Descriptions and Prescriptions
is a sophisticated exploration of the various evaluative decisions that could
reasonably influence the development of the diagnostic manual used by
psychiatrists, psychologists, social workers, and allied mental health
professionals in the United States. 
Also explored are the different values that are expressed in the manual
itself. The book’s purpose is to
encourage a thoroughly rigorous attempt to create the best diagnostic manual
possible. As John Sadler suggests in
his introductory chapter, rigor involves more than collecting data.

It has become a truism among
philosophers of science that the thinkers of the Enlightenment period were
mistaken in advocating a radical distinction between facts and values. It is not that we invent facts; rather there
are too many facts available to us. We
therefore need some guidelines for deciding which facts to study, and how to
interpret them. These guidelines involve assumptions about what count as good
data, what count as good explanations, and what count as good solutions to
problems. The inevitable use of the
word ‘good’ means that evaluations cannot be isolated from the scientific
process.

In addition to scientific values,
the very concept of psychiatric disorder is inherently evaluative – it
depends on what philosophers call normative assumptions. Normative assumptions include notions of
what is normal or what ought to be, for example, to assert that something has
gone wrong with a person who hears a voice in her head that is making a running
commentary on her behavior, we need to have some notion of what she ‘should’ or
‘ought’ to be like instead.

Let me note that the book is not
titled “Descriptions or Prescriptions?” 
As Christian Perring points out in his chapter, the debate about values
has been decided in favor of thinkers such as Bill Fulford, who have taken the
lead in arguing that the notion of mental illness/mental disorder cannot be
value-free. For the most part, this
book doesn’t involve debates about whether the disorders listed in psychiatric
manuals are descriptions of actual conditions or lists of behaviors that have
been evaluated to be socially undesirable. 
The authors in this volume differ in emphasis with respect to how much
description is desirable and how much prescription is acceptable, but they
generally agree that understanding psychiatric disorders requires both
description and prescription.

When the American Psychiatric
Association revolutionized diagnostic practice in 1980 with the publication of
the DSM-III, it did so by providing a concrete and systematic description of
each psychiatric disorder. This
revolution evolved into a search for the most reliable criteria for identifying
these disorders, and is currently focused on an evaluation of the evidence for
the scientific legitimacy of each disorder. 
Sadler refers to this as descriptive rigor. What has been lacking, however, is an
equally systematic analysis of all the evaluative decisions that are made in
defining disorders. The inclusion of evaluative
rigor would clearly make the process of revising diagnostic manuals more
thorough than it has been in the past. 
Exploring what could be called the Sadler-Agich notion of evaluative
rigor is the putative justification for this collection of papers.

Their concurrence regarding the
presence of values in diagnostic practice does not mean that the contributors
to this volume constitute a happy family who all agree about basic issues –
they don’t. They agree that it is important to develop the best manual
possible, and they all want to make a contribution toward that end, but there
are significant disputes about fundamentals.

One group of thinkers concedes that
values play a role in the construction of diagnostic manuals and are part of
the meaning of ‘disorder,’ but they also believe that the goal of psychiatry
should be to maximize the scientific attributes of the manual. They tend to see values as potentially
corrupting influences. This group
includes those who were among the architects of the DSM-IV – Thomas Widiger and
Harold Pincus & Laurie McQueen.

Any reader inclined to view the DSM
architects as unreconstructed positivists or scientistic thinkers of a
narrow-minded bent is advised to read their chapters. Those pejorative
descriptions are exaggerations. The DSM architects are (generally) a pretty
sophisticated bunch, and are well-aware of the complexities involved in
constructing and using manuals. I’m
convinced they have a more elaborate understanding of classificatory pragmatics
than many users of the manual.

The issue of whether or not values
constitute corrupting influences that should be minimized even if they can’t be
eliminated is a contentious one. 
Another apparent member of the ‘science maximization’ group is Lee Anna
Clark. What is especially interesting
about her contribution is that she makes it clear that ‘science maximization’
is how she was trained to think – it is what her profession brings to the
table. That profession is clinical
psychology, and more specifically, the clinical-scientist tradition (as opposed
to scientist-practitioner). Trained to
be scientific researchers first and foremost, clinical scientists learn to
identify when questions can be answered empirically, and gain the skills to
develop and run studies that will answer those questions. As George Agich might say, because that is
what they are trained to do, that is what they are likely to value in the
DSM. Clark’s point is also a good one;
when there is empirical information relevant to answering questions such as
‘what counts as extreme,’ we should seek it out.

