Finding Jesus in the Storm. John Swinton

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СКАЧАТЬ DSM as the basis for your diagnostic practices, that becomes the way you see people. Diagnoses will help you to see some things very clearly, but they will inevitably occlude other things. The DSM thus propagates a certain type of clinical gaze that is bounded by the parameters of the knowledge and expectations of the clinician. The expectations of the clinician are not free-floating. Clinicians are deeply aware of the expectations of the system and the limitations of time. Shorthand descriptions are very helpful within a system that is bounded and limited by the pressures of time.

There is thus a complicated dialectic between the consensus-based formation of diagnoses by clinicians and the pressures of the system clinicians have to use. A system like the DSM fits well into a pragmatic and instrumental system where therapeutic explanation and “getting things done” may be perceived as primary goals. There is little room here for thick descriptions that require more than fifteen minutes with a patient. This is why many people don’t recognize themselves in the descriptions that emerge from the DSM. As Esmé Weijun Wang puts it: “To read the DSM-5 definition of my felt experience is to be cast far from the horror of psychosis and an unbridled mood; it shrink-wraps the bloody circumstance with objectivity until the words are colorless.”24 This is clearly a problem. However, there are other, perhaps greater problems with the thin descriptions that we encounter in the DSM. It is descriptive and formative, but it is also a mode of creation: it brings mental health conditions into existence and takes some out of existence.

       Making Up “Mentally Ill” People

      The philosopher Ian Hacking opens his paper “Making Up People” with a quite startling assertion:

Were there any perverts before the late nineteenth century? According to Arnold Davidson, “The answer is NO…. Perversion was not a disease that lurked about in nature, waiting for a psychiatrist with especially acute powers of observation to discover it hiding everywhere. It was a disease created by a new (functional) understanding of disease.” Davidson is not denying that there have been odd people at all times. He is asserting that perversion, as a disease, and the pervert, as a diseased person, were created in the late nineteenth century. Davidson’s claim, one of many now in circulation, illustrates what I call making up people.25

      The description of someone as a “pervert” wasn’t available before the late nineteenth century. It was only when law and medicine created a category and described those who fit that category as “perverts” that being a pervert became possible. Similarly, prior to formal categorization, again in the late nineteenth century, it was not possible to be either a homosexual or a heterosexual. There has been same-sex activity in all eras, but it was not until the legislative categories became available that one could be named “homosexual” or “heterosexual.” Once these categories (kinds of people) came into existence, a variety of responses became possible: a position for or against homosexuality, heterosexuality, gay rights, homophobia, and so forth. Once these categories were created, it was possible to be these kinds of people.

However, the existence of such persons is fragile, determined by the shifting will of society and the transitive nature of the legislative system, which can in principle take them out of existence as well. For many people, it is not who they are as unique individuals that gives their existence substance and durability but the way society chooses to describe them at any moment in time. They remain in existence only as long as the category continues to be given social, political, and legal validation. It would be legislatively possible to eradicate homosexuality, heterosexuality, or perversion simply by changing the legal categories. We may find it difficult to imagine a society where people are forced to be homosexual. We may have less trouble imagining a society where people are forced to be heterosexual, as there are recent and even contemporary precedents to indicate that some would be quite comfortable with such a suggestion.26 We would have no difficulty at all imagining a society where Jewish people were legislatively considered to be less than human. Europe has a dark history that makes this point tragically. Recognizing how and why we make up people is of the ultimate importance.27

      What Hacking observes about the ways we make up people resonates with the people-making power of the DSM. It is possible for a particular form of mental health challenge to come into existence only if psychiatry continues to name the set of experiences that make up such a diagnosis in the same way it always has. The problem is that the DSM keeps changing its mind. Unlike the scientific process that goes into the development of the diagnosis of physical illnesses, a committee decides the presence or absence of particular forms of mental health challenges. One reason why the DSM has to be continually revised, updated, and rereleased is that the various committees vote to add, take out, or modify particular diagnoses or aspects of diagnoses. At the end of this process of discussing, arguing, and categorizing, these committees present the categories and criteria that, in their opinion, form the basis for classifying people’s mental health experiences. The DSM has the power to create and establish, or at least to give formal, organized existence to, mental health experiences that are considered to be unconventional. These committees make up or invent mentally ill people, but they also reverse that process.

A good example of this de-creative process can be found in the response of psychiatry to homosexuality. In 1972, homosexuality was considered a treatable form of mental illness.28 In 1973, the American Psychiatric Association decided it was no longer to be described in this way. The change came about not because of any new scientific evidence but because of pressure from gay rights activists who felt the designation was unjust and unfair and that psychiatry was acting more in moral judgment than in the cause of clinical necessity. The description of homosexuality as a mental health issue was eliminated by the votes of the committee.

More recently, Asperger’s syndrome has been taken out of existence. Prior to DSM-5, it was possible to have Asperger’s syndrome. Now it’s not. Asperger’s has been subsumed into a broader category of autism. The National Autistic Society describes Asperger’s syndrome in this way: “People with Asperger syndrome see, hear, and feel the world differently to other people. If you have Asperger syndrome, you have it for life—it is not an illness or disease and cannot be ‘cured.’ Often people feel that Asperger syndrome is a fundamental aspect of their identity.”29 Although some people choose to retain the term “Aspie,” technically this way of being a person is no longer available. For many people, having Asperger’s syndrome was important. It was not, and still is not, a problem to be solved but is more a way of life that provides an important source of identity:

The news that the term “Asperger’s syndrome” will soon cease to exist has some parents concerned—especially parents raising “Aspie” children. Starting May 2013, the American Psychiatric Association’s new diagnostic manual, known as the DSM-5, will go into effect, stripping the well-known condition—a condition sometimes associated with loner geniuses like Albert Einstein and Andy Warhol—of its name. Instead, Asperger’s syndrome will simply be known as ASD-Level 1 (mild), a top rung in the ladder of autism spectrum disorders. For those who viewed an Asperger’s diagnosis as light-years away from clinical autism, this new classification may feel like a fall from grace.30

This change is problematic for some. Timothy Bumpus, who lives with autism, points out that “some of the most brilliant people had Asperger Syndrome, and you just can’t put that under the title of Autism…. This disability, which is ironically not at all a disability, causes the recipient to be antisocial, physically weak…. However, it is so much more. It allows a person to think in whole different ways, СКАЧАТЬ