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By: Theodore R. Sarbin University of California, Santa Cruz and
James C. Mancuso University at Albany
Copyrights: Theodore R. Sarbin and James C. Mancuso. Posted by permission.
Introduction
The practice of revising DSM every few years reflects an obsessive preoccupationwith diagnosis. This preoccupation flows from the medical profession’slong-standing formula for managing sickness: first diagnosis, then treatment
Psychiatrists have uncritically adopted this formula for managingunwanted conduct. The Manuals are supposed to provide unequivocalcriteria for diagnosis, the first step in the formula.
We submit that the developers of these Manuals have unwittingly beenguided by 19th century mechanistic science, the goal of which is the discoveryand utilization of cause and effect relationships. We say “unwittingly”because the promoters of DSM appear to be unaware that they operate underthe influence of a particular ideology: a set of beliefs based on the root-metaphorof the transmission of forces. One cannot question the success with whichthis root metaphor has guided research in the physical sciences.
The successful achievements of the physical sciences have justifiedthe ideological premises. The authors of the Manuals have taken advantageof the resulting epistemic power granted to the mechanistic ideology. Asa result, DSM diagnosticians feel no need publicly to declare their credo.An unarticulated ideology directs the rhetoric that frames the diagnosisof unwanted behaviors — a rhetoric that prompts speakers and listenersto surround the diagnostic system with a halo of scientism.
Such textbooks shape the beliefs of thousands of students who acceptthe 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 formulatingquestionable social policies and action programs.
In our 1980 book (Sarbin and Mancuso, 1980) we identified nine ideologicalpremises as superordinate constructions that maintain the rhetorical contextin 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 thesearch for cause-and-effect relations on the order of those developed bypractitioners of the physical sciences with its attendant dependence onquantification and on the publication of research findings. Those who usethe 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 researchreports on patients diagnosed as schizophrenic are presented as if theprediction criterion had been satisfied.
In fact, the reports show only degrees of association between dependentand independent variables. The rhetoric of science, however, influencesthe investigator and the reader of the research reports to glidefrom a legitimate claim of association to an illegitimate claim of causality.
The typical research report attempts to establish a particular instanceof conduct as a “symptom” that signifies a particular diagnosis.Golden and Meehl (1979), for example, assert that persons of “a particulargenetic constitution” (a cause) have some “liability for schizophrenia”(an effect) ( p. 217). The authors then proceed to lay out more specificexemplars of the cause-and-effect formulations that buttress the epistemicstrategies of mechanistic science.
They assert that “The effects of a history of social learning uponschizotaxic individuals results in a personality organization … calledschizotypy” (pp.223-4,emphasis ours). Reading further into Goldenand Meehl’s text, the reader is to infer the causes for the schizotypicperson 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’sreport could influence the reader to the fallacious conclusion that thepresence of schizotypy would be the determinate cause for a specific detailof action, such as responding affirmatively to the MMPI item, “I havenot lived the right kind of life” (p. 225).
Without the tacit rhetorical buttressing of the causality theorem ofmechanistic science, DSM systems would gain little support from the plethoraof research reports like that of Golden and Meehl. If the supporting rhetoricwere eliminated, the implied claim to prediction would lose its awesomestatus. Scholars could then compete for journal space to propose alternativeexplanations of unwanted behaviors — explanations based on epistemic valuesother than pseudo-demonstrations of mechanistic causality; for example,internal cohesion, external consistency, parsimony, or range of convenience.
“Mind” and “emotion” refer to body functions. Anelaborate set of assumptions supports the ideology grounded in the generalview that “mind” and “emotion” function as quasi-organsof the body. Having generated social constructions of mind and emotionas corporeal entities, society willingly allocates to medical professionalsthe enterprise of “curing” disordered minds and adjusting inappropriateemotions. The Cartesian concept of mind as an entity analogousto an organ of the body has infiltrated the common sense of the cultureso that metaphors such as “mental illness” and “sound mind”are treated as if they had existent referents rather than being treatedas evaluative judgments.
The concept of mind is a prime example of a socio-linguistic processknown 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 contactwith reality” being a symptom of a diseased mind, the Manuals continueto speak of “distortions or exaggerations of inferential thinking(delusions), perception (hallucinations), language and communication (disorganizedspeech)” (American Psychiatric Association, 1994, pp. 274-275) assymptoms of schizophrenia.
