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Medical Disorders
Mental Disorders
Mental Health Professions

by John Z. Sadler (Editor)
Johns Hopkins University Press, 2002
Review by Peter Zachar, Ph.D. on Feb 3rd 2003

Descriptions and Prescriptions

Descriptions and Prescriptions is a sophisticated exploration of the various evaluative decisions that could reasonably influence the development of the diagnostic manual used by psychiatrists, psychologists, social workers, and allied mental health professionals in the United States.  Also explored are the different values that are expressed in the manual itself.  The book’s purpose is to encourage a thoroughly rigorous attempt to create the best diagnostic manual possible.  As John Sadler suggests in his introductory chapter, rigor involves more than collecting data.

It has become a truism among philosophers of science that the thinkers of the Enlightenment period were mistaken in advocating a radical distinction between facts and values.  It is not that we invent facts; rather there are too many facts available to us.  We therefore need some guidelines for deciding which facts to study, and how to interpret them. These guidelines involve assumptions about what count as good data, what count as good explanations, and what count as good solutions to problems.  The inevitable use of the word ‘good’ means that evaluations cannot be isolated from the scientific process.

In addition to scientific values, the very concept of psychiatric disorder is inherently evaluative - it depends on what philosophers call normative assumptions.  Normative assumptions include notions of what is normal or what ought to be, for example, to assert that something has gone wrong with a person who hears a voice in her head that is making a running commentary on her behavior, we need to have some notion of what she ‘should’ or ‘ought’ to be like instead.

Let me note that the book is not titled “Descriptions or Prescriptions?”  As Christian Perring points out in his chapter, the debate about values has been decided in favor of thinkers such as Bill Fulford, who have taken the lead in arguing that the notion of mental illness/mental disorder cannot be value-free.  For the most part, this book doesn’t involve debates about whether the disorders listed in psychiatric manuals are descriptions of actual conditions or lists of behaviors that have been evaluated to be socially undesirable.  The authors in this volume differ in emphasis with respect to how much description is desirable and how much prescription is acceptable, but they generally agree that understanding psychiatric disorders requires both description and prescription.

When the American Psychiatric Association revolutionized diagnostic practice in 1980 with the publication of the DSM-III, it did so by providing a concrete and systematic description of each psychiatric disorder.  This revolution evolved into a search for the most reliable criteria for identifying these disorders, and is currently focused on an evaluation of the evidence for the scientific legitimacy of each disorder.  Sadler refers to this as descriptive rigor.  What has been lacking, however, is an equally systematic analysis of all the evaluative decisions that are made in defining disorders.  The inclusion of evaluative rigor would clearly make the process of revising diagnostic manuals more thorough than it has been in the past.  Exploring what could be called the Sadler-Agich notion of evaluative rigor is the putative justification for this collection of papers. 

Their concurrence regarding the presence of values in diagnostic practice does not mean that the contributors to this volume constitute a happy family who all agree about basic issues - they don’t. They agree that it is important to develop the best manual possible, and they all want to make a contribution toward that end, but there are significant disputes about fundamentals.

One group of thinkers concedes that values play a role in the construction of diagnostic manuals and are part of the meaning of ‘disorder,’ but they also believe that the goal of psychiatry should be to maximize the scientific attributes of the manual.  They tend to see values as potentially corrupting influences.  This group includes those who were among the architects of the DSM-IV - Thomas Widiger and Harold Pincus & Laurie McQueen. 

Any reader inclined to view the DSM architects as unreconstructed positivists or scientistic thinkers of a narrow-minded bent is advised to read their chapters. Those pejorative descriptions are exaggerations. The DSM architects are (generally) a pretty sophisticated bunch, and are well-aware of the complexities involved in constructing and using manuals.  I’m convinced they have a more elaborate understanding of classificatory pragmatics than many users of the manual.

The issue of whether or not values constitute corrupting influences that should be minimized even if they can’t be eliminated is a contentious one.  Another apparent member of the ‘science maximization’ group is Lee Anna Clark.  What is especially interesting about her contribution is that she makes it clear that ‘science maximization’ is how she was trained to think - it is what her profession brings to the table.  That profession is clinical psychology, and more specifically, the clinical-scientist tradition (as opposed to scientist-practitioner).  Trained to be scientific researchers first and foremost, clinical scientists learn to identify when questions can be answered empirically, and gain the skills to develop and run studies that will answer those questions.  As George Agich might say, because that is what they are trained to do, that is what they are likely to value in the DSM.  Clark’s point is also a good one; when there is empirical information relevant to answering questions such as ‘what counts as extreme,’ we should seek it out. 

