A paper on the ideological premises supporting the rhetoric of DSMIV

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Wed, 16 Aug 1995 16:27:27 -0400 (EDT)

Hello to the PCP net participants:

=09The text of the paper on ideological premises underlying the rheto=
of science supporting Amer Psychiatric Assoc's DSMIV follows.
=09Terms preceded and followed by "_" would be italicized.


Some Unarticulated Premises in the Rhetorical
Construction of DSM Categories

Theodore R. Sarbin
University of California, Santa Cruz
James C. Mancuso
University at Albany
The practice of revising DSM every few years reflects an
obsessive preoccupation with diagnosis. This preoccupation
flows from. the medical profession's long-standing formula
for managing sickness: first diagnosis, then treatment.=20
Psychiatrists have uncritically adopted this formula for
managing unwanted conduct. The Manuals are supposed to
provide unequivocal criteria for diagnosis, the first step
in the formula.
We submit that the developers of these Manuals have
unwittingly been guided by 19th century mechanistic science,
the goal of which is the discovery and utilization of cause
and effect relationships. We say "unwittingly" because the
promoters of DSM appear to be unaware that they operate
under the influence of a particular ideology: a set of
beliefs based on the root-metaphor of the transmission of
forces. One cannot question the success with which this
root metaphor has guided research in the physical sciences.=20
The successful achievements of the physical sciences have
justified the ideological premises. The authors of the
Manuals have taken advantage of the resulting epistemic
power granted to the mechanistic ideology. As a result, DSM
diagnosticians feel no need publicly to declare their credo.
An unarticulated ideology directs the rhetoric that
frames the diagnosis of unwanted behaviors -- a rhetoric
that prompts speakers and listeners to surround the
diagnostic system with a halo of scientism. Unchallenged,
these premises will continue to provide a mute context for
the role enactments of magistrates and psychiatrists (and
their surrogates) in conferring the status of mentally ill,
psychotic, insane, schizophrenic, manic, etc., upon persons
whose conduct comes under their evaluative scrutiny.
Unchallenged, these premises continue to inhibit the
development of alternatives to the prevalent illness
perspectives. Unchallenged, these unspoken premises will
continue to provide the structure for the contents of
numerous textbooks of abnormal psychology. Such textbooks
shape the beliefs of thousands of students who accept the
rhetorically driven DSM categories as scientifically
established Truth. In turn, these young people enter
professions -- law, social work, education, medicine, etc.
-- in which they may employ these premises in formulating
questionable social policies and action programs.
In our 1980 book (Sarbin and Mancuso, 1980) we
identified nine ideological premises as superordinate
constructions that maintain the rhetorical context in which
unwanted conduct is transfigured to medically-inspired
diagnoses. In this brief presentation, we elaborate three of
these premises:=20
(1) the practice of uncritically assigning positive
value to activities that fall under the general
rubric of "research;"
(2) the reification of mind and emotion metaphors,
(3) the unique authority granted to physicians and
their surrogates.

Research has high positive value.
The rhetoric of science features the search for
cause-and-effect relations on the order of those developed
by practitioners of the physical sciences with its attendant
dependence on quantification and on the publication of
research findings. Those who use the diagnostic manuals
quickly become immersed in the ideological traditions. They
gain certification as scientists by publishing their own
The research journals place a high value on prediction.=20
In the psychiatric and psychological journals, the tedious
research reports on patients diagnosed as schizophrenic are
presented as if the prediction criterion had been satisfied.=20
In fact, the reports show only degrees of association
between dependent and independent variables. The rhetoric
of science, however, influences the investigator and the
reader of the research reports to glide from a legitimate
claim of association to an illegitimate claim of causality.
The typical research report attempts to establish a
particular instance of conduct as a "symptom" that signifies
a particular diagnosis. Golden and Meehl (1979), for
example, assert that persons of "a particular genetic
constitution" (a cause) have some "liability for
schizophrenia" (an effect) ( p. 217). The authors then
proceed to lay out more specific exemplars of the
cause-and-effect formulations that buttress the epistemic
strategies of mechanistic science. They assert that "The
effects of a history of social learning upon schizotaxic
individuals results in a personality organization ... called
schizotypy" (pp.223-4,emphasis ours). Reading further into
Golden and Meehl's text, the reader is to infer the causes
for the schizotypic person becoming clinically schizophrenic
-- constitutional weaknesses, a history of social learning
influenced by schizophrenogenic mothers, etc. Using the
rhetoric of implying causal connections, Golden and Meehl's
report could influence the reader to the fallacious
conclusion that the presence of schizotypy would be the
determinate cause for a specific detail of action, such as
responding affirmatively to the MMPI item, "I have not lived
the right kind of life" (p. 225).
Without the tacit rhetorical buttressing of the
causality theorem of mechanistic science, DSM systems would
gain little support from the plethora of research reports
like that of Golden and Meehl. If the supporting rhetoric
were eliminated, the implied claim to prediction would lose
its awesome status. Scholars could then compete for journal
space to propose alternative explanations of unwanted
behaviors -- explanations based on epistemic values other
than pseudo-demonstrations of mechanistic causality; for
example, internal cohesion, external consistency, parsimony,
or range of convenience.=20

