Finding Jesus in the Storm. John Swinton

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СКАЧАТЬ has emerged known as descriptive psychopathology. This phenomenological tradition provides rich and deep descriptions of psychopathology so that psychiatrists can gain insight and create rich and thick descriptions that help them develop deep and therapeutic understandings that lead to effective clinical intervention. Andrew Sims lays out this approach as follows:

The study of individual personal experience is fundamental to psychiatry. Descriptive psychopathology is the precise description and categorization of abnormal experiences as recounted by the patient and observed in his behavior. There are two components to this: careful and informed observation of the patient, and phenomenology, which implies, according to Karl Jaspers, the study of subjective experience. The descriptive psychopathologist is trying to hear what the patient is saying without any theoretical, literary or artistic gloss of interpretation, and without the mechanistic explanations of science used inappropriately. In order to achieve understanding, phenomenology uses empathy as a precise clinical tool.13

The purpose of such a phenomenological approach is not to explain what is going on but to try to understand it: “In Jaspers’ usage, understanding is contrasted with explanation. Understanding, in this sense, involves the use of empathy, subjective evaluation of experience by the ‘understander’ using his or her own qualities of observation as a human being: feeling inside. Explanation is the normal work of natural science involving the observation of phenomena from outside, and objective assessment. Both are required of the practicing doctor but whereas the method of observation in science is carefully and comprehensively taught, teaching the method of empathy to give subjective understanding is frequently neglected.”14 Sims draws attention to this phenomenological tradition but acknowledges that it does not get the recognition it deserves either in medical education or in practice.

      One of the reasons this phenomenological tradition has been “lost” relates to the systems currently in place through which we make diagnoses and describe mental health challenges. These systems prefer thin descriptions to the richness and thickness of the phenomenological look. Part of the issue, as we have seen, relates to time. If you have only fifteen minutes with a patient, gathering rich phenomenological detail is not going to be high on your list of priorities. But lack of time is not the only reason for the thinness of psychiatric descriptions.

       The Power of the DSM

The practice of psychiatric description (diagnosis) is organized according to the groupings and categorizations that compose diagnostic manuals such as the World Health Organization’s International Classification of Diseases (ICD)15 and the American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).16 These manuals contain the criterion used to redescribe persons’ experiences in terms of commonly observed symptoms and to develop the formal names for mental health conditions. By “redescribing,” I refer to the process whereby a person brings a set of experiences to the attention of the psychiatrist, who then redescribes them in terms of signs and symptoms of some kind of underlying pathological process.

The World Health Organization (WHO) claims that the “ICD is the foundation for the identification of health trends and statistics globally, and the international standard for reporting diseases and health conditions. It is the diagnostic classification standard for all clinical and research purposes. ICD defines the universe of diseases, disorders, injuries and other related health conditions, listed in a comprehensive, hierarchical fashion.”17 Defining the universe is a pretty impressive claim, even for an organization as esteemed as the World Health Organization! Nevertheless, the ICD criteria have been deeply influential in diagnosing mental and physical conditions and have been adopted in Europe, North America, China, Korea, Sweden, and Thailand.18 The ICD and the DSM are closely connected:19 “Although the [DSM] manual is American, it is much used elsewhere, despite the fact that the International Classification of Diseases, drawn up under the auspices of the World Health Organisation in Geneva, is usually seen as the official manual, if there is one. DSM-5 gives ICD codes when they match, and there is a project aimed at harmonising the two rulebooks.”20 While recognizing the importance of the ICD system, we will focus on the DSM, which is the main classification system used in the United States and is highly influential throughout the world.21

The most recent incarnation of the DSM, DSM-5, was published in May 2013 by the American Psychiatric Association and claims to offer standard criteria for the classification of mental disorders. The DSM-5 provides a series of descriptions of mental health phenomena, which are clustered together to form various diagnostic categories. Each category is given a number: schizophrenia is 295.90, schizoaffective disorder is 295.70[F25.0], and so forth. In this way, a statistical system is merged with the self-narrated qualitative experiences of mental health, as numbers are assigned to people’s experiences. The manual is statistical because “its classifications can be used for studying the prevalence of various types of illness. For that one requires a standardised classification. In a sense, the manual has its origins in 1844, when the American Psychiatric Association, in the year of its founding, produced a statistical classification of patients in asylums. It was soon incorporated into the decennial US census. During the First World War it was used for assessing army recruits, perhaps the first time it was put to diagnostic use.”22

This manual is used by a wide variety of persons and groups: researchers, clinicians, drug regulation agencies, pharmaceutical companies, and health insurers. The presence of a DSM diagnosis is necessary, not only in terms of accurate diagnosis, but also (at least in the United States and parts of Canada) to access Medicare and insurance plans provided in Canadian provinces.23 Its influence can be seen in the fact that the majority of English-language journals insist that the language of DSM be used to characterize any research published. The DSM is a purely descriptive document and offers no recommendations for treatment, although those who use it might argue that accurate diagnosis leads to the most appropriate treatment. In determining the kinds of areas that are fundable and not fundable for research, the descriptions contained in DSM-5 are seen to serve bureaucratic as well as medical intentions. In short, DSM-5 has a good deal of clinical, political, and financial power.

       Categorizing Mental Health Experiences

      The process for determining diagnostic categories begins when groups of psychiatrists meet in various hotels across America to discuss which mental health experiences should fit within the various diagnostic categories. After a lot of discussing, arguing, categorizing, and recategorizing, the psychiatrists judge which classifications, names, and criteria are appropriate descriptions to guide clinical practice. Thus is born the DSM.

      Any given diagnostic category—schizophrenia, bipolar disorder, obsessive-compulsive disorder—comes into existence as it is constituted by the DSM criteria. The DSM has the power to establish, or at least to give formal, organized existence to, mental health experiences. As such, it is not only descriptive but also formative. Diagnoses are shorthand descriptions of complex human behavior. In descriptive mode, DSM-5 provides clinicians with concepts and forms of language that can be used to make sense of clusters of unusual human experiences. However, such descriptions also form СКАЧАТЬ