When you go round in circles…. The search for psychiatric sense

I once knew a lady who was cured twice in one week from bipolar disorder.  She had been diagnosed for about 15 years.  She went into a hospital that had a psychiatrist there who really didn’t much believe in bipolar.   After talking to her for about 30 minutes he told her not to worry she was not bipolar.  She was discharged a couple days later and went to see her regular psychiatrist who thought a lot of people were bipolar and just didn’t know it.   Her told her not to worry.   She was still bipolar. By the end of the week she was back in crisis and back in the hospital.   When the hospital psychiatrist saw her he said, “I am so sorry things are so hard.   At least we know you are not bipolar.   Let’s try to figure out what is really going on….” 

Back in the 1920’s social psychology fell in love with instincts.   Everything we did we did because we had an instinct to do it.   Finally someone realized that explaining anything by the name we gave it was really not an explanation.   Saying that people had an instinct to do something and that the proof they had an instinct to do it was that they did was circular reasoning and made no sense. 

In almost a hundred years we have made some progress.  We have moved from instincts to diagnoses.   We still believe what we call things explains it.   We have just found new names to call it. The proof of bipolar is that you do bipolar things and how could you do bipolar things if you did not have bipolar. 

We are in love with things and we believe anything that happens is because some-thing  made it happen.   We give a pattern a name and then believe that pattern happened because of the name we gave it.   It is called reification and in assessing other people psychiatrists would call it a cognitive distortion but it is central to the way many people make sense of psychiatric stuff.   In order to understand yourself you need to know what you “have.” This simple notion drives much of the discussion about mental health reform currently going on in this country.   Mental illness is something you “have.”   We can diagnose what you have and provide effective treatment for it.   But some people because what they have has damaged their brains can’t realize they have what they have.   For their own good we must force them to accept the treatment they need.   

This is far from a merely academic point.  

Are psychiatric diagnoses real things?  They are certainly not real like chairs or birds but are they real in any other way?  Is there a definable concrete something that results in this-thing called bipolar?   If you are nothing but a pool ball,  something whose path is caused by the impact of some real thing, have we found the cue ball?  Is the life we lead nothing but a symptom of some something we somehow “have?” 

I wonder how many psychiatrists even believe this. 

A couple of years ago Gary Greenberg wrote this about the new DSM… 

“But  if you ask any of them (and I have) about the DSM diagnoses and criteria…he or she will tell you they are only “fictive placeholders” or “useful constructs” the best the profession can do with the knowledge at hand…They are fully aware, in other words, that their opportunity to name and describe in psychiatric terms suffering far exceeds their knowledge.”

What he is saying is that the question of whether or not diagnoses are real things is not even a  real question.   Most psychiatrists know this.  They know psychiatric diagnoses are not discovered.   They are constructed. 

  A diagnosis is a way to group symptoms that is either useful or not.  At best it is a description.  It helps or it doesn’t.   All diagnoses are subtractions.   They are what you take away from a wider experience.  They are what you say matters.   Either it helps you to see clearer by focusing your attention or it leaves you blind by leaving out things that matter. 



It gets murkier.  If giving something a name makes it a real thing then everything that has the same name is the same thing.   Names give identity.   But people with the same diagnosis are often as different as they are similar.  And sometimes the differences are as important,  if not more so,  than the similarities.   There is no reason that I know to assume bipolar or schizophrenia or anything else is simply one thing other than that was what the people that vote voted for it to be.   Things that look alike are not necessarily the same thing.   People who in some way share the same characteristics are not the same people.   This is one time where keeping it simple makes it stupid. 

Psychiatrists may or may not know that diagnoses are convenient fictions.   If so they don’t share it with many other people.   It is hard to say that your special knowledge is neither special or knowledge.   It is hard to say that the thing that gives you leverage,  the thing that defines your niche,  your territory primarily exists primarily  to tell people they should listen to you,  that you have an essential expertise.   I wonder though if that is not the primary function of psychiatric diagnosis.  

There is a lot riding on acting like mental illness is something we have discovered rather than something we have constructed to try to understand very real problems.   A lot of power,  a lot of position,  a lot of money is riding on it.  A lot of common language and everyday culture is tied up in describing people as “crazy.”   

I am not saying psychiatry cannot be useful.   I have known people who found it very useful.   I am saying given what we know right now it cannot be true and that when it’s truth is accepted as an article of faith it has an incredible ability to do real harm. 

Psychiatry does not lend itself to humility.   It seems largely allergic to the notion that what it doesn’t know is as important as what it does know. 

Until it does it will for many be a scary and threatening thing.   If Rep Murphy had his way it would be an unquestionable authority and that would be the largest terror of all. 

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