Abstract
The myriad controversies embroiling the mental health field—heightened in the lead-up to the release of DSM-5 (2013)—merit a close analysis of the field and its epistemological underpinnings. By using DSM as a starting point, this paper develops to overview the entire mental health field. Beginning with a history of the field and its recent crises, the troubles of the past “external crisis” are compared to the contemporary “internal crisis.” In an effort to examine why crises have recurred, the internal dynamics of the field are assessed: applying Kuhn’s paradigmatic framework, crises are appraised to situate the differences between the natural sciences and the mental health field. Next, a Foucauldian analysis examines the functioning of the field’s power over the body, which is disproportionate in comparison to its scientific grounding. This is followed by investigating the field’s combination of contested scientific grounding and significant power, through a Latourian consideration of the assumptions and meaning behind the mental health field’s deployment of science. This includes scrutinizing the history of the classification of Post-Traumatic Stress Disorder (PTSD). The paper closes by assessing the field’s potential to address these issues effectively.
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Notes
This paper focuses on the American mental health field, which primarily utilizes DSM, instead of the ICD manual, which is more widely used internationally.
Hannah Decker (2013) highlights a telling selection of the mental health field’s power, through the widespread and varied use of DSM: In addition to the power of diagnosing mental disorders, “to get reimbursed from health insurance companies, DSM diagnoses and codes must be submitted. Medical students, psychiatry residents, and psychology interns learn diagnostic psychiatry from the manual. Applications for research grants risk losing their funding if they do not use the manual’s diagnoses and language. Lawyers, judges, and prison officials use the manual throughout the judicial system. Parents can get free special services for their children in public schools if their child’s diagnosis is in the DSM. As an example of how deeply the DSM penetrates into everyday life, regard, for a moment, labor and employment law. The DSM affects what accommodations need to be made by employers for mentally disabled workers, under the Americans with Disabilities Act. Claims citing mental disorders under the Family Medical Leave Act and workers’ compensation laws are adjudicated using the current DSM” (p. xviii).
Beyond its use among clinicians, DSM is “used as a reference for the courts and attorneys in assessing the forensic consequences of mental disorders” (American Psychiatric Association 2013, p. 25).
Kuhn (1962/2012) makes sure to clarify that “if an anomaly is to evoke crisis, it must usually be more than just an anomaly” (p. 82). Were this not the case, all science would be in constant crisis.
In one of their papers, Robins and Guze explained five steps they “thought necessary to develop a valid (i.e., useful because correct) classification: (1) description of the clinical picture (signs and symptoms); (2) laboratory studies (which they admitted did not exist for ‘the more common psychiatric disorders’); (3) exclusion criteria to weed out patients with other illnesses; (4) follow-up studies; and (5) family studies” (Decker 2013, p. 56).
These figures included Nancy Andreasen, Dennis Cantwell, Paula Clayton, George Saslow, and Robert Woodruff.
A contemporary counterpart to these Washington University members’ emphasis on validity is the US National Institute of Mental Health’s Research Domain Criteria (RDoC) project, which researches the biological validity of mental disorders outside the bounds of DSM’s diagnostic system.
Gary Greenberg (2013) reiterates this point: “reliability—the extent to which diagnostic criteria would yield agreement among clinicians—was not the same as validity, or the extent to which the diagnosis described an actual disease” (p. 40, emphasis in original). Thus Kraemer et al.’s (2012) claim that DSM-5 aims “to provide the greatest possible assurance that those with a particular disorder will have it correctly identified” is problematic if the “correct identification” lacks validity (p. 13). The question thus uncomfortably surfaces: how can a reliably invalid diagnostic system ward off future crisis, and how can legitimacy be indefinitely maintained in the face of this?
This is corroborated by a statement from the two leaders of the DSM-5 Task Force: “we expected that some of the limitations of the current psychiatric diagnostic criteria and taxonomy would be mitigated by the integration of validators derived from scientific advances in the last few decades” (Kupfer & Regier 2011, p. 672). Regier (2007) also implies that legitimacy depends on reliability and utility eventually matching validity (p. S2). However, as Phillips (2013a) recognizes, the science has not fallen into place because of the DSM categories’ very ambiguities (p. 145).