 
Also important to the ‘science maximization’ proponents, especially
Widiger, are some non-empirical assumptions, specifically, that psychiatrists
and psychologists are supposed to be finding out what psychiatric disorders
really are, that progress is equated with being ‘more true’, and that discovering
the truth is what scientific research does.

 With respect to these philosophical assumptions, a second group of
thinkers represented in this volume are inclined to be querulous. They reject the contamination metaphor when
discussing values and believe that evaluations guide the process of knowledge
generation. They are more comfortable
defining progress in terms of improvement. Whatever else they might be,
categories such as schizophrenia and depression are instruments that
psychiatrists and psychologists use to help their patients. Certain members of this group also
understand truth as a species of the good, i.e., an evaluative term. The true is the name of whatever proves
itself to be good in the way of belief as William James famously defined it. Included in this collection are
philosophers who specialize in psychiatric issues and mental health
professionals who are philosophically minded (and trained). Among them are John Sadler, George Agich,
Bill Fulford, Jennifer Radden, Christian Perring, Michael Schwartz and Osborne
Wiggins – all luminaries in the field. 
Although I’m lumping them together, the chapters written by members of
this second group are diverse, detailed, and incisive. They compromise the core of the book.

Another prominent presence, and one
who is harder to classify, is Jerome Wakefield. He is a quintessential description and prescription proponent,
claiming as he does that any legitimate disorder has to be an objective
dysfunction that is evaluated by society or an individual as causing harm. His harmful dysfunction model of mental
disorder considers the value-neutral view and the value-only view to be
fallacies, which he names the essentialist and normativist fallacies, respectively. Wakefield, however, is not an instrumentalist. He believes that we can correctly specify
what we mean by mental disorder, and we have a moral obligation to not confuse
a true mental disorder with a merely harmful condition. He also doggedly maintains that
‘dysfunction’ is value neutral. The
harmful dysfunction model neatly accepts some of Thomas Szasz’s claims about
the evaluative elements in attribution of mental illness without accepting the
claim that mental illness is ill a myth. Wakefield’s chapter highlights the
importance of making these distinctions with respect to disorders of childhood
and adolescence.

There is also a conscious and
pervasive radical edge to the book, and it makes for some of the more eye
opening chapters. A fundamental insight
driving the radical analyses is expressed by Schwartz and Wiggins, who argue
that it is the idea of Science or the promise of scientific knowledge that has
afforded the DSM-III, III-R, IV (and IV-TR) so much influence. Applications of scientific thinking have
taught us that the earth is round, that it revolves around the sun, and that
life on this planet has changed systematically for millions of years. They have brought us more food, more warmth,
more knowledge, more entertainment, better health and longer life. The conceptualizing of scientific knowledge
as a valuable resource that needs to be supported is firmly entrenched in
Western culture, and that cultural value inevitably drives the attempt to
create better diagnostic manuals.

So what’s the problem? The problem is something that has been
recognized on a small scale by social psychologists and on a larger scale by
social-political philosophers, particularly post-structuralists (or
post-modernists) and critial social theorists. 
Our notion of science, what science does, and how it works is a popular
cultural story. It includes mini-stories such as Galileo’s house arrest, the
Scopes monkey trial, and the discovery of penicillin. The larger meta-narrative expresses group values. We tend to conform to and understand the
world in terms of the grander narrative, but no narrative can tell the whole
story. Even the mini-narratives such as
what happened to Galileo are simplified and interpreted evaluatively. The parts
of the story not told, the facts left out, and the experiences not acknowledged,
are marginalized.

The DSM is an official story about
psychiatric disorders. It is a story about how American psychiatry became
scientific without abandoning its clinical roots. Subplots within the bigger story are found in the different
sections of the manual and in all of their background assumptions. This includes the technical details, for
example, the reasons for implementing the positive versus negative symptom
distinction in schizophrenia comprise a story. 
As stated, the DSM also carries a stamp of legitimacy; its users
therefore tend to see both psychopathology and problems-in-living through its
lenses. Some of ways in which this
happens is described in a chapter by Berrenkotter and Ravotas.

Any psychiatrist or psychologist
willing to step outside their professional role and look beyond the
conventional goods they pursue, defined in terms of their profession’s goals,
would find it informative to adopt the viewpoint of the social critic. Once they do this, there are various
attitudes they can take toward the problem of grand narratives and totalizing
discourse. The attitude most people are familiar with is what Ian Hacking has
called the revolutionary attitude – often seen in postmodernist critiques. The revolutionary attitude holds that the
grand narrative is a harmful force that must be overthrown. That attitude is barely evident in this
book.

