The Diagnostic and Statistical Manual

Inthe same volume he explicitly denied that any classification “could be rigorously correct, for such divisions have not been made by nature and cannot be observed in practice.”8 Despite

The Diagnostic and Statistical Manual: A history of critiques of

psychiatric classification systems

Craig Newnes

Critiquing psychiatry’s Diagnostic and Statistical Manual (DSM) can be viewed as both a

thankless and impossible task In constructing psychiatry’s bible numberless

professionals have debated and promoted the classification and aetiology of madness espousing, along the way, contradictory and complicated systems of nosology and cause – as if they could somehow step outside their necessarily limited perspective on human conduct and take a detached view Deconstruction is no different; attempting to

summarize the myriad influences on why certain schemes (e.g., diagnosis) prosper and others fail is likely to provoke suspicions of hubris

This chapter addresses two particular (possibly hubris-defying) questions in relation to

the latest DSM; are the objections so different from previous attempts to derail

psychiatric nosologies and will these objections make more than a cosmetic difference?

Classifying conduct

This section examines some of the history of attempts to classify human behaviour as different types of madness and explores the historical consistency of critiquing these attempts

Before the nineteenth century, though rich in detail, references to insanity were made in molar (all or none) terms Behavioural criteria (signs) had been the basis for melancholia,mania and dementia, subjective experience barely figuring The establishment of a truly

Descriptive Psychopathology took around a hundred years, from the 1820s to the First

World War.1

Plato and Aristotle had regarded reason as the defining human characteristic, a

characteristic vulnerable to the perturbations of the passions Madness could be easily detected through observation, mental states only being occasionally referred to

According to Berrios,2 it wasn’t until the 1830s that books on insanity came to include clinical vignettes and reports of subjective experience, so called “elementary” symptoms (p17) He goes on to note the “marked difference” over a period of barely fifty years between the work of Haslam, Rush and Pinel and that of Esquirol, Morel and Tuke Therewere few diagnostic groupings prior to the 1830s; melancholia, mania, phrenitis,

delirium, paranoia, lethargy, carus and dementia were the main ones As new nosologies appeared so did new categories; others, like carus and phrenitis, disappeared

The mid-nineteenth century is rich ground for historians attempting to chart the

bewildering variation in psychiatric nomenclature In Germany first Krafft-Ebing in 1867

and then Westphal used a technical term – Zwangsvorstellung – to refer to irresistible

thoughts (obsessions in modern parlance) In France, Falret in 1866 had already used the

term obsession and Morel had written on emotion as contributing to obsessional

aetiology Later Luys brought subjective experience to the fore by defining obsessions as private, individual events By the end of the century Esquirol, Ball, Magnan, Kahlbaum, Kraepelin and Maudsley were merely some of the more renowned nosologists to have produced extensive and competing classifications of psychiatric morbidity

In 1906 the Joint College of the Royal College of Physicians of London drew up the fourth edition of the Nomenclature of Diseases, forerunner to the International

Classification of Diseases, now in its tenth edition.

The publication of yet another classificatory scheme was not universally welcomed: in

his Presidential address to the American Medico-Psychological Association Charles Hill the following year observed the only diagnosis omitted was, “the classifying mania of

medical authors.”3 Over a hundred years later his wry comment found a sympathetic

response in Levy’s proposed category, Pervasive Labelling Disorder.4

The origins of DSM

The first official, largely Kraepelinian, classificatory system in the US was produced by

the forerunner of the American Psychiatric Association – the American

Medico-Psychological Association – in 1918 There were 22 principal groups of mental disorder

Two mood disorders – manic-depressive psychosis and involutional melancholia – were

listed “Affective Disorders” were introduced by the Standard Veteran’s Administration classification in 1951 The first DSM, produced the following year, was similar to the VA system; “Affective Disorders” became “Affective Reactions” In all, DSM-I described

112 different diagnostic categories

The ontogenesis of DSM-I was a more fraught, contested and drawn out process than the

simple summary above might imply Grob5 notes that, “classification systems are neither inherently self-evident nor given,” and, “although nosological debates dealing with mental disorders were (and are) phrased in scientific and medical language, they were shaped by…the social origins and ideological, political and moral commitments of psychiatrists; their desire for legitimacy…(and)…the broader social and intellectual currents prevalent…” (p.421).6,7