  Also important to the ‘science maximization’ proponents, especially Widiger, are some non-empirical assumptions, specifically, that psychiatrists and psychologists are supposed to be finding out what psychiatric disorders really are, that progress is equated with being ‘more true’, and that discovering the truth is what scientific research does.

 With respect to these philosophical assumptions, a second group of thinkers represented in this volume are inclined to be querulous.  They reject the contamination metaphor when discussing values and believe that evaluations guide the process of knowledge generation.   They are more comfortable defining progress in terms of improvement. Whatever else they might be, categories such as schizophrenia and depression are instruments that psychiatrists and psychologists use to help their patients.  Certain members of this group also understand truth as a species of the good, i.e., an evaluative term.  The true is the name of whatever proves itself to be good in the way of belief as William James famously defined it.   Included in this collection are philosophers who specialize in psychiatric issues and mental health professionals who are philosophically minded (and trained).  Among them are John Sadler, George Agich, Bill Fulford, Jennifer Radden, Christian Perring, Michael Schwartz and Osborne Wiggins - all luminaries in the field.  Although I’m lumping them together, the chapters written by members of this second group are diverse, detailed, and incisive.  They compromise the core of the book. 

Another prominent presence, and one who is harder to classify, is Jerome Wakefield.  He is a quintessential description and prescription proponent, claiming as he does that any legitimate disorder has to be an objective dysfunction that is evaluated by society or an individual as causing harm.  His harmful dysfunction model of mental disorder considers the value-neutral view and the value-only view to be fallacies, which he names the essentialist and normativist fallacies, respectively.  Wakefield, however, is not an instrumentalist.  He believes that we can correctly specify what we mean by mental disorder, and we have a moral obligation to not confuse a true mental disorder with a merely harmful condition.  He also doggedly maintains that ‘dysfunction’ is value neutral.  The harmful dysfunction model neatly accepts some of Thomas Szasz’s claims about the evaluative elements in attribution of mental illness without accepting the claim that mental illness is ill a myth. Wakefield’s chapter highlights the importance of making these distinctions with respect to disorders of childhood and adolescence. 

There is also a conscious and pervasive radical edge to the book, and it makes for some of the more eye opening chapters.  A fundamental insight driving the radical analyses is expressed by Schwartz and Wiggins, who argue that it is the idea of Science or the promise of scientific knowledge that has afforded the DSM-III, III-R, IV (and IV-TR) so much influence.  Applications of scientific thinking have taught us that the earth is round, that it revolves around the sun, and that life on this planet has changed systematically for millions of years.  They have brought us more food, more warmth, more knowledge, more entertainment, better health and longer life.  The conceptualizing of scientific knowledge as a valuable resource that needs to be supported is firmly entrenched in Western culture, and that cultural value inevitably drives the attempt to create better diagnostic manuals.

So what’s the problem?  The problem is something that has been recognized on a small scale by social psychologists and on a larger scale by social-political philosophers, particularly post-structuralists (or post-modernists) and critial social theorists.  Our notion of science, what science does, and how it works is a popular cultural story. It includes mini-stories such as Galileo’s house arrest, the Scopes monkey trial, and the discovery of penicillin.  The larger meta-narrative expresses group values.  We tend to conform to and understand the world in terms of the grander narrative, but no narrative can tell the whole story.  Even the mini-narratives such as what happened to Galileo are simplified and interpreted evaluatively. The parts of the story not told, the facts left out, and the experiences not acknowledged, are marginalized.

The DSM is an official story about psychiatric disorders. It is a story about how American psychiatry became scientific without abandoning its clinical roots.  Subplots within the bigger story are found in the different sections of the manual and in all of their background assumptions.  This includes the technical details, for example, the reasons for implementing the positive versus negative symptom distinction in schizophrenia comprise a story.  As stated, the DSM also carries a stamp of legitimacy; its users therefore tend to see both psychopathology and problems-in-living through its lenses.  Some of ways in which this happens is described in a chapter by Berrenkotter and Ravotas.

Any psychiatrist or psychologist willing to step outside their professional role and look beyond the conventional goods they pursue, defined in terms of their profession’s goals, would find it informative to adopt the viewpoint of the social critic.  Once they do this, there are various attitudes they can take toward the problem of grand narratives and totalizing discourse. The attitude most people are familiar with is what Ian Hacking has called the revolutionary attitude - often seen in postmodernist critiques.  The revolutionary attitude holds that the grand narrative is a harmful force that must be overthrown.  That attitude is barely evident in this book. 

