Text by Paula Hartl (Freie Universität Berlin)
© Pablo Dohms
As a student of psychological anthropology, I am becoming increasingly aware that psychiatry is not a closed sector but rather relational and charged with meaning by different actors. As I started to scan the literature for this essay I also realized, that it is a highly debated field. I stumbled across key words like Big Pharma, high prescribing, placebo – words that sound like the perfect mixture for a scandal. But at the same time, I am engaging in the biomedical world, not only as a patient but also as a professional. For years I worked as a student assistant in various doctors’ offices and more than once mental health disorders came across my work or the work of friends and colleagues. Pathologisation and medicalisation often were components that came with it. At the same time, as an anthropologist I am aware of the cultural variation of mental health disorders and the stigmatisation when people do not fit into normative categories. When I started confronting myself as well as friends and colleagues working in the medical sector with the things I learned, I was more and more becoming insecure about my role as an anthropologist, respective my role within the biomedical world. Both roles, the psychological anthropologist and the “medical professional” (or at least engaging in a biomedical setting) seem to me as two opposing poles. What factors influence this tension? And what consequences does this have for the people directly affected by this – the patients? I want to take this essay as a starting point to critically examine the biomedical setting of psychiatry and provide an anthropological point of view.
The DSM-5 controversy
In the same field of tension lies the DSM-5 controversy. I want to take the controversy as a starting point to reflect on my role within that overlapping worlds. In 2011, the fifth revision of the DSM (Diagnostic and Statistical Manual of Mental Disorders) sparked controversy within the psychological-psychiatric profession and beyond. In an open letter to the DSM-5 Task Force and the American Psychiatric Association (APA), a group of psychologists and psychiatrists expressed their concerns about the changes in the latest edition of the DSM. Their main concerns were the lower threshold for diagnosing disorders, the addition of new disorders, which could lead to inappropriate medical treatment, and the lack of empirical data serving as a basis for those modifications and the determination of disorders in general (Robins N.D.). Even more interestingly – from an anthropological point of view – they further criticized the growing emphasis on biological theory in defining mental disorders and warned against the consequences for patients and the profession if sociocultural variations are increasingly left out of the picture (ibid.).
According to James Davies, an anthropologist and trained psychotherapist, the roots of the controversy surrounding the DSM-5 are lying in its predecessor, DSM-III, as this version established the modern diagnostic system that serves as the basis for subsequent editions (Davies 2017, p.33). James Davies, whose focus lies on psychiatry, psychotherapy, and its intersections with psychological and medical anthropology, did detailed research about the development of the Diagnostic Manual and its mechanisms. The DSM-III emerged in1980 from the need to address the poor diagnostic reliability of its predecessor, the DSM-II, with a revised, empirically based system (ibid., p. 32). To develop more specific guidelines for diagnosing mental disorders, a task force was formed, led by the psychiatrist Robert Spitzer. Their vision for the DSM-III was to stir out of analytical tendencies of the DSM-II, to be more descriptive and develop new criteria for disorders (ibid., p.34) – which was already a quite ambitious endeavour. Therefore, the task force consulted other APA members, examined existing research papers, and tested proposed disorders in the field setting (ibid., p.34). But even if no data existed, the task force came to a decision – through clinical consensus (ibid., p.35) According to Davies’ research,
“[…] the consensus that mattered was that reached by the Task Force itself […]. Task Force consensus could, therefore, overrule that attained by any advisory committee, lobbying faction or group […]” (ibid.).
In an interview with Davies, Robert Spitzer admitted, that “it became a question of how much consensus there was to recognize and include a particular disorder.” (Davies 2014, p.24) If that method for establishing a manual cohere with the ICD (International Classification of Diseases) is not questionable, then the more is the composition of the task force: white, middle-class American psychiatrists and psychologists (except one) (Davies 2017, p. 34). This composition did not nearly represent the population, which would soon be diagnosed according to the DSM-III. Even though roughly the same method was applied to the elaboration of the latest version, the DSM-5 task force consisted of various study groups, including a cross-cultural, a gender study group, and collaborated with international health organizations (Aggarwal 2013, p. 394).
Still, one of the main critiques remained the increasing addition of disorders and the thus resulting inflation of diagnoses. In a conversation with James Davies, Frances Allan, psychiatrist and the leader of the task force for the DSM IV, shares his concerns for the future of psychiatry:
“The DSM-5 is proposing changes that will dramatically expand the realm of normality – resulting in the conversion of millions more patients, millions more people, from currently being without mental disorders to be psychiatrically sick” (Davies 2014, p. 52).
Diagnosis in a Field of Tension: Between Pathologisation and Relief of Suffering
One example of this “inflation” is the pathologisation of grief, which fired up a heated debate in a wider community from newspaper articles to petitions. “Who suffers from lack of appetite, avolition, bad sleep […] after the death of a loved one, would now be diagnosed with depression after only two weeks”, writes a German newspaper (Habekuß 2013). With this diagnosis one can likely get prescribed antidepressants. James Davies agrees with this fear of inflating diagnosis, describing a similar situation when one of his colleagues’ patient was diagnosed with depression after he lost his wife and suffered from insomnia, lack of appetite, outbursts of grief. According to the DSM, he fulfilled all criteria for depression. He was immediately prescribed antidepressants. But instead of helping him, the medication made him feel numb and if his internal pressure was “stuck in his head” (Davies 2014, p. 97). This example clearly shows the weakness of the DSM: it misses the chance to try to get to the bottom of the patients’ stress and rather offers a short time solution in form of medication, which, as James Davies states, “[…] don’t cure us – they simply change us.” (ibid., p. 99) Even though Davies makes a valid point, I would partly disagree, respectively raise another question: what does “being cured” mean and is that the ultimate aim of any form of therapy – medical or not?