Nineteenth century psychiatrists and alienists had long believed that mental illness was precipitated by a combination of psychological and environmental factors which might include improper living conditions For many, the innumerable forms of human conduct were barely explicable and impossible to classify Following Esquirol, for example, Ray,

in 1838, had divided insanity into idiocy and imbecility for those with congenital defects and a second group where lesions were the probable cause of either mania or dementia Inthe same volume he explicitly denied that any classification “could be rigorously correct, for such divisions have not been made by nature and cannot be observed in practice.”8

Despite such doubts, by 1885, a group of American psychiatrists under the direction of

Clark Bell, President of the New York Medico-legal Society, had followed British

counterparts in producing an eight-fold categorization of mental disorder, a slight

increase on the seven-fold nosologies of the International Congress of Alienists (1867) and the Association of Medical Superintendents of American Institutions for the Insane

(1869) Only a year later Bell found himself rejected by Pliny Earle, a grand figure in US alienism, on approaching him for help with yet another classificatory system Earle’s discouraging response has been echoed by critics to the present day: “…no classification

of insanity can be erected on a pathological basis…for…the pathology of the disease is

unknown…we are forced to fall back upon the apparent mental condition, as judged from

the outward manifestations.” Grob notes that, in the absence of clear indication of organic injury or decay, psychiatrists had no hesitation in looking for environmental factors in insanity; sexual excess, diet, housing, misdirected education, domestic,

financial and occupational difficulties were cited in an ever-lengthening list Pre-dating,

by over 150 years, the technique of “Problem Formulation” embraced by UK Clinical Psychologists and acknowledging the lack of utility of classificatory systems, Samuel B

Woodward, the first President of the Association of Medical Superintendents of American Institutions for the Insane (now the American Psychiatric Association) had already

recognized that therapy was, “independent of any nosological system, but, rather had to reflect the unique circumstances presented by each individual case.”9 In fact, as detailed

by Valenstein, 10 an obsession with technologies of intervention led psychiatrists to attempt a host of deadly interventions based on putative theories of organic aetiology rather than an analysis of personal and environmental factors unique to the individual For Smail11 similar, if less physically dangerous, techno-procedures are avidly pursued byclinical psychologists

Of the 22 groups in the first Statistical Manual for the Use of Institutions for the Insane

twenty represented forms of disorder assumed to have biological foundations These

included psychosis with arterial sclerosis, general paralysis, Huntington’s Chorea, and psychoses with brain tumour, cerebral syphilis, pellagra and epilepsy The preference for

somatic nosology might be explained by the fact that the overwhelming majority of psychiatrists dealt with hospitalized patients with severe physical impairments Between

1918 and 1942 the Statistical Manual went through ten editions, the tenth making

provision for psychoneuroses and behaviour disorders – almost certainly a response to

the observation that soldiers could be returned to the battle-field of the Second World War within days of treatment involving little more than rest and companionship, an

outcome that common sense suggested could not be achieved if their distress had an organic substrate

Statistical Manual for the Use of Institutions for the Insane had appeared Mental

disorders were now divided into two main categories; disturbance resulting from

impairment of brain function (trauma, alcoholism, multiple sclerosis, etc) and disorders resulting from an inability to adjust The second group was further divided into psychotic and psychoneurotic disorders

Post-war, the psychiatric community, influenced by psycho-dynamic theory, moved towards a position whereby mental health and illness were on a continuum and sought to

treat more individuals diagnosed as psychoneurotic The Group for the Advancement of Psychiatry went further, urging a preventative psychiatry aimed at social action;

including, “a conscious and deliberate wish to change society.”12 Again, there are

contemporary echoes here; Psychology, Politics and Resistance and the Community Psychology Section of the British Psychological Society both advocate social change.