As chair of the DSM-IV task force, Allen Frances (2013) states that “the seven years each between DSM-III, DSM-IIIR, and DSM-IV (1980, 1987, and 1994) had not generated compelling research findings to warrant a significant revision of the diagnostic system” (p. 71). One example of Frances’s own careful sharpening without attempting to overhaul the diagnostic system is his decision to adopt meta-analysis, which could synthesize different research projects (Greenberg 2013, p. 47).
Toward this end, Widiger and Samuel (2005) point out that “it is simpler to inform a colleague that a patient has a borderline personality disorder than to describe the patient in terms of the 30 facets of the FFM [Five Factor Model of Personality]” (p. 500).
These criteria are stated in Kendler et al.’s (2009) “Guidelines for Making Changes to DSM-V,” (p. 1).
Hobsbawm (1987/1989) acknowledges this absence of agreed upon principles for the social sciences, as he states that “unlike the natural sciences, [the social sciences] lacked a generally accepted central body of cumulative knowledge and theory, a structured field of research in which progress could be claimed to result from an adjustment of theory to new discoveries” (p. 269).
However, this scientific progress does not develop without its own resistances. One example is that “even after the discovery of Copernicus’s law, the Ptolemaic worlds long went on being studied” (Tolstoy 1869/2007, p. 1213). Kuhn (1977) adds further context to this resistance as he explains that “Copernicus’s system…was not more accurate than Ptolemy’s until drastically revised by Kepler more than sixty years after Copernicus’s death. If Kepler or someone else had not found other reasons to choose heliocentric astronomy, those improvements in accuracy would never have been made, and Copernicus’s work might have been forgotten” (p. 323).
On elements of the periodic table as indifferent kinds, Hacking (1999) focuses on the example of Plutonium, as he states that “plutonium does not interact with the idea of plutonium, in virtue of being aware that it is called plutonium, or experiencing existence in plutonium institutions like reactors, bombs, and storage tanks” (p. 105). For non-human animals as indifferent kinds, he mentions horses: “horses are no different for being classified as horses” (p. 107).
It is important to clarify that different theoretical frameworks in the mental health field have different application, but should not be seen as different paradigms. For example, Cognitive Behavioral Therapy has more support for anxiety disorders than couples therapy, but this does not imply that a multitude of paradigms allows for more tailored treatment. Instead, a firm paradigm outlining existence and diagnosis of mental disorder could be used as a starting point for different theoretical frameworks, in the same way that the firm paradigm of the periodic table is used as a foundation for both organic and inorganic chemistry.
While Foucault’s theories on power have been judiciously criticized by commentators such as Anderson (1983) for their at times excessive detachment from historical circumstances and social relations (p. 51); and Dews (1987/2007) for their consequent slide into metaphysics and homogeneity (p. 203, 281), these theories profoundly help illuminate the stakes of an essential internal dynamic of the mental health field—the too-rarely addressed lacuna between its power and its scientific backing.
It is also essential to remember that this power is always calculated and exercised with certain aims and objectives as an end rather than an amorphous and aimless procedure (Foucault 1978/1990, p. 95). It should be clarified that Foucault’s notion of power, which operates beyond repression and coercion to become “productive,” is not a value judgment, but an exegetical assessment. Furthermore, in contrast to Adorno and Horkheimer’s (1944/2002) assessment of knowledge and power as “synonymous” (p. 2), Foucault (1994a) rightly specifies that because they are not identical, he is concerned with studying their relation (p. 133).
Foucault (1972/2010) somewhat tautologically defines discourse as “a group of statements in so far as they belong to the same discursive formation…it is a body of anonymous, historical rules, always determined in the time and space that have defined a given period” (p. 117). In addition to being shaped by authorities, (Foucault 1972/2010, p. 68), discourses are not “timeless” (p. 70), and thus should not be viewed as static.