More evident is what Hacking has
termed a reformist attitude. The reformist attitude views grand narratives as
partly resulting from what social psychologists call group think. Reformists reject the charge that the ruling
narratives are simply the creation of villains at the top of the social
hierarchy who are cynically manipulating the discourse for their own personal
interests; rather, they claim that these narratives are historical products,
created and recreated by the group. 
John Sadler refers to it as the politics of concordance. The reformers seek to moderate the negative
consequences of this massive kind of group think.

Two noteworthy chapters reflecting
the radical approach are contributed by the physician James Phillips and the
philosopher Allyson Skene. Phillips
critiques a set of assumptions about what counts as a good scientific explanation,
especially assumptions that are associated with an evaluative preference for
technological reason. To my mind this
echoes Horkheimer and Adorno, but he obviously got it from Gadamer. The basic idea is that the technological
model of rationality leads us to expect that good explanations are mindless and
algorithmic, and once you really understand any natural phenomenon, you should
be able to devise a set of rules or formulae which – when correctly applied –
will solve the problem. He argues that
even though some of the DSM architects are aware of this affront to complex
problem solving, the operationalized polythetic criteria model encourages it.

Allyson Skene suggests that the
Agich and Fulford attempt to conceptualize psychiatric disorders as both
descriptions and prescriptions fails to provide a legitimate alternative to the
prescription-laden view of the anti-psychiatry movement. Actually, Szasz must feel he has won the day
with respect to characterizing our talk about schizophrenia because most noticeable
complaints about him from psychiatrists and psychologists emphasize what an immoral
and irresponsible theory he has proposed. Christian Perring’s and Skene’s chapters both imply that
questioning Szasz’s rugged libertarian politics would be a more effective
argument strategy with respect to disputing the issues he values. Skene shows that, in contrast to the
anti-psychiatrists, Foucault offers a more refined articulation of strong
normativism in which negatively valued conditions can be said to exist, and
cannot be reduced to creations of powerful forces that want them repressed.

A crucial section of the book
provides a voice to non-specialists – those who are not professionally engaged
in studying the philosophical aspects of psychiatric classification. These will
be the easiest chapters for most readers to understand, but they will also have
the most bite for those who already worked through the philosophical arguments
in the previous sections of the book. A
chapter by Cathy Leak makes several interesting points, one of which is that rather
than using case studies to illustrate and conform to DSM diagnosis, case
studies would be more valuable if they challenged the diagnosis and showed us
aspects of the person to which the diagnosis is blind.

Speaking on behalf of the National
Alliance for the Mentally Ill is neuroscientist Laura Lee Hall. If anyone understands the political and
evaluative consequences of psychiatric diagnostic manuals it is those who have
had a family member diagnosed with a major mental illness. Hall argues that the manual mistakenly
avoids making distinctions between major mental illness and other more
‘neurotic’ conditions. The reason this
is a mistake is that when they are all lumped together as ‘mental disorders’ it
makes it easier for legislators and lobbyist rich insurance companies to not
treat major mental illness as seriously as they should.

The attorney Daniel Shuman, an
expert on using psychology in the courtroom, contributes an argument that
should give proponents of the Sadler-Agich call for evaluative rigor some
pause. Shuman claims that it would be
better with respect to forensic applications if the DSM emphasized its
scientific attributes and not the value elements. This is because the courts historically have a tendency to accept
professional clinical opinion as fact – but this practice has been attenuated
in recent years due to the standards articulated in the Daubert
decision. Daubert asks the
courts to consider the quality of the reasoning underlying scientific
expertise, with quality including publication in peer-reviewed journals and
falsifiable propositions. If the DSM
architects were to make the value dimensions more explicit, the public may come
to see it as a manual of opinion and partisan agenda, and Daubert could
be undermined. If psychiatrists and
psychologists were to be philosophically honest regarding the complex nature of
psychiatric disorders, their scientific credentials would be put at a forensic
disadvantage. I suspect that this disadvantage
would be accentuated should psychiatric expertise ever be compared to the
expertise of the social, biological, and physical sciences, and to the law
itself which will still wrap themselves in a flag of common sense objectivity
and value neutral-knowledge. Makes you
think.

There are 21 chapters; each quite
good. Nor could I fit them all into the
plan I adopted for summarizing the book. For example, Chris Mace writes a
chapter for philosophers of science, suggesting that Thomas Kuhn’s and Karl
Popper’s theories have become the new received view. He reminds us that there are alternative models that might
usefully be applied to our understanding of the process of nosological
revision, specifically Stephen Toulmin’s concept-based and evolutionary model
of scientific progress. It’s an excellent
point.