DSM-II was published in 1968 Like Bell, in 1885, its authors turned their sights to the

wider community for corroboration and collaboration Influenced by the eighth edition of

the International Classification of Diseases (ICD-8), affective reactions became major affective disorders, now including involutional melancholia and listing psychotic

depressive reaction separately The overall number of disorders rose to 163

Robert Spitzer, lead author of DSM-III, a volume now containing 265 disorders and

published in 1980, has the following to say about how the committee approached the challenge of categorizing mood disorders, “In the absence of such evidence (for etiology

[sic] as a classificatory device) categories are grouped together if they share important

clinical-descriptive features This includes all of the depressions and manias regardless ofseverity, chronicity, course, or apparent associations with precipitating stress”13 (p.75)

The reader is referred to Jackson14 for an extensive exploration of theories of the

construction and treatment of depression, for example, and its forebear melancholia Jackson charts the history of the diagnosis from humoral postulants of the fifth century

BCE to the publication of DSM-III in 1980 He notes numerous attempts by, amongst

others, Samuel Johnson, Tuke, Pinel, Esquirol, Morel, Krafft-Ebing, Kraepelin, Meyer, Henry Maudsley and Freud to categorize and delineate forms of distress variously

described as melancholia, involutional melancholia, insanity and psychonerosis;

“depression” he notes as, “a relative latecomer to the terminology for dejected states.” (p5) In 1725 Blakemore writes of “being depressed into deep Sadness and Melancholy,”

while in 1801 David Daniel Davis’s translation of Pinel’s Treatise on Insanity, rendered l’abbattement as “depression of spirits.”

Aetiology has been as debated as classification, psychological theorizing being as varied

as physiological explanations For Esquirol, for example, season, climate, gender, age, idleness and scholarliness vied with “organic lesions of the lungs” and “displaced colons”

as putative causative factors Potential treatments included Moral Medicine (aimed at a sympathetic lifting of the spirits), a clear sky, exercise, attention to diet, baths and coitus

By 1980 Spitzer and his colleages, in publishing DSM-III, agreed on a scheme wherein

depression was classified as an affective disorder sub-divided into bipolar and major depressions and further into cyclothymic, dysthymic and (again) into atypical bipolar disorders and atypical depressions By the mid 1980s aetiological theories included loss, learned helplessness, separation anxiety, life events, cognitive distortions, genetics, endocrine changes and depletion or excess of neurotransmitters

Aidan Kelly claims that some of these changes incorporated into DSM-III were provoked

by a ‘crisis’ in psychiatry during the 1970s when a group of critics from within the

discipline (e.g., Ronnie Laing and David Cooper, leaders of the anti-psychiatry

movement) questioned psychiatry’s standing as the authority on mental health issues.15Psychiatry’s reaction to its critics was to change how mental illness was talked about by re-incorporating psychological and sociological factors into a bio-psycho-social (BPS) model.16 DSM-III and IV were subsequently written to incorporate more BPS language in

their criteria

A new feature of DSM-III was its multiaxial orientation, Axis I describing

symptom-based disorders, Axis II personality disorders The remaining three axes specified

medical conditions (an intriguing feature in a nosology supposedly articulating all

psychiatric disorders as medical phenomena), severity of stressors and the best level of psychological functioning during the preceding year.17 The all-encompassing nature of thenew volume was commented on by Jay Katz, a professor of psychiatry at Yale: “If you

look at DSM-III you can classify all of us under one rubric or another of mental

disorder.”18 Szasz 19 notes that Katz’s statement was not followed by any comment to the effect that such a position rendered the concept of mental illness meaningless

Freud, Marie Jahoda and Karl Menninger were amongst many Psy professionals to already be on record as suggesting that we were all mentally ill at one time or another, to

a greater or lesser degree This position enables those frequently critical of the diagnostic endeavour, for example, clinical psychologists, to have their cake and eat it; distress can

be normalized or placed on a continuum wherein it is the suffering of the individual (or

others, e.g., the family) or the temporary apparent inability to function socially (so called

‘problems in living’) which dictate the need for professional intervention At no point in this enterprise does the professional ask what right he or she has to interfere with a stranger’s distress

