term, schizophrenia.
Though recent editions of DSM contain cautions about "loss of contact with reality" being a symptom of a diseased mind, the Manuals continue to speak of "distortions or exaggerations of inferential thinking (delusions), perception (hallucinations), language and communication (disorganized speech)" (American Psychiatric Association, 1994, pp. 274-275) as symptoms of schizophrenia.
Thus, the myth of a diseased mind-as-organ supports the rhetoric that guides the discussion sections of hundreds of studies of schizophrenia. For example, in concluding their report, one research team offered the following recommendation: "The two experiments ... may also be useful in diagnosing schizophrenia, for they offer a highly objective means for assessing the characteristic errors in perception that are part of the definition of schizophrenia" (Schwartz-Place & Gilmore, 1980, p. 417).
Notwithstanding that in almost 100 years, no marker has been uncovered that would identify schizophrenia without unacceptable proportions of false positives and false negatives, the prevailing rhetoric leads both the authors and their readers to engage in an unwitting collusion.
Concomitantly, a review of social constructions associated with the term "emotion" yields evidence that scholars as well as the person in the street inextricably link "emotional functioning" and "mental functioning." Diagnostic systems inevitably look for disordered emotion functioning as a symptom of "mental illness." Indeed, improper expression of "mood" forms the basis of an entire subset of diagnostic categories in DSM IV. For example, "A manic episode is defined by a distinct period during which there is an abnormally and persistently, expansive or irritable mood" (emphasis ours, American Psychiatric Association, 1994, p. 326). The mood "may be recognized as excessive by those who know the person well.
The expansive quality of the mood is characterized by unceasing and indiscriminate enthusiasms . . ." (p. 326).
The implicit workings of the ideologies of emotion as a somatic event are apparent: diagnosticians hold expectations of what emotional displays are "normal" and they have the ability to detect improper displays. Indeed, even when a person does not report that he or she feels in a depressed mood, it is possible that (quoting DSM) "the presence of a depressed mood can be inferred from the person's facial expression and demeanor" (p. 321). The ideology that supported the writing of the Manuals would support the claim that specific embodied emotions are expressed in ways that are biologically predetermined.
Two strong basic assumptions buttress the ideologies of mind-as-organ and emotion as a bodily process. The first is that a "healthy mind" can detect logical flaws, can detect self-evident truths (especially self evident moral truths), and does not misconstrue sensory inputs. The second is that the users of DSM have a special skill to determine which emotional reactions are authentic and which should be regarded as inappropriate.
It is apparent that the ideologies of mind-as-organ and emotion as psychophysiological event have important societal uses. These ideologies clearly figure into the assignment of responsibilities for dealing with nonconforming behavior.
DSM diagnosticians, tacitly holding to their allegiance to the moral enterprise of controlling unwanted conduct, tend to ignore controversies that would challenge crucial assumptions within the system. For example, DSM-IV users would hardly be interested in the carefully worked-out challenges (by a wide assortment of scholars) to the validity of the entrenched idea of discrete "natural" emotions [see for example Averill (1986), Harr=8A (1986),MacIntyre (1981), Mandler (1992), Sarbin, (1989), Solomon (1976)].
Physicians and their Surrogates Merit a Unique Authority. The Manuals are developed by the American Psychiatric Association, the members of which are physicians who have elected to specialize in psychiatry. The various editions of DSM have been collated by task forces made up primarily of psychiatrists.
Since DSM has been declared the authoritative guide to diagnosis, it would be instructive to examine the authority granted to physicians. Contemporary medical doctors derive their authority from the historical images of the healer. Aesculapian authority, named after the Greek god of healing, combines three discrete types of control.
The history of psychiatric treatments shows clearly how medical practitioners have employed Aesculapian authority to administer various draconian treatments, for example, lobotomies, to persons diagnosed as "mentally ill." The current use of this authority justifies prescribing medications that block the neural transmissions that depend on dopamine, a brain chemical. Psychiatric textbooks have created the context for administering these drugs with such pronouncements as: "Thus, psychiatry stretches from mind to molecule and from clinical neurobiology to molecular neurobiology as it attempts to understand how aberrations in behavior are rooted in underlying biological systems" (Andreasen & Black, 1995, p.130).
Under the spell of this kind of rhetorical grandeur, psychiatrists are empowered to label a certain class of chemicals as antipsychotic drugs, rather than tranquilizers. Thus, the phenothiazines -- chemical antagonists to dopamine -- are not prescribed for the ethically questionable purpose of tranquilizing.
Redoubtable investigators assume that dopamine antagonists are "truly" antipsychotic, and that researchers are en route to discovering the neurochemical basis of schizophrenia. An editorial in the prestigious New England Journal of Medicine questioned the wisdom of continuing this line of inquiry: "Despite a number of suggestive findings....there is currently no proof that either a neurotoxin or an abnormality of transmission (including a dopaminergic abnormality) is a primary feature of schizophrenia" (Mesulam, 1990).
Yet Andreasen and Black (1995) persist in asserting the authoritative sounding text which invokes a hypothesis embedded in the metaphors of chemistry and physiology.
What support, other than that devolving from Aesculapian authority, leads to this hypothesis? The claim that a dopaminergic abnormality underlies the expression of "symptoms of schizophrenia" is derived from the observation that some patients who ingest a dopamine blocker desist from enacting unwanted behaviors. (They also desist from enacting all varieties of behavior that would not be regarded as symptoms of mental illness, such as, automatic swallowing of saliva.)
The publication of research projects, many of which are sponsored by pharmaceutical companies, has been instrumental in forging a tenuous causal chain of great rhetorical power. The chain may be represented as follows:
The absurdity of the causal claim requires no further comment.
Conclusion
Faced with the heavy burden of social control, our society has conveniently borrowed the power of the medical profession to pursue the moral enterprise: the sorting out of those people who must be marginalized because they engage in behaviors that annoy and disrupt.
The politics and rhetoric involved in creating a diagnostic system (Kirk and Kutchins, 1992), of questionable utility (Boyle, 1990) which supposedly follows medical ideologies have been well documented .
Other ideologies and other professionals offer solutions to problems of unwanted conduct based on premises consistent with contextualism, a competing ideology to the world view of mechanism. To direct attention to these alternatives, we must demonstrate to the power centers of our society the bankruptcy of the moral enterprise that for so long has been guided by the root metaphor of mechanistic science. At the same time, we must convince the power centers of the potential utility of an alternate ideology, the root-metaphor of which is the narrative and the recognition that we live in a story-shaped world.
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