"Mind" and "emotion" refer to body functions.
An elaborate set of assumptions supports the ideology
grounded in the general view that "mind" and "emotion"
function as quasi-organs of the body. Having generated
social constructions of mind and emotion as corporeal
entities, society willingly allocates to medical
professionals the enterprise of "curing" disordered minds
and adjusting inappropriate emotions.
The Cartesian concept of mind as an entity analogous to
an organ of the body has infiltrated the common sense of the
culture so that metaphors such as "mental illness" and
"sound mind" are treated as if they had existent referents
rather than being treated as evaluative judgments. The
concept of mind is a prime example of a socio-linguistic
process known as the metaphor-to- myth transformation (Chun
and Sarbin, 1970). Originally a verb for talking about such
functions as thinking, perceiving, remembering, and so on,
"mind" became the preferred metaphor, later to be reified as
a quasi organ. Being an organ, "mind" could be split, hence
the obfuscating Greek term, schizophrenia.
Though recent editions of DSM contain cautions about
"loss of contact with reality" being a symptom of a diseased
mind, the Manuals continue to speak of "distortions or
exaggerations of inferential thinking (delusions),
perception (hallucinations), language and communication
(disorganized speech)" (American Psychiatric Association,
1994, pp. 274-275) as symptoms of schizophrenia. Thus, the
myth of a diseased mind-as-organ supports the rhetoric that
guides the discussion sections of hundreds of studies of
schizophrenia. For example, in concluding their report, one
research team offered the following recommendation: "The two
experiments ... may also be useful in diagnosing
schizophrenia, for they offer a highly objective means for
assessing the characteristic errors in perception that are
part of the definition of schizophrenia" (Schwartz-Place &
Gilmore, 1980, p. 417). Notwithstanding that in almost 100
years, no marker has been uncovered that would identify
schizophrenia without unacceptable proportions of false
positives and false negatives, the prevailing rhetoric leads
both the authors and their readers to engage in an unwitting
Concomitantly, a review of social constructions
associated with the term "emotion"
yields evidence that scholars as well as the person in the
street inextricably link "emotional functioning" and "mental
functioning." Diagnostic systems inevitably look for
disordered emotion functioning as a symptom of "mental
illness." Indeed, improper expression of "mood" forms the
basis of an entire subset of diagnostic categories in DSM
IV. For example, "A manic episode is defined by a distinct
period during which there is an abnormally and persistently,
expansive or irritable mood" (emphasis ours, American
Psychiatric Association, 1994, p. 326). The mood "may be
recognized as excessive by those who know the person well.=20
The expansive quality of the mood is characterized by
unceasing and indiscriminate enthusiasms . . ." (p. 326).=20
The implicit workings of the ideologies of emotion as a
somatic event are apparent: diagnosticians hold
expectations of what emotional displays are "normal" and
they have the ability to detect improper displays. Indeed,
even when a person does not report that he or she feels in a
depressed mood, it is possible that (quoting DSM) "the
presence of a depressed mood can be inferred from the
person's facial expression and demeanor" (p. 321). The
ideology that supported the writing of the Manuals would
support the claim that specific embodied emotions are
expressed in ways that are biologically predetermined.
Two strong basic assumptions buttress the ideologies of
mind-as-organ and emotion as a bodily process. The first is
that a "healthy mind" can detect logical flaws, can detect
self-evident truths (especially self evident moral truths),
and does not misconstrue sensory inputs. The second is that
the users of DSM have a special skill to determine which
emotional reactions are authentic and which should be
regarded as inappropriate.
It is apparent that the ideologies of mind-as-organ and
emotion as psychophysiological event have important societal
uses. These ideologies clearly figure into the assignment
of responsibilities for dealing with nonconforming behavior.=20
DSM diagnosticians, tacitly holding to their allegiance to
the moral enterprise of controlling unwanted conduct, tend
to ignore controversies that would challenge crucial
assumptions within the system. For example, DSM-IV users
would hardly be interested in the carefully worked-out
challenges (by a wide assortment of scholars) to the
validity of the entrenched idea of discrete "natural"
emotions [see for example Averill (1986), Harr=8A (1986),=20
MacIntyre (1981), Mandler (1992), Sarbin, (1989), Solomon