DSM-IIIR, DSM-IV and DSM IV-TR were published in 1987, 1994 and 2000

respectively The 265 diagnoses in DSM-III duly increased to 292 for DSM-IIIR and 365 for both the later editions Perhaps the profession had finally recovered from the one disorder still not listed – Pervasive Labelling Disorder.20

The debates within and about the various classifications of madness are too numerous to elucidate here From Hellenic dichotomous systems simply differentiating normality frominsanity via the more complex systems of Kraepelin and his contemporaries to the recent return to a more descriptive and deceptively detailed nosology surrounding the

publication of DSM-5, 21 physicians, mad-doctors, alienists, psychiatrists and

psychologists have dissected nomenclature supposedly offering objective descriptions of both the conduct of the insane and reasons for the insanity That their descriptions are based on frequently second hand reports or clinical examples featuring only one

diagnosed person seems to have provoked little concern That some of these practitioners

and theorists were themselves mad or incarcerated in asylums for the insane has been of

interest only to historians Berrios,22 for example, notes the ways in which some

nineteenth century French writers lost no credibility for their theories despite being

asylum patients at the time; indeed, some modern psychologists have gained credibility

by openly declaring their diagnoses and symptomatology Peter Chadwick, a

psychologist, for example, has this to say, “Discomforting though it is to admit it, I have

been insane…Psychological knowledge is no insurance policy against madness (p5) It was helpful to me to regard myself as having had an illness, by gradual re-employment

and by (marriage to) a woman who makes her points (during conflict) only by attacking

my behaviour not my character It was very helpful to mix with people who ‘called a

spade a spade.’(p6) Sending patients back into exactly the same scenario in which they became ill is, quite simply, a disaster (p8)23, 24

In the UK ex-patient, patient and survivor groups have gained ground in influencing policy Rufus May, a clinical psychologist, is but one example of a professional with a previous psychiatric diagnosis regularly consulted by government in relation to policy and praxis In Europe, the European Network of Users and Survivors of Psychiatry is consulted by the World Health Organization and, on a global scale, the World Network ofUsers and Survivors employs Human Rights specialists to advocate for the rights of survivors as citizens.25

These “critics from experience” are not new: in 1843 Dorothea Dix – a schoolmistress who had witnessed the mixing of the insane with criminals in Boston jail whilst

conducting a Sunday school service – addressed the state legislature in Massachusetts By

1855 she had addressed the general assembly in North Carolina, Congress in Washington,met with Tuke at the York retreat and embarked on a government-backed survey of lunatic asylums in Scotland By then the Alleged Lunatics’ Friends Society had formed inBritain to advocate for more humane treatment of the incarcerated insane

Criticizing DSM-5

What follows addresses recent criticisms to the proposed DSM-5 focusing on the official

response of the British Psychological Society

The proposed publication of DSM-5 engendered numerous criticisms, by the British Psychological Society26, the Australian Psychological Society, and an online petition

supported by over fifty mental health associations.27 Critics from within psychiatry

included the chair of the DSM-IV taskforce Allen Frances.28

The BPS response was prepared by, amongst others, Professor Peter Kinderman, Chair of the Division of Clinical Psychology (DCP), Susan van Scoyoc, DCP committee member and member of the Division of Heath Psychology (DHP), Dr David Harper, Professor David Pilgrim and Professor Richard Bentall, all members of the DCP, Lucy

Johnstone, committee member of the DCP and Dr Amanda C de C Williams, member of both the DCP and the DHP The critical psychiatry background of some of these authors

is well established David Pilgrim has post-graduate qualifications and a considerable bibliography in the fields of clinical psychology, psychotherapy and sociology; he has been a foremost critic of the professional ambitions of clinical psychology.29 Lucy Johnstone, ex-director of the Bristol clinical psychology doctorate was one of the first clinical psychologists in the UK to outline, in book form, the abuse inherent in

psychiatric practice.30 David Harper, Reader at the University of East London Clinical Psychology Doctoral Programme has repeatedly exposed the solipsistic theorizing

around the concept of paranoia31 and Richard Bentall’s work includes two renowned volumes psychologizing madness.32 In a similar vein both Johnstone and Harper are

contributing authors to De-medicalizing Misery.33

It is as psychologists that these authors’ expertise is utilized As Smail, however, has

noted, it is not possible to separate action from the vested interest of the actor, even, perhaps especially, when that actor is an authorized professional.34

The introduction to the response begins; “The British Psychological Society thanks the American Psychiatric Association (APA) for the opportunity to respond to the DSM-5 Development.”