Now let me switch sides for a minute and look at this from the health care workers’ point of view. “Curing” within the biomedical context is the overall goal of patient treatment. The treatment starts with the anamnesis or medical history of the patient, followed by a diagnosis or further examinations which ideally results in a curing treatment. From my own experience, the health care professional has about 15 to 30 minutes available per patient appointment. This depends on the doctor, the number of patients that get accepted and other circumstances. Each component of the treatment gets compensated, the (technical) examinations and the prescriptions make up for the largest part. This is basically the system behind the clinicians’ wages. It is self-evident that the pressure on the clinician is high – and time is money. Of course, as flawed as the DSM is, for the health care professional, it offers an “easy” diagnosis system, which – in the best case – can lead to the ideal treatment and therefore quick relief or cure of the patients’ suffering. Obviously, I am describing the best-case scenario. It can also develop into a contra-productive, prescription-based process. Micheal Oldani, a psychiatric and pharmaceutical anthropologist, calls this process high prescribing (Oldani 2014, p. 258). In his fieldwork, he observed the practice of pharmaceutical detox by two psychiatrists in high prescribing landscapes. One of his interlocutors stated that she hated her job, because “it [was] all about productivity,” (ibid., p. 266). When she got a new job as a salaried employee, everything changed for the better.” [H]er productivity is not central to billing nor is it part of the formula for overall compensation and year-end bonus […]” (ibid., p. 267). Now she has extra time for each patient – extra time to treat each patient according to his*her needs and therefore reducing or changing medical prescriptions.
I think here lies a very important point: time is a crucial but scarce resource for any healing process – its absence often has tremendous effects on the patient as well as the clinician.
Conclusion
I think the idea behind the DSM is to establish a manual that can moderate these effects, an undertaking that went entirely wrong. Instead of offering empirically based, accurately examined diagnostic guidelines to support and advance the mental health professionals’ work, it developed into a rigid classificatory system, which can easily lead to an inflation of diagnoses and prescriptions. Needless to say, there are countless speculations that the ultimate beneficial party in this complex field is the pharma industry – and thus involved in the establishment of the DSM-5. Reportedly several workgroups consisted of authors with ties to the industry, like the mood disorder group, the psychotic disorder group – disorders often treated with pharmaceutics (Aldhous 2012).
Despite all this critique, especially as a former health care worker, I am not entirely opposed to the DSM, even though I find the establishment questionable and Eurocentric. Having a coherent diagnostic system can be very helpful – but something is going wrong in its implementation. The lack of time ultimately determines the diagnosis and thus the treatment. In other words, if clinicians had more time, I think many diagnoses would be made differently – or not at all.
And I think here the two poles, the anthropological and the biomedical one – would profit of working together: Anthropology offers us the chance to ask basic questions and to observe how mechanisms are perceived by different actors and transfer it to a bigger picture. Anthropology raises questions like: What does a particular phenomenon mean for a particular group of people? How is it referred to? How is it perceived?
As the health care worker, I have biomedical knowledge but as the anthropologist, I can monitor the processes and the effects not only on the individual but society as a whole. I agree with Micheal Oldaniwhen stating:
“Ethnography can and should intervene as a counter-force to overmedicating, polypharmacy, and pharmaceuticalization by bringing more doubt than certainty to the very cultural and psychiatric categories of being that have been inscribed in and through us by the simple act of writing a prescription” (Oldanie 2014, p. 259).
References
Aggarwal, Neil Krishan 2013. “Cultural Psychiatry, Medical Anthropology, and the DSM-5 Field Trials”, Medical Anthropology, 32:5, p. 393 -398.
Aldhous, Peter 2012. „Many authors of the psychiatric bible have industry ties “, New Scientist, 13.03.2012, https://www.newscientist.com/article/dn21580-many-authors-of-psychiatry-bible-have-industry-ties/, last access on May 29, 2018
Davies, James 2014. Cracked – why psychiatry is doing more harm than good. Icon Books, London 2014.
Davies, James 2017. „How Voting and Consensus Created the Diagnostic and Statistical Manual of Mental Disorders (DSM III)”, Anthropology & Medicine, 24:1, p. 32-46.
Habekuß, Fritz 2013. „Heute noch normal, morgen schon verrückt“, Zeit Online, 07.05.2013, https://www.zeit.de/wissen/gesundheit/2013-05/dsm-5-bibel-der-psychatrie, last Access on May 29, 2018.
Micheal Oldani 2014. “Deep Pharma: Psychiatry, Anthropology, and Pharmaceutical Detox”, Cult Med Psychiatry, 38, p. 255-278.
Robbins, Brent N.D. „Open Letter to the DSM 5“, https://www.ipetitions.com/petition/dsm5/ (last accessed May 27, 2018).