Thus, the myth of a diseased mind-as-organ supports the rhetoric thatguides the discussion sections of hundreds of studies of schizophrenia.For example, in concluding their report, one research team offered thefollowing recommendation: “The two experiments … may also be usefulin diagnosing schizophrenia, for they offer a highly objective means forassessing the characteristic errors in perception that are part of thedefinition of schizophrenia” (Schwartz-Place & Gilmore, 1980,p. 417).
Notwithstanding that in almost 100 years, no marker has been uncoveredthat would identify schizophrenia without unacceptable proportions of falsepositives and false negatives, the prevailing rhetoric leads both the authorsand their readers to engage in an unwitting collusion.
Concomitantly, a review of social constructions associated with theterm “emotion” yields evidence that scholars as well as the personin the street inextricably link “emotional functioning” and “mentalfunctioning.” Diagnostic systems inevitably look for disordered emotionfunctioning as a symptom of “mental illness.” Indeed, improperexpression of “mood” forms the basis of an entire subset of diagnosticcategories in DSM IV. For example, “A manic episode is defined bya distinct period during which there is an abnormally and persistently,expansive or irritable mood” (emphasis ours, American PsychiatricAssociation, 1994, p. 326). The mood “may be recognized as excessiveby those who know the person well.
The expansive quality of the mood is characterized by unceasing andindiscriminate enthusiasms . . .” (p. 326).
The implicit workings of the ideologies of emotion as a somatic eventare apparent: diagnosticians hold expectations of what emotional displaysare “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 depressedmood, it is possible that (quoting DSM) “the presence of a depressedmood can be inferred from the person’s facial expression and demeanor”(p. 321). The ideology that supported the writing of the Manuals wouldsupport the claim that specific embodied emotions are expressed in waysthat are biologically predetermined.
Two strong basic assumptions buttress the ideologies of mind-as-organand emotion as a bodily process. The first is that a “healthy mind”can detect logical flaws, can detect self-evident truths (especially selfevident moral truths), and does not misconstrue sensory inputs. The secondis that the users of DSM have a special skill to determine which emotionalreactions are authentic and which should be regarded as inappropriate.
It is apparent that the ideologies of mind-as-organ and emotion as psychophysiologicalevent have important societal uses. These ideologies clearly figure intothe assignment of responsibilities for dealing with nonconforming behavior.
DSM diagnosticians, tacitly holding to their allegiance to the moralenterprise of controlling unwanted conduct, tend to ignore controversiesthat would challenge crucial assumptions within the system. For example,DSM-IV users would hardly be interested in the carefully worked-outchallenges (by a wide assortment of scholars) to the validity of the entrenchedidea of discrete “natural” emotions [see for exampleAverill (1986), Harr=8A (1986),MacIntyre (1981), Mandler (1992), Sarbin,(1989), Solomon (1976)].
Physicians and their Surrogates Merit a Unique Authority. The Manualsare developed by the American Psychiatric Association, the members of whichare physicians who have elected to specialize in psychiatry. The variouseditions of DSM have been collated by task forces made up primarily ofpsychiatrists.
Since DSM has been declared the authoritative guide to diagnosis, itwould be instructive to examine the authority granted to physicians. Contemporarymedical doctors derive their authority from the historical images of thehealer. Aesculapian authority, named after the Greek god of healing, combinesthree discrete types of control.
The history of psychiatric treatments shows clearly how medical practitionershave 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 thatblock the neural transmissions that depend on dopamine, a brain chemical.Psychiatric textbooks have created the context for administering thesedrugs with such pronouncements as: “Thus, psychiatry stretches frommind to molecule and from clinical neurobiology to molecular neurobiologyas it attempts to understand how aberrations in behavior are rooted inunderlying biological systems” (Andreasen & Black, 1995, p.130).
Under the spell of this kind of rhetorical grandeur, psychiatrists areempowered to label a certain class of chemicals as antipsychotic drugs,rather than tranquilizers. Thus, the phenothiazines — chemical antagoniststo dopamine — are not prescribed for the ethically questionable purposeof tranquilizing.
