Finding Jesus in the Storm. John Swinton
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 the ways psychiatrists (and others) see and describe the person before them. Once you accept the 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