Physicians and their Surrogates Merit a Unique Authority.
The Manuals are developed by the American Psychiatric
Association, the members of which are physicians who have
elected to specialize in psychiatry. The various editions of
DSM have been collated by task forces made up primarily of
psychiatrists. Since DSM has been declared the
authoritative guide to diagnosis, it would be instructive to
examine the authority granted to physicians.
Contemporary medical doctors derive their authority from
the historical images of the healer. Aesculapian
authority, named after the Greek god of healing, combines
three discrete types of control. First, physicians are
granted expert authority. That is, the public regards them
as having specialized knowledge and skills. Second, doctors
are perceived to have moral authority -- they are dedicated
to performing acts that would ease suffering and save lives.=20
Third, the public confers upon doctors charismatic or
priestly authority, a form of control derived from the
mysteries and rituals historically associated with the
healing professions.
The history of psychiatric treatments shows clearly how
medical practitioners have employed Aesculapian authority to
administer various draconian treatments, for example,
lobotomies, to persons diagnosed as "mentally ill." The
current use of this authority justifies prescribing
medications that block the neural transmissions that depend
on dopamine, a brain chemical. Psychiatric textbooks have
created the context for administering these drugs with such
pronouncements as: "Thus, psychiatry stretches from mind to
molecule and from clinical neurobiology to molecular
neurobiology as it attempts to understand how aberrations in
behavior are rooted in underlying biological systems"
(Andreasen & Black, 1995, p.130). Under the spell of this
kind of rhetorical grandeur, psychiatrists are empowered to
label a certain class of chemicals as _antipsychotic drugs_,
rather than tranquilizers. Thus, the phenothiazines --
chemical antagonists to dopamine -- are not prescribed for
the ethically questionable purpose of tranquilizing.=20
Redoubtable investigators assume that dopamine antagonists
are "truly" antipsychotic, and that researchers are en route
to discovering the neurochemical basis of schizophrenia.
An editorial in the prestigious New England Journal of
Medicine questioned the wisdom of continuing this line of
inquiry: "Despite a number of suggestive findings....there
is currently no proof that either a neurotoxin or an
abnormality of transmission (including a dopaminergic
abnormality) is a primary feature of schizophrenia"
(Mesulam, 1990).
Yet Andreasen and Black (1995) persist in asserting the
authoritative sounding text which invokes a hypothesis
embedded in the metaphors of chemistry and physiology. What
support, other than that devolving from Aesculapian
authority, leads to this hypothesis? The claim that a
dopaminergic abnormality underlies the expression of
"symptoms of schizophrenia" is derived from the observation
that some patients who ingest a dopamine blocker desist from
enacting unwanted behaviors. (They also desist from
enacting all varieties of behavior that would not be
regarded as symptoms of mental illness, such as, automatic
swallowing of saliva.) The publication of research projects,
many of which are sponsored by pharmaceutical companies, has
been instrumental in forging a tenuous causal chain of great
rhetorical power. The chain may be represented as follows:
1. unwanted conduct is noted as symptomatic of a
malfunctioning mind-as-organ,=20
2. a diagnosis of schizophrenia is pronounced by a
doctor who has been granted Aesculapian authority
3. who prescribes an "antipsychotic" drug; =20
4. there follows a diminution of unwanted behaviors
(as well as other nontargeted behaviors) and,=20
5. employing logic-in-reverse, the researcher
concludes that the unwanted behavior was caused by
malfunctioning of the tissues that produce
dopamine. =20
The absurdity of the causal claim requires no further

Faced with the heavy burden of social control, our
society has conveniently borrowed the power of the medical
profession to pursue the moral enterprise: the sorting out
of those people who must be marginalized because they engage
in behaviors that annoy and disrupt. The politics and
rhetoric involved in creating a diagnostic system (Kirk and
Kutchins, 1992), of questionable utility (Boyle, 1990) which
supposedly follows medical ideologies have been well
documented . Other ideologies and other professionals offer
solutions to problems of unwanted conduct based on premises
consistent with contextualism, a competing ideology to the
world view of mechanism. To direct attention to these
alternatives, we must demonstrate to the power centers of
our society the bankruptcy of the moral enterprise that for
so long has been guided by the root metaphor of mechanistic
science. At the same time, we must convince the power
centers of the potential utility of an alternate ideology,
the root-metaphor of which is the narrative and the
recognition that we live in a story-shaped world.

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