The Problems with the DSM Mask a Dark Reality We’re All Complicit In — Mad in America

The reductive, materialist approach to ‘mental disorder’ is running on fumes. The idea that disorders are simple, empirical things, comprised of smaller empirical things (thoughts, beliefs, desires etc.) that can be differentiated and isolated, reduced and explained by physical causes is a tale that is losing credibility by the day. The core philosophy that our mental experience just is physical experience really and is, as such, entirely conducive to the scientific method is therefore, I argue, lost. For far too long we have been seduced and overwhelmed by these ideas, and the time is increasingly upon us to reject them and think again about what ‘mental disorder’ is.

Although there are several studies or avenues to make the case I wan to make in this regard, I will focus on a very recent paper by Allsopp et al (2019).1 This paper comes to the arguably alarming conclusion that the DSM is not only conceptually problematic but “scientifically meaningless.” The very fact that there is considerable overlap between disorders and that two people can (so the DSM says) have the same disorder but share none of the same symptoms, it is argued, contradicts the very purpose and relevance of a system that was based on discerning ‘discrete disorders.’ And it must be noted that Allsopp et al’s paper is not a theoretical paper in a psychotherapy journal, but a study in a psychiatry journal. Being that the DSM essentially represents the culmination of decades of empirical research on the Psyche, and being that it also represents the very philosophy of minds, brains, and experience described above as applied in the real world, then this is clearly no small deal.

Before getting into the weeds, however, I would like to first very briefly paint the broader picture here. While it is certainly exciting that these kinds of conclusions are finding expression through more formal, scientifically accredited avenues, the truth of the matter is that a large portion of people in the mental health field — workers and service-users alike — already knew that DSM-type thinking was deeply problematic, and (behind closed doors at least) did not employ its terms in any decisive, meaningful way. Indeed, there are decades-long strands of argument and opposition that reject this kind of thinking, since at least the anti-psychiatry movement of the 1960s and in psychoanalytic circles in some way since its inception. The general argument is that this kind of thinking is not only deeply problematic in its own terms — as if we only need to start the empirical project of categorizing and predicting Psyche and its ailments again in a different way — but that by its very nature it exactly misses human experience in all its complexity, and precisely because it aims to categorize psychological experience in this way.

While the 'anti-psychiatry' movement went over similar ground as these kinds of studies (Thomas Szasz, as problematic as some of his opinions were, argued that there was “no such thing as mental disorder” on conceptual grounds, for example),2 that movement did not really survive in any efficacious way. These days it is mostly treated as an amusing historical anomaly of the supposedly naïve, idealistic woo that that period has come to be characterized as producing. After a brief flash of influence, it quickly waned, and along with a lot of thought at that time was gobbled up by the behemoth of empirical science that promptly ensued — cognitive science, neuroscience, genetic research, etc. Taking on its modern incarnation in the 1950’s, the empirical project of the Psyche offered something that more complex, existentially and experientially accurate theories and accounts of mental distress could not: the tantalizing possibility of a scientific explanation of distress that we could all then locate the problem of suffering in, try to ‘solve’, and then breathe a collective sigh of relief.

But whereas in the 1960s one could convincingly argue the case against 'anti-psychiatry' type criticisms and for a reductive approach to Psyche on the grounds that the ‘science of mind’ was just getting started, this time the approach has unarguably had its day in the sun — its shot, so to speak. And now, not only has our understanding arguably not progressed as a result of mass empirical projects like the DSM, it has arguably regressed.

So, let’s dig into this. The entire DSM project was premised on the idea of discrete, differentiated and differentiable mental ‘disorders’ that people effectively ‘had,' much like one has a physical illness such as Parkinson’s or heart disease. The core problem with this is that while you can empirically discover, identify and objectively treat Parkinson’s or heart disease, this has never been achieved for a single ‘mental disorder’ through the empirical investigation of the Psyche and its ailments. Ironically, this was Thomas Szasz’s main argument in the 1960’s, and it is still valid. The counter-argument was and still is that eventually science will discover the underlying physical explanation and cause(s), at which point the embarrassment will be over, and that we are effectively doing the best we can in the meantime. But unless there is a specific time limit, which there isn’t, this is tantamount to an unfalsifiable claim. As falsifiability is supposedly a key criterion for considering something a science, this is not a scientific statement, but an argument based on faith.

The only thing that is not scientific about the science in this context is therefore, ironically, itself. And here we are half a century later and nothing has decisively been discovered. So even its faith has not gone rewarded. It must be a wonderful thing if you are of that persuasion to be able to fall back on, “Well, we haven’t discovered the physical explanation that proves it, yet.”