It is unfortunate that UK psychology, as represented by the BPS, “thanks” the APA

Thomas Szasz35 would have seen this kind of gesture as one profession supporting – despite certain reservations – a system used to rob citizens of agency through designation

of illness, a position mirrored in the work of Peter Breggin;36 both psychiatrists, the work

of Szasz and Breggin remains something of a rearguard attempt to undermine the

psychiatric project.37 Jeffrey Masson, ex director of the Freud Archive, goes further in his

comparison of psychiatric practice with rape; rape is not something society should try to refine but something which is already illegal, a fate he sees as psychiatry’s just desserts.38Wolfensberger’s concept of “death-making” can equally be used to suggest that

psychiatric praxis is designed to kill body, spirit or both and should be banned.39

An alternative statement from an organization apparently standing for individual agency and the application of genuine scientific endeavour might read, “The British

Psychological Society rejects all nosologies of human conduct as un-scientific and, in the

case of DSM-5, yet another technological praxis which will only further the interests of

psychiatric practitioners, the pharmacological industry and state control.” Such a

statement would betray the very raison d’être of the discipline, a discipline which

continues to profit from statistically-driven notions of abnormality Equally, such a statement would jeopardize the Society’s position as a politically neutral “Learned Body”

with charitable status One might conjecture that, given their publication record, a

conversational analyst observing the debates amongst the authors of the response could

have proposed the brief statement suggested above as one possible interpretation of their

discussions

After the introductory section the BPS response begins: “The Society is concerned that

clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.”

“The Society” has around 50,000 members.40 As in most documents of this type this usage is both impersonal and a rhetorical device implying consensus amongst the

members of “The Society” (there is no note in the BPS response to the effect that the

views expressed are only the views of the named authors) No mention is made of the considerable numbers of member psychologists in organizational, clinical and

counselling specialisms who unquestioningly utilize diagnoses in their praxis, design or

use questionnaires to aid the diagnostic endeavour of psychiatric or other colleagues and

have no hesitation in publishing journal articles and books suggesting psychological

“treatments” for virtually all diagnosed conditions, medical and psychiatric

The history of the profession of clinical psychology in Great Britain can be approached using Goldie’s schema outlining three possible positions taken up by non-medical

professions in a context where medicine is the dominant discourse.41 According to Goldie professions and individual professionals move between the three positions

depending on context and the point in their professional development Non-medical

professions, relative to medicine, can be positioned as compliant, eclectic or radically opposed

Compliance is best summarized as taking care not to rock the medical boat In the United

Kingdom since clinical psychology’s establishment as a profession under the 1948 National Assistance Act, compliance has been a persistently held position An example is

the use of psychometric assessment procedures for a host of assumed ills – from the tests

for “Schizophrenogenic Thought Disorder” of the 1960s via the Beck Depression

Inventory to many different tests for so-called Attention Deficit Hyperactivity Disorder of

today In the United States, where the majority of health care is paid for via private

insurance, insurance companies insist on psychometric assessment and subsequent

psychiatric labelling before agreeing to fund treatment The point was not lost on Spitzer

and his colleagues when revising DSM-III: Time magazine reported from the first of their meetings that the most important thing, “…is that DSM-III is of crucial importance to the

profession (because) … its diagnoses are generally recognized by the courts, hospitals and insurance companies.”42

Though not constrained by such institutional demands in the UK, clinical psychologists

in the compliant position perform psychometric assessment thereby giving the diagnostic

system a scientific gloss This can range from agreeing that someone “has”

post-traumatic stress to confirming that a person’s IQ is less than 70

Eclecticism has all the signs of a collaborative endeavour but with a hint of offering an

alternative to the diagnostic and physical excesses of psychiatry and psychology

Psychotherapy and counselling professionals offering therapy as an adjunct to medication

for a host of diagnosed individuals might be positioned as eclectic In such praxis the

clinical psychologist offering therapy neither directly challenges the diagnosis (“What on

earth do you mean by the term schizophrenia?”) nor the use of medication (“Have you

tested for the brain-biochemical imbalance you say is producing this person’s feelings of overwhelm?”) Instead, the clinical psychologist offers a variety of psychotherapy to the patient and reports progress to the referring physician or psychiatrist Such practice has been predominant in clinical psychology in the UK for over fifty years from the

