Leaving Psychiatry. J. R. Ó’Braonáin. M.D.
2013 Royal Australian & New Zealand College of Psychiatrists (RANZCP) Mood Disorder Guidelines is the specimen to be studied, at its time the most up to date international guidelines in print. It remains perhaps the largest undertaking into mood and its disorders, so long in the planning that the previous guidelines were published a full decade prior. Weighing in at greater than one hundred pages, with more than a thousand references and a few dozen committee expert authors and advisors, it includes the claim to have consulted widely with many stakeholders including the laity.
The first section titled “Classification of mood disorders” opens with subtitle
“A pragmatic approach to mood disorder classification.”
It continues; “There is growing consensus that psychiatric diagnoses are akin to social constructs (Insel, 2014; Zachar and Kendler, 2007). It is nonetheless appropriate for the structure of this guideline to adopt an accepted mood disorder taxonomy because, (i) there is broad agreement about definitions, and (ii) diagnostic terms have accrued valuable meaning through scientific (e.g. clinical trials) and social processes (e.g. advocacy). (See: Figure 1). Using the terms as pragmatic organising constructs should not translate into their reification – the optimal classification of disorders must await a quantum leap in our understanding of the aetiology and pathophysiology of abnormal behaviour.”
The references are these.
Insel TR (2014) The NIMH Research Domain Criteria (RDoC) Project: Precision medicine for psychiatry. American Journal of Psychiatry 171: 395–397.
Zachar P and Kendler KS (2007) Psychiatric disorders: A conceptual taxonomy. American Journal of Psychiatry 164: 557–565.
We will dispense at the outset with the words “akin to”. This is written I suspect to allow one to evade critique by denying having made a definite statement, only something akin to the statement. The same is the case with the word “consensus”, as I suspect were I to say the consensus is the RANZCP they would say “no not us”, and have me running down labyrinthine alleys searching for the target.
The RANZCP guidelines are a lesson into the dangers of secondary reading and that bloating an article with references (or a book, hence my refrain) neither adds to the weight of scholarship or the strength of argument. You see neither the Insel or the Zachar and Kendlar articles state anything like approaching that diagnoses are akin to social constructs. Insel speaks of the DSM, “like other medical disease classifications”. His article is thoroughly wedded to the so called medical model and it would dishonour the man to suggest a social constructivist subtext that clearly is not present. It simply posits that medical science (under the RDoC framework) will grant the tools to reorganize a taxonomy of mental illness that would be an improvement on the existing one. There is not one single mention of any psychiatric disorder being etiologically either a psychological or social phenomena, much less specifically a “social construct” designed by a consensus group of powerful stakeholders.
And what of Zachar and Kendlers paper? Having been published pre DSM 5 in 2007, it’s a curious choice, with both authors publishing widely since. For Zachar this has reached its peak as a contributor in a multi-perspective wonderful series of articles in 2012 in Philosophy and Ethics in Humanities and Medicine. Suffice to say for now, Zachar sides with the American psychiatric guild and its colonies (Australia included) on the side of philosophical pragmatism. To use Allen Frances baseball metaphor of truth, he thinks the reality of an umpire’s call lay in how he uses it (Frances was chair of the various DSM IV committees). Or to speak of psychiatry, he considers models and explanations as more or less as a means to an end. For Kendler, he was a task force member of DSM IV and a member of the psychotic disorder working group, the group in which one hundred percent of its membership were in receipt of monies from the pharmaceutical industry. He also was part of the DSM 5 mood disorder working group 2007-2010. His views on the DSM are sympathetic at the very least, even whilst paying lip service to their imperfection. The cited 2007 article speaks of a need to revise the DSM for sure, though posterity has shown this revision to the DSM 5 be modest, to capture more people under diagnostic umbrellas than in earlier editions, and the DSM has continued to underwrite psychiatric diagnoses as bona fide medical illnesses. The article takes us on a journey not of consensus to social constructs but of many ways in which psychiatric classification may be considered. The authors do this by comparing 6 sets of dipoles as dimensions of categorization. (Causalism vs descriptivism, Essentialism vs nominalism, Objectivism vs evaluativism, Internalism vs externalism, Entities vs Agents and Categories vs Continua). Nonetheless at the end of the day and of the article the use of the word “construct” is endorsed as being synonymous with that of a scientific hypothesis that can be empirically tested within a scientific framework. The authors make no statement as to their diagnoses being a consensus held (presumably by a powerful interest group) and thus a “social” construct.
Returning to the RANZCP guidelines and the quoted text above; we need be clear that social constructivism is essentially antithetical to metaphysical naturalism. Water as being two parts hydrogen to one part oxygen is not socially constructed. It is a fact of the world, as is its boiling point at a given pressure. As is the location of brain in the skull and not the chest and the fact that it contains certain component parts that if ablated will result in blindness etcetera. The list of these natural facts are endless. They are not established by opinion of an individual or a consensus group or contingent in any way on the same. Compare this with social construction in the ordinary language use of the term. Though both made art and placed paint upon the canvas, the distinction between the baroque and rococo periods is a matter of social construction, as are endless lists of human belief and behaviour in fashions and politics. A bone is either broken or it is not. The sport played in which the bone was broken is a social construction, as is its rules. Whether unhappiness is to be seen as part of the human condition, a challenge to change one’s life or to be medicalised as if it were disease (though it is not), this too is a social construction.
Now the psychiatric guilds wish to have their cake and eat it too. They are forced to acknowledge that they can no longer claim all psychiatric diagnoses to be naturalistic medical facts of the world of a broken body or brain. The evidence simply is not there. Yet they hold onto pretences to scientific legitimacy and an appeal to the status quo whilst holding out a faith that “the optimal classification” would involve greater knowledge of the “pathophysiology” i.e. they are nailing their colours to the wall that mood and its disorders are naturalistic phenomena whose pathological mechanism is yet to be discovered, whilst acknowledging it isn’t at this time. The acting “as if” to a pragmatist is all that matters, as we have discussed above. Why? Because to act “as if” if directed to a given end of prosperity to the guild is the end of the journey to truth. The rest is just persuasion and propaganda, again to a desired end. It’s pragmatism through and through, where pragmatism is what one does when one has abandoned all principles. Pragmatism is the philosophy of choice for the merchant. It is a trading of the staff of Aesculapius for the caduceus of Hermes.
Perhaps I could make my point clearer by an analogy with religion. Imagine that some grand ecumenical council were to convene and issue the following edict;
“There is growing consensus that our faith in anything transcendent is akin to social constructivism and by extension God or Gods probably don’t exist as such. It is nonetheless appropriate for the way of life of humankind to continue practicing, living in hope and dying for faiths following the status quo mix of religious doctrines because, (i) there is broad agreement about the operational notion of the God or Gods as defined, and (ii) religious ways of life have accrued valuable meaning through sacraments and observed “miracles” (e.g. prayer, fasting, confession, healings and resurrections etc) and social processes (e.g. churches, monasteries, martyrdom, faith based wars, charities, alliances of church and state, orphanages etcetera). Using the notion of God or Gods or anything supernatural as a pragmatic organising construct should not be reified and translate into their genuine faith or belief in them as existing beyond their identity as akin to a social construct – the optimal determination of theological truth must await a quantum leap in our understanding, a miracle never before experienced”.
Surely we would be aghast to read such a thing and question the seriousness, logical and moral coherence of those who would say such nonsense.