composer George Gershwin went to seek help for severe headaches. He ended up at the office of a psychoanalyst, who assumed he had a “neurotic” disorder and put Gershwin into deep therapy. The therapy lasted for two years. On July 11, 1937, Gershwin died of a brain tumor.
No one knows if Gershwin would have lived had someone reached the correct diagnosis — even today malignant brain tumors are untreatable — but surely he would have been spared considerable guilt, anxiety, discomfort, and the psychological pain had the tumor been diagnosed. Think of the precious time he wasted being treated for the wrong thing.
Diagnosis also has more direct social consequences. It permits some people to get paid. Therapists and physicians get paid for treating those who are ill. It removes guilt and it overemphasizes the pathology in normal behavior. Not all of these things are bad, but to decide what ones might be, we should inspect the processes that have led up to and maintain diagnosis in mental health treatment.
Diagnosis is the process of applying labels to describe people’s problems. Medical doctors do it — you have appendicitis, ulcers, heart disease, or cancer. Dentists do it — you have periodontal disease, cavities, an abscessed tooth. Psychotherapists do it too — you are paranoid, bipolar or manic-depressive, depressed, schizophrenic.
Did you notice a difference in the phrasing?
In medicine, people have conditions. In mental health, people are their conditions. They are depressed, schizophrenic, bipolar, anxious. This is not a simple matter of differences in terminology. It represents how our society — and particularly how mental health practitioners — thinks of people with emotional and behavioral problems. It is part of the social construction of mental diseases. By way of these differences in phrasing, people may lose their individual identities, at least partially, when labels are applied so decisively to them.
To understand this point, remember that one difference between medical diagnoses and those in mental health is that the latter are largely social constructs, rather than diseases of the body. Albeit that some conditions are heavily influenced by biological factors, for example, schizophrenia and manic-depressive illness, all diagnostic categories in the field of mental health rely on social behavior-they are in effect reflections of social judgments that are placed on behaviors that we find discomforting and disturbing.
Mental health diagnoses are not accurate and direct reflections of physical conditions, even when they include physical conditions. If you have a virus, you have an alien creature inside your body doing vile things. Not so in mental health. What is more important, identifying what is and is not included as a mental “disorder” serves certain social and political ends. Social values determine what behavior is acceptable and what behavior is not, and unacceptable behavior can be called a disorder. The types of behaviors identified as “disordered” change as the values of society change. In medicine, an ulcer is an ulcer, even though the means of diagnosing and treating it may change. In mental health, different disorders come and go, the frequency of their being assigned waxes and wanes, and even the symptoms change from time to time, all by cultural, sociological, and political processes. A few decades ago, psychiatrists classified homosexuality as a mental disorder; however, pressure from gay and lesbian political coalitions forced the American Psychiatric Association ( APA) to reassess its approach to homosexuality, and now it has been largely removed from the official list of disorders and diseases. Whether a behavior is a mental disorder or just a variation of normal behavior arises from these kinds of social valuing processes.
These values, at least as much as any gains we may make in our knowledge about behaviors, determine how we will think about emotional disorders, what symptoms will be defined as “illnesses,” and who gets the responsibility for correcting the problems defined.
The Social Construction of Mental Illnesses
The U.S. Bureau of the Census first classified disordered behavior. In 1840, census workers identified individuals with disturbing behavior and classified them as either “idiots” (that was the scientific term at the time, implying that these individuals lacked intellectual abilities) or “insane,” implying that they engaged in socially unacceptable and unusual behavior.
From the outset, these diagnoses served clear political and social purposes: to maintain records, to track problems in society, to allow or prevent the use of certain resources. Few people then believed in the concept of mental or emotional illness, and doctors assigned little value to these labels for medical purposes. At some point, diagnoses became reified — they became treated as if they were true or real entities instead of abstract constructs — in the minds of clinicians and the public. In 1952, the American Psychiatric Association published the first systematic and uniform list of “diseases of the mind” and their associated behaviors, called the Diagnostic and Statistical Manual, DSM for short.
From the beginning, both the identity of the illnesses included in the official DSM and their symptoms were defined by vote. That might strike you as a very democratic way of defining illnesses, except that only those who made the diagnoses, treated the conditions, and otherwise financially benefited by having a large number of individuals qualifying for their services did the voting. There was little effort to ensure, through the solicitation of independent evidence, that these behaviors arose from true diseases. A strong belief by the membership was sufficient for distinguishing between what was a problem of morality and what was a problem of illness. As a result, the nature of mental illness has always reflected the changes in moral temperament and values of the time.
When, in 1979, the third edition of the Diagnostic and Statistical Manual (DSM-III) removed homosexuality as a “disease,” the behaviors had not changed, only the social acceptance, significance, and value given to them by society and political forces.
Between the mid- 1960s and the 1990s, societal acceptance grew for explaining behaviors as a product of their ” psychological roots.
Over this period, an increasingly large variety of behaviors, previously attributed to lack of self-control or lack of morals, became identified as “psychological illnesses.” As the view that social ills were at the root of these “illnesses of the mind” grew, the legal sanctions and prerogatives of diagnosing and treating these illnesses were extended beyond the medically trained to those who held degrees in social work, sociology, religion, and psychology. Expanding the workforce was probably necessary since the number of behaviors being identified as “illnesses” was exploding. The number of professionals expanded as the number of disorders that needed treating grew — probably not a coincidence.
