Thursday, February 7, 2013

The recent revisions to the DSM's definition of depression are based on a questionable conception of what is "normal." Why is that dangerous?

Opinionator | The Stone: Depression and the Limits of Psychiatry


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February 6, 2013, 3:45 pm

Depression and the Limits of Psychiatry

I've recently been following the controversies about revisions to the psychiatric definition of depression. I've also been teaching a graduate seminar on Michel Foucault, beginning with a reading of his "History of Madness." This massive volume tries to discover the origins of modern psychiatric practice and raises questions about its meaning and validity. The debate over depression is an excellent test case for Foucault's critique.
At the center of that critique is Foucault's claim that modern psychiatry, while purporting to be grounded in scientific truths, is primarily a system of moral judgments. "What we call psychiatric practice," he says, "is a certain moral tactic . . . covered over by the myths of positivism." Indeed, what psychiatry presents as the "liberation of the mad" (from mental illness) is in fact a "gigantic moral imprisonment."
Foucault may well be letting his rhetoric outstrip the truth, but his essential point requires serious consideration. Psychiatric practice does seem to be based on implicit moral assumptions in addition to explicit empirical considerations, and efforts to treat mental illness can be society's way of controlling what it views as immoral (or otherwise undesirable) behavior. Not long ago, homosexuals and women who rejected their stereotypical roles were judged "mentally ill," and there's no guarantee that even today psychiatry is free of similarly dubious judgments. Much later, in a more subdued tone, Foucault said that the point of his social critiques was "not that everything is bad but that everything is dangerous." We can best take his critique of psychiatry in this moderated sense.
Current psychiatric practice is guided by the "Diagnostic and Statistical Manual of Mental Disorders" (DSM). Its new 5th edition makes controversial revisions in the definition of depression, eliminating a long-standing "bereavement exception" in the guidelines for diagnosing a "major depressive disorder." People grieving after the deaths of loved ones may exhibit the same sorts of symptoms (sadness, sleeplessness and loss of interest in daily activities among them) that characterize major depression. For many years, the DSM specified that, since grieving is a normal response to bereavement, such symptoms are not an adequate basis for diagnosing major depression. The new edition removes this exemption.
Disputes over the bereavement exemption center on the significance of "normal." Although the term sometimes signifies merely what is usual or average, in discussions of mental illness it most often has normative force. Proponents of the exemption need not claim that depressive symptoms are usual in the bereaved, merely that they are appropriate (fitting).
Opponents of the exemption have appealed to empirical studies that compare cases of normal bereavement to cases of major depression. They offer evidence that normal bereavement and major depression can present substantially the same symptoms, and conclude that there is no basis for treating them differently. But this logic is faulty. Even if the symptoms are exactly the same, proponents of the exemption can still argue that they are appropriate for someone mourning a loved one but not otherwise. The suffering may be the same, but suffering from the death of a loved one may still have a value that suffering from other causes does not. No amount of empirical information about the nature and degree of suffering can, by itself, tell us whether someone ought to endure it.
Foucault is, then, right: psychiatric practice makes essential use of moral (and other evaluative) judgments. Why is this dangerous? Because, first of all, psychiatrists as such have no special knowledge about how people should live. They can, from their clinical experience, give us crucial information about the likely psychological consequences of living in various ways (for sexual pleasure, for one's children, for a political cause). But they have no special insight into what sorts of consequences make for a good human life. It is, therefore, dangerous to make them privileged judges of what syndromes should be labeled "mental illnesses."
This is especially so because, like most professionals, psychiatrists are more than ready to think that just about everyone needs their services. (As the psychologist Abraham Maslow said, "If all you have is a hammer, everything looks like a nail"). Another factor is the pressure the pharmaceutical industry puts on psychiatrists to expand the use of psychotropic drugs. The result has been the often criticized "medicalization" of what had previously been accepted as normal behavior-for example, shyness, little boys unable to sit still in school, and milder forms of anxiety.
Of course, for a good number of mental conditions there is almost universal agreement that they are humanly devastating and should receive psychiatric treatment. For these, psychiatrists are good guides to the best methods of diagnosis and treatment. But when there is significant ethical disagreement about treating a given condition, psychiatrists, who are trained as physicians, may often have a purely medical viewpoint that is not especially suited to judging moral issues.
For cases like the bereavement exclusion, the DSM should give equal weight to the judgments of those who understand the medical view but who also have a broader perspective. For example, humanistic psychology (in the tradition of Maslow, Carl Rogers, and Rollo May) would view bereavement not so much a set of symptoms as a way of living in the world, with its meaning varying for different personalities and social contexts. Specialists in medical ethics would complement the heavily empirical focus of psychiatry with the explicitly normative concerns of rigorously developed ethical systems such as utilitarianism, Kantianism and virtue ethics.
Another important part of the mix should come from a new but rapidly developing field, philosophy of psychiatry, which analyzes the concepts and methodologies of psychiatric practice. Philosophers of psychiatry have raised fundamental objections to the DSM's assumption that a diagnosis can be made solely from clinical descriptions of symptoms, with little or no attention to the underlying causes of the symptoms. Given these objections, dropping the bereavement exception-a rare appeal to the cause of symptoms-is especially problematic.
Finally, we should include those who have experienced severe bereavement, as well as relatives and friends who have lived with their pain. In particular, those who suffer (or have suffered) from bereavement offer an essential first-person perspective. As Foucault might have said, the psyche is too important to be left to the psychiatrists.
Gary Gutting is a professor of philosophy at the University of Notre Dame, and an editor of Notre Dame Philosophical Reviews. He is the author, most recently, of "Thinking the Impossible: French Philosophy since 1960," and writes regularly for The Stone. He was recently interviewed in 3am magazine.