More evident is what Hacking has termed a reformist attitude. The reformist attitude views grand narratives as partly resulting from what social psychologists call group think.  Reformists reject the charge that the ruling narratives are simply the creation of villains at the top of the social hierarchy who are cynically manipulating the discourse for their own personal interests; rather, they claim that these narratives are historical products, created and recreated by the group.  John Sadler refers to it as the politics of concordance.  The reformers seek to moderate the negative consequences of this massive kind of group think. 

Two noteworthy chapters reflecting the radical approach are contributed by the physician James Phillips and the philosopher Allyson Skene.  Phillips critiques a set of assumptions about what counts as a good scientific explanation, especially assumptions that are associated with an evaluative preference for technological reason.  To my mind this echoes Horkheimer and Adorno, but he obviously got it from Gadamer.  The basic idea is that the technological model of rationality leads us to expect that good explanations are mindless and algorithmic, and once you really understand any natural phenomenon, you should be able to devise a set of rules or formulae which - when correctly applied - will solve the problem.  He argues that even though some of the DSM architects are aware of this affront to complex problem solving, the operationalized polythetic criteria model encourages it.

Allyson Skene suggests that the Agich and Fulford attempt to conceptualize psychiatric disorders as both descriptions and prescriptions fails to provide a legitimate alternative to the prescription-laden view of the anti-psychiatry movement.  Actually, Szasz must feel he has won the day with respect to characterizing our talk about schizophrenia because most noticeable complaints about him from psychiatrists and psychologists emphasize what an immoral and irresponsible theory he has proposed.  Christian Perring’s and Skene’s chapters both imply that questioning Szasz’s rugged libertarian politics would be a more effective argument strategy with respect to disputing the issues he values.  Skene shows that, in contrast to the anti-psychiatrists, Foucault offers a more refined articulation of strong normativism in which negatively valued conditions can be said to exist, and cannot be reduced to creations of powerful forces that want them repressed.

A crucial section of the book provides a voice to non-specialists - those who are not professionally engaged in studying the philosophical aspects of psychiatric classification. These will be the easiest chapters for most readers to understand, but they will also have the most bite for those who already worked through the philosophical arguments in the previous sections of the book.  A chapter by Cathy Leak makes several interesting points, one of which is that rather than using case studies to illustrate and conform to DSM diagnosis, case studies would be more valuable if they challenged the diagnosis and showed us aspects of the person to which the diagnosis is blind. 

Speaking on behalf of the National Alliance for the Mentally Ill is neuroscientist Laura Lee Hall.  If anyone understands the political and evaluative consequences of psychiatric diagnostic manuals it is those who have had a family member diagnosed with a major mental illness.  Hall argues that the manual mistakenly avoids making distinctions between major mental illness and other more ‘neurotic’ conditions.  The reason this is a mistake is that when they are all lumped together as ‘mental disorders’ it makes it easier for legislators and lobbyist rich insurance companies to not treat major mental illness as seriously as they should.

The attorney Daniel Shuman, an expert on using psychology in the courtroom, contributes an argument that should give proponents of the Sadler-Agich call for evaluative rigor some pause.  Shuman claims that it would be better with respect to forensic applications if the DSM emphasized its scientific attributes and not the value elements.  This is because the courts historically have a tendency to accept professional clinical opinion as fact - but this practice has been attenuated in recent years due to the standards articulated in the Daubert decision.  Daubert asks the courts to consider the quality of the reasoning underlying scientific expertise, with quality including publication in peer-reviewed journals and falsifiable propositions.  If the DSM architects were to make the value dimensions more explicit, the public may come to see it as a manual of opinion and partisan agenda, and Daubert could be undermined.  If psychiatrists and psychologists were to be philosophically honest regarding the complex nature of psychiatric disorders, their scientific credentials would be put at a forensic disadvantage.  I suspect that this disadvantage would be accentuated should psychiatric expertise ever be compared to the expertise of the social, biological, and physical sciences, and to the law itself which will still wrap themselves in a flag of common sense objectivity and value neutral-knowledge.  Makes you think.

There are 21 chapters; each quite good.  Nor could I fit them all into the plan I adopted for summarizing the book. For example, Chris Mace writes a chapter for philosophers of science, suggesting that Thomas Kuhn’s and Karl Popper’s theories have become the new received view.  He reminds us that there are alternative models that might usefully be applied to our understanding of the process of nosological revision, specifically Stephen Toulmin’s concept-based and evolutionary model of scientific progress.  It’s an excellent point.

