This article came to my attention this week from the New York Times
blogs. The author identifies himself as
a philosophy professor and scholar who is an expert in French philosophy. He presents some viewpoints of Foucault and
others to criticize the DSM and of course the clinical method in psychiatry. I will be the first to admit his initial
argument is confusing at best and is based on Foucault’s observation: “What we
call psychiatric practice is a certain moral tactic….covered over by the myths
of positivism.” Indeed, what psychiatry represents
as the “liberation of the mad” (from mental illness) is in fact a “gigantic
moral imprisonment.” In the next
sentence the author acknowledges: "Foucault may well be letting his rhetoric outstrip the truth, but his essential
point requires serious consideration."
From my viewpoint whenever an author’s rhetoric outstrips the
truth it means that at the bare minimum any observer should be skeptical of the
biases involved and these appear to be the common themes that we see from
antipsychiatrists. It does not take the
author very long to develop that angle:
“Psychiatric practice does seem to be
based on implicit moral assumptions in addition to explicit empirical
considerations, and efforts to treat mental illness can be society’s way of controlling what it views as
immoral or otherwise undesirable behavior.”
He gives examples of the previous treatment of homosexuality and
women and uses this as a platform for suggesting “….there’s no guarantee that
even today psychiatry is free of similarly dubious judgments.” With no credit given to Spitzer’s role in
both the DSM and eliminating homosexuality as a mental illness back in the 1970’s
(where is the rest of America on that issue even today?) he latches on to the
bereavement exclusion as the latest example of how psychiatrists are trying to
dictate how people live and how various nonphysicians are better equipped to
decide about whether the bereavement exclusion should be left in place. Like every other commentator he waxes rhetorical
himself using the well worn descriptor “medicalization” and suggesting part of
the motivation for these changes is pressure from the pharmaceutical
industry. I recently posted a response
to a less well written criticism from the Washington Post that addresses these
issues and I would encourage anyone interested in finding out what is really
going on to take a look at that post.
The question here is what have Professors Foucault and Gutting
missed in their critiques about psychiatry? It turns out they have missed a lot. The first obvious flaw is the misinterpretation
about the role of psychiatric diagnosis and a diagnostic manual for
psychiatrists. The DSM (or any technical diagnostic manual) does not represent
a blueprint for living and there is no psychiatrist who has ever made that
claim. This error is promulgated in the media by referring to the DSM as
a "bible". In fact, it is not a bible or blueprint for living.
Psychiatrists more than anyone realize that they are addressing
a small spectrum of human behavior with the goal
of alleviating suffering and restoring function. The
second flaw is that changing a diagnostic criteria in a DSM has any meaning
with regard to treatment and diagnosis. In the case
of bereavement that ignores the fact that only a tiny fraction of patients with
complicated bereavement or depression ever come to the attention of a
psychiatrist. Grief is a normal human
reaction and everybody knows it. Taken to an absurd level – if organized psychiatry said that everyone with grief needed to take an antidepressant for the simple fact that “we have special
knowledge about how people should live”
we would have no credibility at all.
People everywhere know that grief is common and expected and severe
mental illnesses are not. At that level
psychiatry is an extension of the common man’s psychology. The third flaw has to do with
impairment. A diagnosis can be made only
with an impairment dimension. From
DSM-IV:
“In DSM-IV, each of the mental disorders
is conceptualized as a clinically significant behavioral or psychological syndrome
that occurs in an individual and that is associated with present distress
(e.g., a painful symptom) or disability (i.e. impairment in one or more areas
of functioning) or with significantly increased risk of suffering, death, pain,
disability or an important loss of freedom.
In addition, this syndrome or pattern must not be merely an expectable
and culturally sanctioned response to a particular event, for example, the
death of a loved one.” –
DSM-IV
The critics never acknowledge that like all physicians, a psychiatrist’s
role is to treat illness and alleviate suffering. Further, the clinical method in psychiatry is
the only specialty training that emphasizes clinical neutrality and recognizing
emotional and intellectual biases that impact the physician patient relationship
and offers ways to resolve them. That is
hardly a model for forcing value judgments about preferred mental states on
people who other physicians are frequently unable to treat because of their own value judgments.
