The Dehumanizing Aspect of DSM

In January 2014, the journal Research on Social Work Practice published a special issue: A Critical Appraisal of the DSM-5: Social Work Perspectives.  There were many excellent articles in this volume, some of which I have highlighted in earlier posts.

One of the very outstanding articles is The Diagnostic and Statistical Manual of Mental Disorders as a Major Form of Dehumanization in the Modern World, by Eileen Gambrill, PhD, a graduate school Professor at the School of Social Welfare, University of California, Berkeley.

Here’s the abstract:

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is one of the most successful technologies in modern times. In spite of well-argued critiques, the DSM and the idea of ‘mental illness’ on which it is based flourish, with ever more (mis)behaviors labeled as brain diseases. Problems in living and related distress are converted into  medical problems, obscuring the role of environmental factors such as poverty and related political, social, moral, and economic factors such as the interest of the state in controlling deviant behavior and maintaining the status quo. This view shrinks rather than expands opportunities for freedom, growth, and dignity. It ignores the vast literature showing that unusual environments create unusual behaviors and that by arranging learning opportunities we can change behavior. Reasons for this marketing success are discussed and alternatives suggested including consensual counseling regarding problems in living and drawing on a science of behavior attending to environmental learning opportunities.”

This article presents a fundamental and thorough challenge to the idea of mental illness, with its dehumanizing consequences, and its decontextualized approach to human problems.

The article is lengthy – 19 pages plus references – and it is impossible for me to convey the depth and impact of the piece in a short post of this kind.  Here are some quotes:

“Psychiatric labels have been applied to an ever-increasing variety of behaviors viewed as mental disorders.”

“Biomedical psychiatry and pharmaceutical companies, with the help of the state, have been very successful in forwarding medical views of problems-in-living including transforming everyday behaviors, thoughts, and feelings into mental illnesses requiring medical solutions (medication), as illustrated by the ever-lengthening list of behaviors viewed as signs of mental illness and promotion of medical remedies (prescribed medication).”

“Acceptance of the statistically normal condition as equivalent to the psychologically healthy one results in pathologizing people who vary from the statistical norm and even imposing intervention on such individuals.”

“A DSM label gives an illusion of understanding, encouraging detachment from lived experiences.”

“Central to the understanding of words and their effects is reification: the assumption that use of a word means that the reality to which the word allegedly refers actually exists.”

“The promotion of the belief that deviant or troubling behaviors are caused by an illness (a brain disease) has spawned scores of industries and thousands of  agencies, hundreds of research centers, and thousands of advocacy groups that forward this view, none more successful than the industry of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.”

“Being labeled may result in attention only to characteristics that complement the label – a confirmation bias.”

“An individual functional analysis will typically reveal that behaviors, even those that appear bizarre and irrational ‘make sense.’   That is, there is a payoff for the client but at a high cost.”

“Stripping life’s trials and tribulations from their context is dehumanizing in understanding related experiences and potential remedies.”

“With the publication of the DSM 5, there is yet another opportunity for social work to think carefully about its role in promoting and being a handmaiden to a medicalized view of troubling, troubled, and very dependent behaviors. Social work has an inspiring history of attention to avoidable suffering and injustice—not just talking about it, but actively trying to reduce it.”

“The DSM shrinks rather than expands opportunities for freedom, growth, and dignity by obscuring the vast literature, which shows that behavior is influenced by the environment. If we accept the grand narrative of disease to understand behavior, we become architects of clients’ dehumanization as well as our own. By recognizing environmental circumstances, we can understand that behavior always makes sense.”

“A number of trends encourage use of a contextualized approach to understanding human behavior and avoidable suffering. One is the sheer excess of medicalization including deception and fraud on the part of the pharmaceutical companies and physicians and scientists…”

“It is time to wake up from our slumber in the arms of a medicalized psychiatry to recognize missed opportunities to help clients.”

Dr. Gambrill’s article embraces almost every facet of the current psychiatry debate.  Her arguments are cogent and clear, and her references are comprehensive.  The article is scholarly without being tedious.

Dr. Gambrill’s call to Social Workers, both in academia and in the field, to emancipate themselves from psychiatric dominance, and to focus more on alleviating distress by mitigating its true causes, will hopefully resonate widely.