Philosopher of science Patricia Ross proposes an objectivity maximization view, but one that views objectivity as a community project rather than the result of an individual correctly applying the appropriate method. She doubts that the process of revising the DSM could be organized as the kind of social process that leads to objective knowledge, but makes some suggestions for organizing the DSM work groups that could increase intersubjective agreement as opposed to the kind of grudging consensus that has been settled for in the past.

One of my favorite thinkers, Irving Gottesman, writes about the role that genetic information should occupy in the diagnostic manuals of the future.  He proposes adding an Axis VI for coding genetic markers.  Acknowledging that this would be valuable scientifically and diagnostically, and also - socially harmful, he suggests that the information on Axis VI be encrypted.  It should be made available only to those who would use it for good (professionals), and not to those who would use it for ill (employers and insurance companies).  Thought-provoking point, but I don’t think we can assume that all mental health professionals will be benign and liberally-minded.

In my graduate classes I use a Gottesman & Meehl-like theory regarding the genetics of schizophrenia as a model for psychiatric disorders in general.  In his chapter Gottesman reviews the genetics of Alzheimer’s disease, and it follows a chapter in which Kenneth Schaffner suggests that Alzheimer’s disease be used as a model for understanding psychiatric disorders in general.  Schaffner concretizes another theme running throughout the book, the notion that the atheoretical descriptive diagnosis and non-etiological model used in the current DSM is scientifically implausible. He proposes a general theory of causation that would be consistent with psychiatry’s traditional acceptance of multiple levels of analysis - biological, psychological, behavioral, interpersonal, and cultural. As Schaffner and Gottesman suggest with respect to genetics and Jennifer Radden suggests with respect to the concept of ‘incapability’ itself, if we have good reasons for conceptualizing a particular condition in causal terms, we should be able to implement those models and those data into the manual. 

I claimed earlier that the putative justification for this volume was the Sadler-Agich call to expose evaluative decisions to more systematic and explicit study.  I used ‘putative’ because there is another, deeper, justification for this book - specifically, the question of how much and what kind of authority should scientific knowledge have with respect to understanding and explaining the world.  This is not a simple question, and in the form of the ‘culture wars’ and the ‘clash of civilizations,’ it may be a question that dominates the early 21st century intellectual landscape.

It is less daunting to address the question if it is focused, for example, ‘what authority does scientific knowledge have with respect to the development and use of psychiatric diagnostic manuals?’  It depends, of course, on what counts as ‘scientific.’  To sidestep that debate for a moment, we can say that in American psychiatry, ‘scientific’ currently refers to an experiment-oriented medical model approach, increasingly biomedical, augmented by the psychometric tradition in scientific psychology with its emphasis on reliability, validity and operationalized constructs, and evaluated whenever possible using statistical methods and research designs developed in epidemiology.  Now the question becomes how much and what kind of authority should we give THAT?  

Most people’s answer about how to balance description and prescription will probably have parallels to their answers about the nature and limits of scientific authority, but not necessarily.  John Sadler would grant authority to a process, the inclusive process of a rigorous democracy - one that is reluctant to make compromises with respect to the values of openness, accountability, sensitivity to diversity, and encouragement of participation.   If what some people identify as scientific knowledge emerges from that process in a privileged position, so be it, but he does not want to grant it a priori authority. 

The question regarding the authority of science has implications extending far beyond psychiatric classification and the philosophy of psychiatry.  I only vaguely know what my answer to the authority question is, and these chapters have encouraged me to think about that problem more deeply. 

In conclusion, this is an excellent book.  It has been thoughtfully edited, and is best read in order from beginning to end.  Some edited books are hodgepodge collections and others are more integrated - this one is remarkably integrated.  There is an experience of complexity, nuance, and an unresolvable yet undeniably rich confrontation of perspectives that emerges by reading the chapters in order.  Those with less training in philosophical evaluation are going to struggle with being presented so much abstract and multifaceted information, but Descriptions and Prescriptions has the comprehensiveness that only interdisciplinary cooperation can bring - a Fulford & Sadler hallmark.  Anyone who believes that developing the best diagnostic manual possible is an important and complicated task, and also wants to contribute to the process in a scholarly and reflective way, is well-advised to study these chapters.

 

© 2003 Peter Zachar

 

Peter Zachar, Ph.D. is an associate professor of psychology at Auburn University Montgomery.  He is a licensed psychologist with additional specializations in psychological measurement, the philosophy of science, and the philosophy of psychiatry.  He is the author of Psychological Concepts and Biological Psychiatry: A Philosophical Analysis.