This week marks the publication of the much anticipated—and much maligned—DSM-5, the latest full revision to psychiatry’s diagnostic handbook. Each new iteration of the DSM alters the official stance on so many conditions that discussion often centers on the introduction or dismissal of particular disorders, virtually naturalizing the philosophy underlying the manual’s overall perspective. In an effort to unsettle that reception, we asked Liah Greenfeld, author of Mind, Modernity, Madness, what single point about the DSM-5 and its diagnostic approach she would most want to convey to the general public, if given the chance. Her response follows.
I would use this opportunity to point out that DSM-V, and DSM in general, is just an expression of the increasing confusion in the mental health community (including both researchers and clinicians, and both psychiatry and psychology with their neuroscience contingents) in regard to the nature of the human mental processes—or the mind—altogether. Before this confusion is cleared, none of the problems with the DSM and the resulting mental health practice can be resolved. And the criticism of the DSM should in all fairness apply also to its critics and judges, such as the NIMH.
One might expect me, as a social scientist, to attack today’s mental health community for its nearly exclusive biological focus. But the source of its confusion in regard to the nature of the mind lies deeper than the equation of the mind and the brain. Psychiatry and psychology consider the human individual as their subject. In this they sharply distinguish themselves from biology, which studies the organic world. The most important causal factor in biology is the environment in which organisms find themselves (think of natural selection) and no specialization in this mighty science, among the sub-disciplines of which neuropsychiatry and neuropsychology, at least, would like to range themselves, would limit itself to the study of a form of life in isolation from the environment. Consider, for example, medical (i.e., applied biological) specializations such as gastroenterology or pulmonology: is it possible to imagine a physician who would be unaware that the process of digestion is necessarily affected by the nature and quantity of food the stomach digests, or the process of breathing by the nature and quantity of the air inhaled? No, because this is what our organs do: they process intakes from the environment, and these intakes have at least as much to do with our health and illness as the structure and physiology of the organs which process them. Yet, we forget this when it comes to the brain and mental processing—the mind.
The environment of the human brain is far more complex than that of the stomach and lungs, or than the environment of the brains of other animals. Most of its intakes come not from the organic and physical world, but, instead, from the world of meanings and symbolic systems which convey them, that is, culture. If digestion can be defined as what happens to food in, and what food does to, the stomach, the mind, by analogy, can be conceptualized as what happens to culture in, and what culture does to, the (human) brain. It is very likely that most mental diseases (just like most gastrointestinal or pulmonary ones) come from the intake of the processing organ, rather than from the organ itself, i.e., it is likely that they are caused by culture. Mental health professions pay no attention to it, and no revision of the DSM will make them improve their ability to help the mentally ill.