Behavioural Therapies of the Maudsley Hospital under Eysenck, via the psychoanalytic approach of the Tavistock Clinic through to the modern obsession with Cognitive

Behaviour Therapy and post-modern narrative approaches

Radical opposition is a polarized fight or flight modality Here, non-medical professions

and individual professionals might take up a public opposition to the dominant medical

discourse or attempt to leave the conflict zone Example from the fight pole can be found

in the work of some critical clinical psychologists, for example, those authors who actively challenge the medical paradigm by facilitating alternative, normative means of – frequently – local and community rather than professional aid.43

Individual practitioners, depending on context, might claim a position not easily

identifiable to an observer; for example, a newly qualified practitioner might well screw

up the courage in a case conference to challenge a consultant psychiatrist’s proposed diagnosis or treatment The psychologist may well assume herself to be in at the fight pole of the fight-or-flight position From a critical perspective, however, that psychologist

is still attending the case conference as a professional and implicitly supporting a medicaldiscourse wherein complete strangers are designated “cases” by powerful others As such, the majority of the profession is positioned as either compliant or eclectic The

Division of Clinical Psychology of the BPS adopts a public stance which consistently fails to challenge a medical discourse and academic journals like The Journal of Clinical Psychology or Clinical Psychology and Psychotherapy have a long history of support for

psychiatric diagnostic nosologies and professional/patient dichotomies In a recent issue

of Clinical Psychology Forum, for example, reference is made to a paper by

Heriot-Maitland, and colleagues work comparing “psychotic-like phenomena in clinical and non-clinical populations.”44 In a profession frequently claiming human experience to be

on a continuum it is self-contradictory to position some experience (“phenomena”) as

“psychotic-like” though, as Rosario has noted, since the mid-nineteenth century Psy

professionals have first claimed madness to be different from normal conduct before finding examples of that madness in virtually anyone even using the literary work of, for

example, Zola to diagnose the author.45

In terms of Goldie’s nosology the profession of clinical psychology in Great Britain can

be seen as moving - broadly - between a primarily compliant position and an eclectic one,with fluctuations between the two

The response continues: “We therefore do welcome the proposal to include a profile of rating the severity of different symptoms over the preceding month This is attractive, not

only because it focuses on specific problems (see below), but because it introduces the concept of variability more fully into the system That said, we have more concerns than plaudits.

“The putative diagnoses presented in DSM-5 are clearly based largely on social norms,

with 'symptoms' that all rely on subjective judgements, with little confirmatory physical 'signs' or evidence of biological causation The criteria are not value-free, but rather reflect current normative social expectations Many researchers have pointed out that psychiatric diagnoses are plagued by problems of reliability, validity, prognostic value, and co-morbidity Diagnostic categories do not predict response to medication or other interventions whereas more specific formulations or symptom clusters might.”46

“Welcoming” the inclusion of “rating the severity of different symptoms” is a rhetorical device of the “I come to bury Caesar not to praise him” type indicating that what may

follow may not be to the liking of the authors of DSM-5 Few of the DSM authors,

however, would be unhappy with the notion of “symptoms” (a medical term) or

“severity.” If the word “experience” – as a normalizing and equally valid term - is

substituted for symptoms, then we are left with the non-technical possibility that

experience might be “severe.” This is immediately identifiable as nonsensical – the

notion of “severity” requires the noun “symptoms” to render the meaning intelligible and

the rightful property of experts As previously noted, psychologists take a default position

of utilizing medical terminology to position themselves as experts in the human

condition

Similarly, welcoming “variability” supports the psychological project, a project

predicated on statistical notions of variability and a consensus around “health” and thus,

“mental health” being on a continuum This position serves members of the profession

well; they can now justify seeing anyone for purposes of assessment or therapy on the

basis that suffering is integral to the need for help (rather than something to be tolerated) and, untreated, such suffering could lead to more severe “symptoms.” This position echoes that of Freud, Menninger, Jahoda and Katz previously noted.47

The authors of the BPS response are well aware that psychiatric diagnoses have always

depended on “subjective judgements”, which have few, if any, “confirmatory physical 'signs' or evidence of biological causation.” Equally, it is hard to imagine criteria that would be “value-free,” or reflecting something other than “current normative social expectations.”