There are two specific problems of note with where the DSM has arrived without such evidence. Firstly, there is explicit and complicated overlap between most diagnoses in the DSM scheme; and, secondly, the related fact that two people can have the same diagnosis but share none of the same symptoms, both of which Allsopp et al focus on in their paper. We might also add to this the very notion of “co-morbidity” — the reality, almost the rule, that people have multiples of these ‘discrete disorders’ at the same time. Many people, of course, end up diagnosed with multiple, overlapping disorders, that are supposed to constitute the cause and explanation of their distress.

This sounds sort of reasonable if we think about people with multiple, complicated physical issues, but let the ramifications of this sink in when used as a description of mental distress. Does it seem rational to conclude that many cases of suffering are best explained as the result of a complex system of unique pathological agents inside someone somewhere, causing an illness like a virus does, when there is absolutely no empirical evidence to suggest this? When a person has had a very difficult childhood characterized by abuse or neglect, say, does it make sense to say that their symptoms are explained by the presence of an anxiety agent, a trauma agent, a depression agent and a psychotic agent that comes in and out of existence every now and again, working inside them and against them (which all then need to somehow be individually treated)? When it is put like this — which it should be because this is the essential message — it sounds more than a little psychotic. And this is not simply hyperbole — we are all subject to the full gamut of ‘disordered’ experience, ‘experts’ included.

Irrespective of what one thinks about this, when the very raison d’etre of the DSM was to outline discrete disorders to be treated specifically, the admission (and indeed promotion) of such a complicated and confusing picture does not just ‘undermine’ the project, it flatly contradicts it. So far as I am concerned, the notion of overlap and co-morbidity in this context (i.e. without empirical evidence in its favor) is just an ad hoc justification to force coherence to something that was incoherent in the first place. I’m sure the “not yet, but later” argument would seem particularly tempting right now to defenders of the approach, but the fact remains that if there is (often considerable) overlap, then there is no discrete disorder. Likewise, if two people can be diagnosed with the same disorder but not share the same symptoms, again the premise is disproved, as the notion of it being discrete then has no meaning. Logic supposedly does not lie, and after all empirical science is supposed to be a logical enterprise.

But this isn’t entirely lost on the DSM. Indeed, it is in some sense admitted. In sections away from the actual diagnoses, it is suggested that there is an essentially heuristic importance and relevance to the scheme employed. Fair enough; I do not disagree with that at all. If it was understood simply as a way of categorizing complex, contradictory, and overdetermined experiences, then great. There is no doubt, not only that this is useful but that some form of categorization is absolutely necessary in any institution of mental health treatment. But — and this is a big but —this is not how it is promoted, nor how it is customarily understood by the lay public. Indeed, despite the fact that they may caveat the approach in such ways, the very fact that these realities are presented as caveats, when the only logical conclusion is that they undermine the very efficacy and relevance of the entire project, supports the idea that there is something more than confusion going on here. Maybe we should conclude then that there is intent to push the agenda of categorical reduction despite the fact that the very reality of people’s experience as empirically recognized by the DSM itself contradicts the idea. Maybe I am now being a little paranoid, but what else can we conclude?

Allsopp et al’s paper comes to the following conclusions: there is far too much subjective discernment employed in the DSM diagnostic process to call it objective, the overlap of mental disorders shows that they do not “always” fit into one category, and there is and needs be a necessary “pragmatism” that “undermines” the project of discrete disorders. These appear to me to be a strain of restrained diplomacy for the above reasons. They simply do not go far enough. Rather, their paper and others like them do not just represent what are arguably fatal blows to the DSM. To my mind, they are actually demonstrating that the very notion that facets of Psyche — thoughts, beliefs, emotions, identities, etc.— are really specific, discrete things that can be located in the head, reduced to brains, or whatever else, is itself incoherent and the root problem, not whatever system is conjured up based on its premises.

Rather, what is at stake, I argue, is the very empirical theory and project of Psyche itself, of which the DSM is simply an applied arm or leg. What these studies are in fact positively showing us is that we are complex, contradictory, multifaceted beings that cannot be readily categorized and therefore reduced — that we are, the Psyche is, dare I say it, illogical.

The truth of the matter is that ‘psychotic disorders’, ‘major depression’ or ‘obsessive-compulsive disorder’, for example, are only abstractions. And abstractions of complex, contradictory phenomena unsurprisingly end up in contradiction. Certainly, there are psychotic, depressive or obsessive-compulsive experiences, but that is a very different statement. We all have such experiences, all the time. If we admit this, if we give validity to these experiences only as experiences and not deviant empirical entities, the notion of ‘disorder’ or ‘pathology’ loses its basis and meaning in the context. This failure is not the failure of the DSM per se, but the failure of the philosophy of reducing complex trans-categorical experiences into simple categories itself. This conclusion was at the core of much of the anti-psychiatry movement of the 1960s and it is still just as valid, if not more so given that the empirical project has become increasingly less valid.