This perceptible shift was from “a technology of power that drives out, excludes, banishes, marginalizes, and represses, to a fundamentally positive power that fashions, observes, knows, and multiplies itself on the basis of its own effects” (Foucault et al. 2003a, p. 48). Again, it cannot be overemphasized that Foucault’s use of “negative” and “positive” power are not value judgments, but didactic explanations for the workings of power. Positive power is positive in the sense of its ability to actively produce knowledge, which is achieved through observation and examination.
In another context, Bourdieu (1984) explains that normalization serves as justification for “doctors and diet experts armed with the authority of science [to] impose their definition of normality with height-weight tables, balanced diets or models of sexual adequacy” (p. 153, emphasis in original). Processes of biopower work on the level of normalizing entire populations (Foucault et al. 2003b, pp. 246–247).
Confession is an important aspect of power for Foucault because it brings the body, knowledge, discourse, and power into a common localization (Dreyfus & Rabinow 1983, p. 169).
Danziger (1990) makes this distinction in the context of psychological experiments (pp. 8–9). While Kuhn (2000) was unsure whether differences between the natural sciences and human sciences were “principled or merely a consequence of the relative states of development of the two sets of fields” (p. 221), such a distinction suggests the former. For an earlier recognition of distinction between the natural and human sciences involving their respective objects of study, see Lyotard (1984, p. 57).
Foucault’s (1978/1990) remark that “the sodomite had been a temporary aberration; the homosexual was now a species” (p. 43) succinctly describes a segment of gender studies interested in this question. He meant that what had once been viewed as sexual practice later became sexual identity as a result of specific historical processes in nineteenth century Western Europe. This periodization is important, as earlier “Europeans” such as Dante Alighieri (The Divine Comedy, New American Library edition, 2003) in the fourteenth century could only mention meeting sodomites in Purgatory’s seventh cornice whose “offenses” were “hermaphroditic” (p. 513, Canto XXVI line 82). By mentioning offenses rather than identities, Dante implicitly makes the distinction between sexual practice and sexual identity. Even earlier than Dante, a dialogue such as Plato’s (1997, Hackett edition) “Phaedrus” has its eponymous character speaking of “seducing a young boy” (p. 508, 227c) without pathologization or comment on abnormality, suggesting that modern categories such as heterosexual and homosexual cannot be anachronistically applied, and lose their meanings when not circumscribed to their own milieus. Homosexuality can thus be seen as an interactive kind, with authors such as Najmabadi (2005); El-Rouayheb (2005); and Massad (2007) contesting the idea of sexual identities as historically transcendent. Najmabadi details the change in Iranian conceptions of gender and sexuality after European interactions, El-Rouayheb explores the differing sexual norms of the Arab world before widespread European interaction, and Massad examines the extent to which the heterosexual/homosexual binary is imposed on the contemporary Arab world by what he terms the “Gay International.” In none of these histories have individuals fit into binaries of sexual identity before exposure to interactive kinds originating in European discourses.
The potential for raising viable alternatives “presupposes that the competitors confront each other on equal terms,” which can be practically impossible (Feyerabend 1975/2010, p. 112).
For the debate about TRF as peptide from which the example of analyzing PTSD draws inspiration, see Latour & Woolgar (1979/1986), pp. 105–150. The statement that TRF is a peptide is an example of ready made science, but before it was determined to be a peptide, or to even exist, the debate around it was one of science in action. At the time of debates over light as wave or particle, Bachelard (1984) points out that “neither can claim to represent the deep, underlying reality” (p. 93), further illustrating the distinction between science in action and ready made science.
The remainder of this sub-section draws on Scott’s (1990) history for its analysis.
For a critical analysis of these studies’ vague conclusions, see Young (1995, pp. 272–285).
In Latour and Woolgar’s (1979/1986) analysis of TRF’s fact construction—the example which inspired this analysis of PTSD—in the process of science in action, differences could be viewed as either “minor noise” or “a major discrepancy” with equal validity (p. 145). The tons of expensive hypothalami that were processed by the “winning” group in addition to their strict standards provides an example of the prohibitive cost of questioning science after facts have been established. Additionally, because mass spectrometry was used in the process, the efforts of future competitors would be faced with the practical but not theoretical impossibility of contesting physics as a whole (Latour & Woolgar 1979/1986, p. 242). As a result, in a million-dollar business like the sequencing of TRF, the chances are that no alternative statement is feasible; the constraints are such that no investment could possibly match those already made.