The author also erroneously concludes that it is dangerous to make
psychiatrists “privileged judges of what syndromes should be labeled mental illnesses”
based on the fact that “they have no special knowledge about how people should
live”. Since psychiatrists do not make
that claim, and since various groups including governments and religious institutions
have been making these judgments for centuries with very poor results, I would
suggest that psychiatry has had some problems – but the progress here is
undeniable. That makes psychiatrists experts
in their own field in their own field and the purveyor of their own diagnostic
methods and not a claim that people should live in a particular way. DSM-IV takes pains to point out that it is
classification system for syndromes and NOT people. The DSM is not designed for an untrained person to look at and make a diagnosis or get guidance for living. It is designed to be a common language for psychiatrists who have all had standardized training.
I would also like to suggest that the same philosophical criteria
be seriously applied by philosophers to the pressing problems within the health
care system. The DSM is not even a gnat
on that landscape. We have had nearly 30
years of active discrimination by governments and insurance companies against
persons with mental illness. While much
criticism has been heaped on the bereavement exclusion criteria, people with
addictions and serious mental illnesses are routinely denied potentially lifesaving
interventions. This discrimination has
been well documented and it has fallen disproportionately on the mentally
ill. Jails and prison have become de
facto mental hospitals. People are being
treated with addicting drugs on a large scale to the point that many consider
opiate use and deaths from overdose to be an epidemic. Governments save money and pharmaceutical companies
and the managed care cartel prosper.
Contrary to the author’s suggestion that “psychiatrists are more than
ready to think that just about everyone needs their services” psychiatrists are
rare and access is strictly controlled by managed care companies and the government. Even if a person sees a psychiatrist, their
medications, access to psychotherapy, and access to hospital treatment are all
dictated by a business entity rather than their doctor.
It would seem that philosophers could find something to critique
in that glaringly bleak health care landscape other than a trivial change in
the diagnostic manual of a vanishing medical specialty. If not,
I would be very skeptical of their arguments.
George Dawson, MD, DFAPA
Gary Gutting. Depression
and the Limits of Psychiatry. New YorkTimes February 6, 2012.
Fulford KWM, Thornton T, Graham G. Oxford Textbook of Philosophy and Psychiatry. Oxford University Press, Oxford, 2006: 17.
"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:
1. The psychological model...
2. The labeling model...
3. Hidden meaning models...
4. Unconscious mind models...
5. Political control models..." <-Foucault is located here. (p. 17)
Shorter E. A History of Psychiatry. John Wiley & Sons, New York, 1997: 302.
"By the early 1990, DSM-III, or the revised version that appeared in 1987 (DSM-III-R), had been translated into over 20 languages. French psychiatry residents, initially taken with antipsychiatry and the doctrines of Jacques Lacan and Michel Foucault, began memorizing the 4 criteria (and 18 possible symptoms) 6 of which must be present for anxiety disorder." (Shorter: p 302)
Addendum:
I made this interesting discovery several years after the original post (on May 22, 2019). Dr. Gutting has a chapter on Michel Foucault in the Stanford Encyclopedia of Philosophy and this is very consistent with his flawed analysis of the DSM-5. Link.
Fulford KWM, Thornton T, Graham G. Oxford Textbook of Philosophy and Psychiatry. Oxford University Press, Oxford, 2006: 17.
"Some of the main models advanced by antipsychiatrists, mainly in the 1960s and 1970s, can be summarized thus:
1. The psychological model...
2. The labeling model...
3. Hidden meaning models...
4. Unconscious mind models...
5. Political control models..." <-Foucault is located here. (p. 17)
Shorter E. A History of Psychiatry. John Wiley & Sons, New York, 1997: 302.
"By the early 1990, DSM-III, or the revised version that appeared in 1987 (DSM-III-R), had been translated into over 20 languages. French psychiatry residents, initially taken with antipsychiatry and the doctrines of Jacques Lacan and Michel Foucault, began memorizing the 4 criteria (and 18 possible symptoms) 6 of which must be present for anxiety disorder." (Shorter: p 302)
Addendum:
I made this interesting discovery several years after the original post (on May 22, 2019). Dr. Gutting has a chapter on Michel Foucault in the Stanford Encyclopedia of Philosophy and this is very consistent with his flawed analysis of the DSM-5. Link.