The real question is, then, why do we too not come to this conclusion, from this study and those like it? Why can we not conclude that we are indeed complex, dynamic, contradictory beings and be done with it? This is where we hit upon the deeper matrix of the issue that it is not so easy to digest.

It would be comforting to conclude that the people who are in charge of such projects as the DSM (indeed, those in charge of any given socio-political project) are perhaps a little sociopathic or deviously immoral. If that were the conclusion, then there is a simple solution: get them out and replace them with people that actually care about what suffering actually is and create a new system that better presents the logic of that suffering. But, ironically, this would only be to commit the very same thing that is being criticized — to reduce the problem to something simple and pathologize the ‘them’ that peddle it. Unfortunately, it is not and cannot be that simple. Rather, if we truly accept the reality that people and their experiences are complex, contradictory and non-reducible, then the very narrative of perpetrators and victims must be disarmed along with it.

In the most basic sense, to come to the conclusion that we are such beings would be to admit that minds and experiences are not empirical objects — which is to say, not ‘things’ that exist in some self-same (i.e. one thing and not another) way and endure as such over time. If we admit that then we are admitting not only that categories of disorders do not actually exist, but that categories of ordered experience do not either. This would mean that the enduring qualities, identities, and roles that we all readily accept and unthinkingly employ on a daily basis become duly suspect too; for they are the other side of the contradiction that would be ‘un-split’. And this applies to the ‘us’ as to the ‘them’ equally.

If we really accepted this, we would have to then say that we are all not what we think we are and what we are actually doing is not what we think we are doing. And I do not mean this in the sense of there being ‘unconscious motivations’ — an idea that I would argue is actually complicit in the very same scheme and project, putting, as it does, the reality of psychic contradiction somewhere else (i.e. the unconscious) — but in the sense of us being explicit, walking contradictions. We would be admitting that the very experiential worlds we dwell in are weaved out of the fabric of this contradiction and paradox. In other words, it would be to say that we are not really good or bad people that are doing what’s right or wrong; that we are not good nor bad parents, healthy nor ill; that we are not feminists nor white supremacists, Democrats fighting the ‘good fight’ nor ignorant Republicans. Well, we may well be those, but we are also, and at the same time, other things, other roles, other personas that contradict and undermine those ‘things’ presently and over time, which again applies to the ‘us’ as to the ‘them’ equally.

It is this that makes it almost unthinkable to actually realize this conclusion, and there is no underestimating how large of a shift in consciousness would be required. Perhaps most disturbing to our self-concepts and societal esteem, it would make a mockery of any real notion of ‘progressing’, individually or on a societal level. For progress — in the way it is customarily used at least — necessitates the very same ethos of specification, exclusion, and reduction as the empirical project in general does; they are, in fact, of a piece. It is only by identifying with a simple notion, idea, or concept (and therefore excluding and othering a plethora of others) that realizing a given ideology, whether personal or social, is rendered possible and meaningful. Political systems and social movements are split into ostensive binaries for a reason.

Complex, contradictory things or identities do not have impetus and are more conducive to stasis than progress. As such, they cannot form the basis of a movement, personal or social; or rather, they can, but they won’t really go anywhere. There must be simple categories — a “me,” a “you,” an “us” and a “them” in its most basic form — for gravity, momentum and direction to be generated and disclosed. On a day-to-day level, in fact, this basic psychological logic is necessary for us all in making sense of our positions in the world and carving out ‘our futures,’ something which applies across the life span at different times. Indeed, the very notion of ‘individuation’ at the core of the entire Western project that we hold so dear is enmeshed with and utterly dependent on this logic and process — becoming an individual with a self is coextensive with this kind of othering and not-me-ing. No small thing.

We would be forced to conclude, in truth, that the core identifications we take to be ‘us’, just like ‘disorders’, are abstractions also, which are good for thinking and acting but not actually real — ways of organizing around time but only at the expense of dissociating the complex, stifling actuality ‘underneath.’ Taken to its logical conclusion, it would mean that it is not really possible to control or predict ourselves or others, as prediction and control also rest on categorization and reduction, on specific entities and identities that are self-same and endure through time. We would ultimately be confronted by the fact that we are radically out of control — or rather, have been laboring under the illusion of control, and actually have been for quite some time. It is not just empirical science that has been seduced by the apparent omnipotence that the empirical, reductive project affords, it is the whole Western structuring of experience and its people. Again, no small thing.