This is why Canguilhem (2012) emphasizes the social component of knowledge about disease (p. 38).
In another register, Henrik Ibsen’s (1882/2007) play “An Enemy of the People” traces the fate of an unfortunate lone man with the truth about the toxic water at his town’s new baths. He is eventually marginalized and castigated by society, but before this peripeteia, even he recognizes the impracticality of standing alone with the truth: “is not the free press standing before me? And is not the solid majority standing behind me? Surely that’s might enough” (p. 56). The dependence of facts on networks is further depicted in the example of a paper that settles a scientific controversy, but is completely ignored (Latour 1987, p. 40).
Foucault postulates that the change in concept of organic structure, general grammar, and the value of objects determined the consequent shifts of emphasis in biology, philology, and economics, respectively. For these changes, see Foucault (1970/1994b, pp. 226–237). However, “it would be false—and above all inadequate—to attribute this mutation to the discovery of hitherto unknown objects…[These disciplines were presented as freeing] themselves from their prehistories through a sort of auto-analysis achieved by reason itself” (Foucault 1970/1994b, p. 252).
Sokal and Bricmont (1998) miss Latour’s point when they contend that “the correct answer to any scientific question, solved or not, depends on the state of Nature,” since for Latour, scientific attitudes are radically different depending on the state of a scientific problem (p. 97). With this nuance, it does not make sense to argue that “Nature” is the answer to a scientific dispute before its resolution.
Latour (1987) provides another example as he states that “as long as there is a debate among endocrinologists about GRF or GHRH, no one can intervene in the debates by saying ‘I know what it is, Nature told me so…’ However, once the collective decision is taken to turn…GRF into an incontrovertible fact, the reason for this decision…is immediately attributed to the independent existence of GRF in Nature” (p. 98).
Although Leeuwenhoek and Hooke used the microscopes they pioneered for microbiology, the general structure of the discursive biological field was not immediately revolutionized upon their arrival, problematizing the notion of linear scientific progress. This is why Foucault can point to an example of a prominent post-Leeuwenhoek and Hooke scientist such as Linneaus, who utilized the microscope and considered it important, yet made negligible contributions to microscopical research. Linneaus’s papers do not reveal the use of a microscope for anything that could not be seen by the naked eye: “the anatomical details, even if a microscope would help to make them easier to perceive, are not those that a microscope reveals” (Ford 2009, p. 71, emphasis added).
Two more examples of this distortion include the revisionist treatment of TRF and Pasteurism (which acknowledged the existence of microbes) after they were both established as scientific fact: “TRF has been there all along, just waiting to be revealed for all to see. The history of its construction is also transformed from this new vantage point: the process of construction is turned into the pursuit of a single path which led inevitably to the ‘actual’ structure” (Latour & Woolgar 1979/1986, p. 177). “When [doctors] at last made up their minds to use Pasteurism, they saw it not as a revolution in their own practices but as a way of continuing in strengthened ways what they had always done” (Latour 1988, p. 116, emphasis in original).
Foucault (1976/2011) states that the task of the doctor in the space of the medical health field was ethical supervision much more than therapeutic intervention (p. 119), and that “it was not as a scientist that homo medicus gained authority in the asylum, but as a wise man. If medical practitioners were required, then it was not for the knowledge that they brought, but rather as a moral and juridical guarantee of good faith. Any man of good conscience and unquestionable virtue, providing he had a long experience of the asylum, could just as well take his place” (Foucault 2006a, p. 504).
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This article greatly benefited from the trenchant insights of three anonymous reviewers, Eva Hall, Alexander Jabbari, and Sara Salessi.
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Sina Salessi is an independent scholar interested in the historical lineages of our time. Previous publications include articles in Third World Quarterly.
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Salessi, S. Aporia of power: On the crises, science, and internal dynamics of the mental health field. Euro Jnl Phil Sci 7, 175–200 (2017). https://doi.org/10.1007/s13194-016-0151-3
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DOI: https://doi.org/10.1007/s13194-016-0151-3