Insel urged the field to leave behind the descriptive approach of the DSM and to develop a new diagnostic scheme based on solid, verifiable scientific research that focused on finding the biological roots of mental disorders.
Insel is correct to suggest that there is a need for a more rigorous and thick process of diagnosis than the DSM can provide on its own. There is an obvious weakness in a system where decisions are made and diagnoses are constructed on the basis of consensus around flexible concepts and constructions, without evidence that stretches beyond the particularities of committee votes. But is his alternative really better or even possible? As Gary Greenberg noted recently in the New Yorker: “Doctors in most medical specialties have only gotten better at sorting our suffering according to its biochemical causes … [but] psychiatrists still cannot meet this demand. A detailed understanding of the brain, with its hundred billion neurons and trillions of synapses, remains elusive, leaving psychiatry dependent on outward manifestations for its taxonomy of mental illnesses.”34 The evidence that Insel wants is, at least at the moment, simply not available. It may become available in the future, but for now, in general terms, the biological evidence for the root causes of all mental health disorders is at best speculative and at worst simply absent.35 Insel may well be correct that patients deserve better, but will a shift from describing symptoms to describing biology really produce better descriptions?
At a personal level, making such a claim without evidence must be deeply troubling for people living with mental health challenges who have been treated under the “old regime.” As Sarah Kamens has pointed out: “It’s … akin to telling patients that we made a huge mistake.”36 If the DSM has interrater reliability—that is, all psychiatrists are using the same set of criteria—but no validity (no empirical evidence to indicate the truth of a given diagnosis), then people have been diagnosed by a set of criteria that is reliable across the sector but lacking empirical verification. This leaves people living with mental disorders in a difficult situation. It is possible that their current diagnosis could be redescribed in the future, and they would have to rebuild their lives and sense of identity accordingly.
It is true that the biological quest is intended to find better treatments and to eradicate symptoms. However, what if your symptoms are meaningful for you? If the only description of your situation is that you have a mental illness that is basically the same as a physical illness with symptoms that are meaningless, then your personal experience of your mental health challenges will be discounted as irrelevant. Critical as I have been of the DSM, at least it holds open the possibility that symptoms are more than mere biological malfunctioning. Such a suggestion—that symptoms are meaningful and should be responded to as such—is counterintuitive. For now, I urge the reader to remain open to the possibility. When we look more closely at the lived experience of mental health challenges, we will see the importance of recognizing the meaningfulness of symptoms and the dangers in trying to merge them into a single biological description. Insel is right: patients deserve better. The problem is that within a universe of multiple descriptions, his solution may not be as helpful as he assumes.
The Danger of Reductive Explanation
It’s not that biological descriptions are not relevant or important. The problem is that they can easily become reductive. In his work on the nature of explanation, the sociologist Alan Garfinkel points out the reductive tendencies of explanation. When people think they have explained something, they tend to exclude other explanations, thus reducing understanding of the situation to a single explanation. “The reductionist claims that one class of phenomena, more or less well explained by some body of theory, is really explainable by some other theory, which is thought of as deeper or more basic; this, we say, reduces the apparent complexity of the world.”37 Such explanations reduce the complexity of multifaceted situations and experiences to a single explanation. Explanations become hegemonic when they insist on explaining unconventional mental health experiences without reference to other possible explanations. Garfinkel suggests that we
pay more attention to what exactly is being explained by a given explanation. Too often, theories talk as if they are addressing some problem, though they are really addressing different problems or different aspects, interpretations, or readings of the problem. For when a theory talks about a phenomenon, it inevitably does so in terms of its own representation of it. The phenomenon gets incorporated into the theory in a particular way, structured by a definite set of assumptions and presuppositions about its nature. This makes it very important that we recognize those presuppositions and discover how the theory has represented a particular object of explanation.38
For current purposes, it is important that we recognize the kinds of presuppositions that lie behind reductive biological explanations of mental health challenges and the dangers of uncritically accepting such explanations.
“Mental Illness” Is Not like Measles
Take, for example, the common strategy of equating mental illness with physical illness. One reason people are keen on this way of thinking is that it destigmatizes mental disorder. It draws it out of the messiness of society, politics, and stigmatizing views and places it on par with forms of physical illness that tend not to attract stigma. In his book Surviving Schizophrenia, the psychiatrist E. Fuller Torey explains what he thinks mental illness is (in this case, schizophrenia): “Schizophrenia is a brain disease, now definitely known to be such. It is a real scientific and biological entity as clearly as diabetes, multiple sclerosis, and cancer are scientific and biological entities. It exhibits symptoms of a brain disease, symptoms which include impairment in thinking, delusions, hallucinations, changes in emotions, and changes in behavior. And, like cancer, [it] probably has more than one cause.”39
Putting to one side the fact that the evidence for the biological roots of schizophrenia is not clear-cut,40 let’s think through how this explanation works. It claims to give us a plausible explanation of the various experiences that bring people under the description of schizophrenia. People experience symptoms because of an underlying biological condition. The primary task for mental health care is to adjust the person’s biology in ways that will bring about relief from suffering. There may be other aspects to the patient and her care, but the central focus is on biology, because that is where the problems are fundamentally located. Schizophrenia is a malignant biological process similar to cancer, over which no one has total control. Within such an explanatory framework, people’s mental health experiences are explained as the result of such things as chemical imbalances, genetic predispositions, neurological pathology, viruses, and so forth. The assertion “Mental illness is like any other medical illness” implies, as Insel suggested, that mental illness can be fully explained according to its biological basis.
Positively, as mentioned, one of the intentions of this kind of approach in general and Fuller Torrey’s approach in particular is to destigmatize mental ill health. When Fuller Torrey wrote his book in 1982, there had been a strong tradition of blaming parents (often mothers) for the formation of schizophrenia. This blaming of family and mother had caused a lot of unnecessary grief for parents.41 Recognizing this, Fuller Torrey had become a strong advocate for families. Surviving Schizophrenia was the first handbook designed specifically to help not patients but families “survive” schizophrenia.