Philosopher of science Patricia
Ross proposes an objectivity maximization view, but one that views objectivity
as a community project rather than the result of an individual correctly
applying the appropriate method. She doubts that the process of revising the
DSM could be organized as the kind of social process that leads to objective
knowledge, but makes some suggestions for organizing the DSM work groups that
could increase intersubjective agreement as opposed to the kind of grudging
consensus that has been settled for in the past.

One of my favorite thinkers, Irving
Gottesman, writes about the role that genetic information should occupy in the
diagnostic manuals of the future. He
proposes adding an Axis VI for coding genetic markers. Acknowledging that this would be valuable
scientifically and diagnostically, and also – socially harmful, he suggests
that the information on Axis VI be encrypted. 
It should be made available only to those who would use it for good
(professionals), and not to those who would use it for ill (employers and
insurance companies). Thought-provoking
point, but I don’t think we can assume that all mental health professionals
will be benign and liberally-minded.

In my graduate classes I use a
Gottesman & Meehl-like theory regarding the genetics of schizophrenia as a
model for psychiatric disorders in general. 
In his chapter Gottesman reviews the genetics of Alzheimer’s disease,
and it follows a chapter in which Kenneth Schaffner suggests that Alzheimer’s
disease be used as a model for understanding psychiatric disorders in
general. Schaffner concretizes another
theme running throughout the book, the notion that the atheoretical descriptive
diagnosis and non-etiological model used in the current DSM is scientifically
implausible. He proposes a general theory of causation that would be consistent
with psychiatry’s traditional acceptance of multiple levels of analysis –
biological, psychological, behavioral, interpersonal, and cultural. As
Schaffner and Gottesman suggest with respect to genetics and Jennifer Radden
suggests with respect to the concept of ‘incapability’ itself, if we have good
reasons for conceptualizing a particular condition in causal terms, we should
be able to implement those models and those data into the manual.

I claimed earlier that the putative
justification for this volume was the Sadler-Agich call to expose evaluative
decisions to more systematic and explicit study. I used ‘putative’ because there is another, deeper, justification
for this book – specifically, the question of how much and what kind of
authority should scientific knowledge have with respect to understanding and
explaining the world. This is not a
simple question, and in the form of the ‘culture wars’ and the ‘clash of
civilizations,’ it may be a question that dominates the early 21^st
century intellectual landscape.

It is less daunting to address the
question if it is focused, for example, ‘what authority does scientific
knowledge have with respect to the development and use of psychiatric
diagnostic manuals?’ It depends, of
course, on what counts as ‘scientific.’ 
To sidestep that debate for a moment, we can say that in American
psychiatry, ‘scientific’ currently refers to an experiment-oriented medical
model approach, increasingly biomedical, augmented by the psychometric
tradition in scientific psychology with its emphasis on reliability, validity
and operationalized constructs, and evaluated whenever possible using
statistical methods and research designs developed in epidemiology. Now the question becomes how much and what
kind of authority should we give THAT?  

Most people’s answer about how to
balance description and prescription will probably have parallels to their
answers about the nature and limits of scientific authority, but not
necessarily. John Sadler would grant
authority to a process, the inclusive process of a rigorous democracy – one
that is reluctant to make compromises with respect to the values of openness,
accountability, sensitivity to diversity, and encouragement of
participation. If what some people
identify as scientific knowledge emerges from that process in a privileged
position, so be it, but he does not want to grant it a priori
authority.

The question regarding the
authority of science has implications extending far beyond psychiatric
classification and the philosophy of psychiatry. I only vaguely know what my answer to the authority question is,
and these chapters have encouraged me to think about that problem more
deeply.

In conclusion, this is an excellent
book. It has been thoughtfully edited,
and is best read in order from beginning to end. Some edited books are hodgepodge collections and others are more
integrated – this one is remarkably integrated. There is an experience of complexity, nuance, and an unresolvable
yet undeniably rich confrontation of perspectives that emerges by reading the
chapters in order. Those with less
training in philosophical evaluation are going to struggle with being presented
so much abstract and multifaceted information, but Descriptions and
Prescriptions has the comprehensiveness that only interdisciplinary
cooperation can bring – a Fulford & Sadler hallmark. Anyone who believes that developing the best
diagnostic manual possible is an important and complicated task, and also wants
to contribute to the process in a scholarly and reflective way, is well-advised
to study these chapters.

 

©
2003 Peter Zachar

 

Peter Zachar, Ph.D. is
an associate professor of psychology at Auburn University Montgomery. He is a licensed psychologist with
additional specializations in psychological measurement, the philosophy of
science, and the philosophy of psychiatry. 
He is the author of Psychological
Concepts and Biological Psychiatry: A Philosophical Analysis.

Categories: Philosophical, Ethics, MentalHealth