Redoubtable investigators assume that dopamine antagonists are “truly”antipsychotic, and that researchers are en route to discovering the neurochemicalbasis of schizophrenia. An editorial in the prestigious New England Journalof Medicine questioned the wisdom of continuing this line of inquiry: “Despitea number of suggestive findings….there is currently no proof that eithera neurotoxin or an abnormality of transmission (including a dopaminergicabnormality) is a primary feature of schizophrenia” (Mesulam, 1990).
Yet Andreasen and Black (1995) persist in asserting the authoritativesounding text which invokes a hypothesis embedded in the metaphors of chemistryand physiology.
What support, other than that devolving from Aesculapian authority,leads to this hypothesis? The claim that a dopaminergic abnormality underliesthe expression of “symptoms of schizophrenia” is derived fromthe observation that some patients who ingest a dopamine blocker desistfrom enacting unwanted behaviors. (They also desist from enacting all varietiesof behavior that would not be regarded as symptoms of mental illness, suchas, automatic swallowing of saliva.)
The publication of research projects, many of which are sponsored bypharmaceutical companies, has been instrumental in forging a tenuous causalchain 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 convenientlyborrowed the power of the medical profession to pursue the moral enterprise:the sorting out of those people who must be marginalized because they engagein behaviors that annoy and disrupt.
The politics and rhetoric involved in creating a diagnostic system (Kirkand Kutchins, 1992), of questionable utility (Boyle, 1990) which supposedlyfollows medical ideologies have been well documented .
Other ideologies and other professionals offer solutions to problemsof unwanted conduct based on premises consistent with contextualism, acompeting ideology to the world view of mechanism. To direct attentionto these alternatives, we must demonstrate to the power centers of oursociety the bankruptcy of the moral enterprise that for so long has beenguided by the root metaphor of mechanistic science. At the sametime, we must convince the power centers of the potential utility of analternate ideology, the root-metaphor of which is the narrative and therecognition that we live in a story-shaped world.
REFERENCES
American Psychiatric Association (1994). Diagnostic and StatisticalManual of Mental Disorders, Fourth Edition. Washington D. C.: AmericanPsychiatric Association. Andreasen, N. C. & Black, D. (Eds.). (1995).Introductory Textbook of Psychiatry (Second Edition). Washington, D. C.:American Psychiatry Press.
Averill, J. R. (1986). The acquisition of emotions during adulthood.In R. Harr=8A (Ed.). The social control of emotion, (pp 98-118). New York;Basil Blackwell. Boyle, M. (1990). Schizophrenia: a scientific delusion.
London: Routlege. Chun, K. & Sarbin, T. R. (1970). An empiricaldemonstration of the metaphor to myth transsformation.
Philosophical psychology, 4, 16-21. Golden, R., & Meehl, P. E. (1979).Detection of the schizoid taxon with MMPI indicators. Journal of AbnormalPsychology, 88, 217-233 Harr=8A, R. (Ed.). (1986). The social constructionof emotions, New York: Basil Blackwell. Kirk, S. A & Kutchins, H. (1992).The selling of DSM: The rhetoric of science and psychiatry. New York: AldineDe Gruyter. Mandler, G. (1992) Emotions, evolution and aggression: Mythsand conjectures. In K. T. Strongman (Ed.), International Review of Studiesof Emotion, pp. (97- 116). New York: John Wiley & Sons. McIntyre, A.(1971) Against the self-images of the age. New York: Schocken Books. Meehl,P. E. (1962). Schizotaxia, schizotype, and schizophrenia. American Psychologist,17, 827-838. Mesulam, M. M. (1990). Schizophrenia and the brain. New EnglandJournal of Medicine, 322, 842-845. Sarbin, T. R. (1986). Emotion and act:Roles and rhetoric.
In R. Harr=8A (Ed.), The social construciton of emotion (pp. 83-97).Oxford: Basil Blackwell.
Sarbin, T. R. & Mancuso, J. C. (1980). Schizophrenia: Medical diagnosisor moral verdict. Elmsford, New York: Pergamon Press. Schwartz Place, E.J.& Gilmore,G. C. (1980). Perceptual organization in schizophrenia.Journal of Abnormal Psychology, 89, 409-418. Solomon, R. (1976). The passions.New York: Anchor Press/Doubleday.