Of course, the fact that insurance carriers promised to pay for the treatment of those who met the criteria of mental illness established by the American Psychiatric Association may have had something to do with the process of including more and more behaviors under the umbrella of “illness.” Between 1952 and 1968, the number of accepted “diseases of the mind” grew from 66 to 111, but by 1994, when the most recent DSM-IV was published, the number of disorders recognized by the association was up to 397. Through forty years and four editions, the number of disorders had increased exponentially as finer distinctions were made among symptoms, and as more mental health practitioners came to identify certain classes and groups of behaviors as being in need of correction.
In the short time between the publication of the DSM-IIIR in 1987 and DSM-IV in 1994, either the labels or the criteria used to identify over 120 disorders were changed; thirteen disorders were added; and eight other conditions were eliminated. Such one-time popular concepts, like “neurosis,” a term we have all heard, was deleted and later reinvented with a different set of accompanying symptoms. Other categories were first introduced and then voted out of existence because it was felt that they were sexist. While it may be possible that these changes really reflect a solid change in the scientific bases of knowledge, it appears more likely that they indicate efforts to adapt to a society whose values change. We doubt that cancer or heart disease could be voted in and out of existence because they were sexist or unfavorable or lacking in political sensitivity. If they were voted out of existence, would they cease to exist and to kill people? We think that such evidence clearly demonstrates that mental health diagnoses are subject to sometimes powerful political influences and are, therefore, also subject to abuse by those forces.
A society that would rather identify disharmonious behaviors as illnesses, addictions, and disorders than problems of morality, discipline, self-knowledge, or criminality may have had something to do with the process. Perhaps the medicalization of deviant behavior is endemic to a political system that has exhausted the usual methods of control and seeks desperately to find some way of controlling unacceptable and disturbing behaviors. Treating “sick” or “addicted” individuals is preferable to acknowledging that deviant individuals may voluntarily choose socially destructive and immoral behavior. That would require that we accept the failures and weaknesses of an open, democratic society.
Applying the democratic process to the election and cure of disease seems to be a reasonable and politically sustaining tactic. When one of the top forensic experts on multiple personality, Margaret Singer of the University of California at Berkeley, was asked to comment on the specifics and origins of another colleague’s diagnosis of Ken Bianchi, the Hillside Strangler, Singer startled the PBS interviewer. She said we don’t really know what creates such monstershe may simply be evil.
How much more acceptable it is to call someone like this ill, or to say he is schizophrenic or paranoid. We contend that the more scientifically sounding terms applied to diagnosis offer little or no more information than the philosophical term “evil.” We maintain that the diagnostic terms, however, partly protect society from a sense of helplessness that terms like evil convey. Were such behaviors less medical, we’d have to confront the nature of a family and society that fosters such behavior and, maybe, even deal with the serious questions of the existence and teleology of evil. With medical terms, even though they explain little, we then have a reason to implement strong institutional controls such as the use of drugs and hospitalization.
The Medicalization of Deviant Behavior
Our discussion of DSM shows us clearly that the categories of deviant behavior voted on from time to time reflect social and political conventions. Depending on the disorder, the sociopolitical role played by diagnoses is either great or small, but the application of a diagnosis is always, to a greater or lesser degree, embracing political and social values.
Diagnostic labels define what limits of difference society can tolerate. Whenever a culture decides that it will define a set of behaviors as “sick” rather than “immoral” or unwitting, it is enacting a social value that favors illness over the view that such destructive or unusual behavior is volitional. Armed with this view of behavior as illness, we can justify forced hospitalization, prison, or “protective care.”
Consider, however, that unlike medical diagnoses, most mental and behavioral diagnoses cannot be defined separately from their behaviors. Regardless of whatever may be happening in one’s chemistry or physiology, if behavior is not disordered, there is no condition. With few exceptions, the diagnosis is only a restatement of the symptoms, not a determination of their cause. Unlike physical medicine where a diagnosis such as hypertension can still be asymptomatic, there is no mental health condition that can exist without symptoms. You can’t be depressed or have a major depression without some of the following behavioral symptoms:
â€¢ Loss of social interest such as decreasing social activities
â€¢ Change of appetite
â€¢ Change in sexual interest
â€¢ Altered sleep patterns
â€¢ Slowing of mental processes
â€¢ Feelings of worthlessness and helplessness
The same holds true for all other mental health or psychiatric diagnoses. They cannot and do not exist apart from their manifestations in a person’s complaints or behaviors.
In medicine, the condition is not dependent on the symptom. The symptom only assists in making the diagnosis; it doesn’t determine it. You may have no gastric distress or other manifest symptoms, but still have an ulcer. Many people, unfortunately, have cancer long before they have symptoms. But we define mental illnesses by subjective reports and overt behaviors. By definition, the symptoms must be present.
The identification of psychiatric disorders always involves a social judgment and often implies a political agenda as well. The definition that behavior constitutes a “problem” for clinical purposes hinges both on what society desires — a social judgment — and what is disruptive of the political order and values — the political agenda. It is less concerned with what is true than with what values it supports and maintains. Research, though also influenced by political forces, is less driven by them than are clinical judgments. Because research methods are less culture specific and are, by their nature, open to replication, the findings may be more likely to be reasonably objective and free from politics. But research needs funding, and political forces and our culture influence such funding decisions.