First Ray, in 1838 and later Earle, in 1886, in turn an alienist and a psychiatrist had, as quoted previously, said much the same thing, both succinctly describing the problem faced by those attempting to understand those for whom they held out the promise of help In fact, the notion of “biological causation” is a red herring here Though suggestingbiological causation legitimizes the use of physical treatment and as Moncrieff,48 amongstothers, suggests, embeds psychiatry in the world of “real” medicine confusion is

maintained about the essential difference between “cause” and “reasons.” Human beings are not billiard balls – human agency must include the notion of reason as one aspect of conduct.49 Thus, intoxication or brain injury may “cause” a person to experience colours, sounds and touch in unfamiliar ways Those ways, however, are particular to the person

in any given time, context and phase of physical development; A does not simply lead to

B Exploring the “reasons” any given individual acts in particular ways necessitates a shared explanatory discourse that may involve concepts such as “beliefs,” “desires,”

“family context” and so on To say someone hears voices “because” they have disorderedbrain biochemistry is to say nothing about why that person hears particular voices saying things at certain times To suggest, as the voice-hearer herself might, that the voices

“caused” her to act in socially undesirable ways is to ignore the concepts of “reason” and

“choice” altogether Psychology and psychologists, though perhaps eschewing ideas about physical “causes” for certain human actions are, necessarily, limited to a social-context bound discourse of “reasons.” This form of explanation requires a shared

discourse involving the idea that a person is capable of giving sufficient reasons for

personal action through access via some kind of inner speech to the essential movers of conduct or that, through attending to what the person says or does a professional can construct sufficient reasons for that conduct For both professional and patient, the

supposed absence of “choice” can be advantageous.50 Psy professionals invoke the need

to offer “compassion” to those claiming to suffer through no fault of their own; their

interventions, whether physical or psychological are thereby legitimized by recourse to

normative (Judeo-Christian) morality (As has been noted, there continue to be a vast number of possible interventions, from electro-shock51 to counselling,52 all justified in thename of compassion.)

Compassion is a value laden concept The act of responding to the proposed DSM-5 is,

itself value laden Nor can the statement be seen beyond “current normative

expectations” for the profession Though accurate, the accusation that diagnoses depend

on social norms can hardly be regarded as critical unless, as in the case of UK

psychology, there is an ongoing attempt, by aligning with the natural sciences, to position

psychologists as objective observers and recorders of human conduct Such objectivity is

supposedly achieved via an arsenal of psychometric tests and the use of “evidence-based”therapeutic technologies Lest there should be any doubt, the fourth paragraph of the introduction to the response reads, “The Society is committed to providing and

disseminating evidence-based expertise ”53 In a modern context where expertise,

particularly, scientific expertise is valued, it seems curiously - for psychologists –

non-reflective to criticize diagnostic praxis as value-laden when the values and methodologies

of science are the means by which much of the ensuing criticism is pursued

The response’s proposal that “more specific formulations or symptom clusters” might

“predict response to medication or other interventions” is not one to unduly trouble those

who see the DSM enterprise as a helpful diagnostic tool As noted above “formulations”

are popular in clinical psychology and might have been expected to appear in the

response document The authors accept a priori that someone using DSM would have a reason for formulating someone’s conduct; once the professional gaze is turned on an

individual that individual will be regarded as odd, whether through “formulation” or the examination of – by definition problematic – “symptom” clusters In promoting one of itsrecent shibboleths (“formulation”) and not criticizing the pseudo-medical praxis inherent

in the language of “symptoms” the response positions psychology as essentially in the