I strongly encourage my readers to read this article and pass it on.

  • Bravo!

  • Jorge_Videla

    I’d still like to know why Robin Williams killed himself, especially in that way. Asphyxiation seems a very unpleasant way to go. I’d prefer one shot myself.

    Apparently he was not broke, despite reports. He had been diagnosed with Parkinson’s. Perhaps it was a drug he was taking. Perhaps it was withdrawal.

  • cledwyn bastardo

    Interesting article, but the elephant in the room, from my perspective, is conflict. At the heart of a lot of human suffering there is some sort of conflict, conflict between the claims of one’s dignity and autonomy on the one hand and those of a society that do not recognize them; conflict between people; inner conflicts etc.

    There is a kind of (not literally) conspiracy of silence regarding the centrality of the role of conflict in our lives. Unless one lives a life secluded from the arena of human conflict (and I would argue that one of the primary reasons for the cloistered existence is to escape conflict), conflict will ultimately come to play an important part in one’s life.

    Our conflicts with others are an inexhaustible source of stress, distress, anger, rage, paranoia. The problem for so many people is that they find themselves on the wrong side of unequal conflictual power relationships (and nothing stirs up an evil brew of emotion like being embroiled in struggles you can’t win, and it is under the force of these emotions, emotions that give us no rest, that the submission of oppressed peoples to their oppressors is usually extorted), and the conferment of power over others brings with it opportunities and temptations, temptations and opportunities that when ensnared in conflictual relations marked by reciprocally intensifying hatred, anger and paranoia, people find much harder to resist, which is why power usually corrupts in some sort of conflictual context where the darker side of a man’s nature prevails; because power, and the greater opportunity and the temptations it brings, allows men to follow the inclinations of their baser appetites, appetites which prior to the conferment or seizure of that power were frustrated. This abuse of power which often happens in conflictual situations only augments the anger and despair of the person on the wrong side of the conflict.

    Conflict also explains the frustration with which the experience of adolescence is charged. Some people think that this rage and frustration is intrinsic to it, when I would say that it is the strive to assert one’s independence (and the intrafamilial conflict this inevitably engenders) that is inherent to this phase of an individual’s development. It is no wonder that in the current cultural climate adolescence is viewed as a psychopathological state, sometimes explicitly, sometimes implicitly, in age when psychiatry wrenches individual suffering from its context, in deference to its true clients, the state, the pharmaceutical industry, family members, the community, all of which have a strong personal interest in divorcing the issue from its context.

    Problem is, the parents have all the power, so the definitions that suit the interests of parents obtain. One thing people can’t be entrusted to do is to define a situation, in which they are invested, honestly, which for those whose distress is rooted in that situation, only adds to their burden of misery, and pushes them only closer to the edge of the precipice overhanging annihilation.

    As the situation of the adolescent shows (apart from those who have been subjected to the kind of strict upbringings that inculcate unconditional obedience to parental, and just about any other, authority), the frustration of will, desire and instinct that are the concomitants of conflictual relations resolved in the others’ favour, can lead to unbearable emotional states which, if they cannot find an outlet (as is the case with people whose position, power, and status do not confer interpersonal leverage, of which in our time the “schizophrenic” is perhaps the paradigm case), will have a corrosive impact.

    Conflict with forces greater than oneself can lead to withdrawal into what one sees as the sanctuary of isolation, but without being anchored in a network of relations, upon whom you can rely for support in your struggle against your foes, fear and paranoia prevail (not that paranoia isn’t to be found amongst closely knit collectives), and the world becomes a far too terrifying place to live in, so they get out of it (and go to a much better place; the grave).

    Drawing attention to conflict is key.

    Coming to the article, I wholeheartedly agree that behaviours that seem to others to be irrational and bizarre actually make sense upon closer inspection, as the preceding argues.

    Delusions, although they can have many causes, and make no distinctions as to whose minds they take up residence in, are often emotional homeostatic mechanisms, restoring emotional balance and harmony, especially delusions about the self, formulated in response to the emotions that engulf a man when his self-esteem is extremely low.