On the ontological status of the psychiatric diagnoses

With all the kvetching I do here about the medicalization of the ordinary problems of being a Homo sapiens, you might think I don't really believe in mental illness. That is not correct. The concept of mental illness has its place, but for the most part, the DSM-IV diagnoses should be understood as categories of convenience, constructed for purposes such as social control, organizing systems of support and assistance, or justifying the use of empirical remedies (i.e., remedies whose mode of action is not understood) which have associated dangers and harms.

In other words, the psychiatric diagnoses -- with limited arguable exceptions -- are not facts about the world in the manner of melanoma, a staph infection, or male pattern baldness (my own sad affliction). They weren't "out there" to be discovered, like a new species of frog or an asteroid. They are categories constructed for instrumental purposes. And, while it is certainly true that distinct, clearly definable organic disease processes can occur in the human brain, as soon as such a process is identified, the disease ceases to be psychiatric and becomes neurological.

The psychiatric diagnoses are useful for several purposes. A diagnostic label is necessary in order to get insurance reimbursement for treatment. It is also needed to declare people incompetent to manage their own affairs, or to force people into institutional care or to receive services. Although nobody actually knows how most psychiatric medications work, criteria are necessary to judge whether to prescribe them. Some people violate the law in one way or another, but appear to have diminished responsibility, or it appears that some form of treatment may be more appropriate for them than prison. Some people's behavior is not illegal, but it is considered offensive or unacceptable, and we need a label in order to define their problem and guide approaches to fixing it.

In all of these cases, we can disagree about where the boundaries should be drawn, or even whether drawing one makes sense at all. (Viz. Glenn Greenwald, who wants to be free to take whatever pills he wants regardless of what his doctor thinks.) But these categories exist because of a social consensus, whether it is very broad, or only within a designated priesthood of pscyhological and psychiatric professionals. People find them useful.

Where we go wrong, however, is in reifying them -- in coming to believe that they correspond to concrete objects. They are social constructions, comparable to the generally, but not universally held opinion that Moby Dick is a great novel, or men should not wear light colored suits during the winter months. That doesn't mean I want them to go away, only that they are continually subject to criticism and reassessment, and one might object to their application in a given case, or the consequences that are attached to them in general.