But as dramatic and fantastical as this sounds, this is exactly what we already know to be true; it is only that we fumble around for coherent explanations and causes for the symptoms that we do see. We, in the West, live in a world where the fact of regular mass shootings, opioid epidemics, rocketing suicide rates, to name but a few — all backgrounded by the brutal destruction of nature and serious geopolitical uncertainty, of course — is apparently the new normal. It is, therefore, such a big issue precisely because the problem we are addressing in mental health treatment is not an isolated error, not by any stretch of the imagination. It is really only a symbol of this grand zeitgeist, this cultural mood in which the preeminence of empirical science is unquestioned, that we have been seduced by for centuries. To reject this would mean to admit that we are all, as such, inextricably bound to, and therefore also complicit in, the problem we are attacking.

But we also know this on some level too, although at times only in a dim, inexplicable way. While we know that we have ‘progressed’ if we deem material gain and wealth, longevity of individual life and the rise of the individual and their individual rights as the sole criteria, we have with equal certainty regressed when it comes to that whole order of existence described by such terms as the ‘illogical’ or ‘irrational,’ such as our Psyches and experiential worlds. It is clear as day to anyone who wants to see that our emotional, psychological, and spiritual well-being has rapidly deteriorated. This is clearly evidenced by the rotting truths of our society mentioned above and in the rotting truths of our personalities and actions in the world that we shove down ‘somewhere.’ And this makes just as much sense as our awareness that mental health has deteriorated as a result of DSM-style pathologizing. In all cases, the ethos of reduction and identification with simple categories has the disturbing consequence of dissociating the vital human actuality underneath, a vitality that in essence we, in fact, are.

Accepting this, furthermore, would mean accepting that our belief that we have somehow transcended the limitations of nature is, and has always been, an illusion, and a very dangerous and damaging one at that. It would mean that we have to acknowledge — all of us, not just the “they” over there doing things to us — that our ‘progress’ does not represent a transcendence of the world’s limitations, but has involved great cost. It would mean opening our eyes to the ways that we have all only transferred various kinds of suffering to others, whether that be to people with ‘mental disorders’, to people working in vast, deplorable factories in the ‘third world’, or whether it be to all the animals in nature that we slaughter in putrid, unimaginably immoral ways. These are also all of a piece.

To accept that we are contradictory, paradoxical, dynamic beings, and therefore also that we have all been suffering an illusion of control, transcendence and ‘progress’ and have gained from this illusion at the expense of others, is a monumental task. However, this is, I argue, what we are being shown here, and in truth we’ve been shown it over and over again but not had the right eyes to see it.

But the question is, can we afford not to address this, this time? We have been vividly awakening to the fact that this ‘normality’ we live in is deeply pathological. If that word has meaning outside of physical medicine, it is in this context. And this is the difference between now and the 1960’s — a time of a renaissance of hope and possibility. We, by contrast, realize this in a helpless, impotent and frustrated way, a lot of the time — related, no doubt, to the actual impotency of empirical science and its philosophy to solve all our problems. And this is important. We have now lived out the reductive, materialist ideology to an obsessive extreme, and its failure is particularly evident when we think about our Psyches, emotions and ‘mental disorders’ that we all know about, more or less firsthand. We are now undeniably seeing, feeling — indeed being overwhelmed by — its horrors. There is no argument, no hope, no “well, back to the drawing board, we’ll work it out this time” when it is increasingly evident that the very drawing board we have been writing on is itself a big part of the issue. This is a big difference from the 1960s.

To bring it back to the point and to the core argument I am making, if we are truly to ameliorate people suffering with complex emotional and psychological distress, and indeed ourselves, from the problems of reduction, we cannot do so in earnest without also at the same time admitting our own complicity and culpability as beings interwoven in, and benefiting from, the very same project. To actually de-reduce and de-pathologize the emotional experience of those suffering, we have to admit that while we do not reduce this or that particular person and negate their experience — persons that we think about and empathize with, whatever our reasons — we do, consciously or not, negate and reduce the experience of peoples and beings that we do not think about or do not empathize with, for whatever reason.

I am making the case, then, that there is a very good reason why this model persists despite the glaring issues: to resolve it would involve the withdrawal of some serious projections, from each and every one of us. But in order to alleviate and dispel the violence done to the people we do think about and empathize with, then we have to — at the same time and in the same breath — admit the violence we do, and have been doing for a long time, to all these ‘others.’ This would be to admit that we are all complex, dynamic, contradictory people and also participating in the problems we attack. The former without the latter is only hypocrisy, and hypocritical action does not tend to bring any real, sustained ‘progress’, which is after all what we really want… or is it?

— Originally published in Mad in America September 21, 2019 here

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