Abstract
When something serves a function, it is easy to overlook its origins. The tendency is to proceed directly to function and retroactively construct a story about origin based on the function it fills. In this article, I address this problem of origins as it appears in the sociology of knowledge, using a case study of the publication of the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. The manual revolutionized American psychiatry and the treatment of mental illness, because it served the function of classification that had become critical to the field of mental health by this time. But this function must be bracketed in order to reveal the “extra-functional” origins of the DSM-III. Using field theory, I argue that the manual was necessary for reasons other than the function it filled as a classification. Specifically, its origin lies in a series of conflicts among psychiatrists, psychoanalysts, and clinical psychologists within the field of mental health, which followed in the wake of the collapse of psychoanalysis as the dominant treatment type for mental illness. I reveal the generative formula behind the production of the DSM-III, capturing a variety of social processes that influenced the format of the manual and made it a useful classification, but which are not reducible to function. In this way, I reproduce its raison d’etre in a manner similar to how the DSM-III appeared for the people who produced it. This focus on generative formulas offers the sociology of knowledge a way to capture the epistemic importance of a range of different social processes. Most importantly, it avoids the functional fallacy of reducing origin to function, and ignoring the idea that innovations might appear necessary even without clear recognition of their functional consequences.
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Notes
As Allan Hobson, professor of psychiatry at Harvard, and a 1959 graduate of Harvard Medical School, later recalled: “The reason twenty-five people from my medical school class went into psychiatry—twenty-five people in a class of one hundred twenty-five, where today it would be more like three or four—was because we all thought that psychoanalysis was the greatest thing since sliced bread. We were completely hooked” (cited in Dolnick 1998, p. 65).
For American psychiatrists, these principles were probably translated most into the practice of psychotherapy by Kurt Eissler, particularly his influential 1953 paper “The effect of the structure of ego on psychoanalytic technique,” and Karl Menninger, particularly his 1958 Theory of Psychoanalytic Technique.
Here, “patient care episodes” indicate the total number of residents admitted to inpatient facilities at the beginning of the year or those listed on outpatient clinics’ “active” roster and admissions into both types of treatment as they occurred over the same year (Grob 1991a, p. 258).
As Robert Felix, director of the NIMH from 1949 to 1964 urged, psychiatrists must “go out and find people who need help and—that means, in their local communities” (cited in Decker 2007, p. 342). This was especially a concern for schizophrenia, which was thought to be preventable if treated during initial stages and would only exhibit full effects after a period of prolonged non-intervention. The “social psychiatry” treatment focus is perhaps best indicated by the fact that only 15% of the extramural research the NIMH sponsored was done by “biological scientists.” In fact, the majority of research funding given by the NIMH during this time went to social scientists (Grob 1987, p. 425).
This list is, of course, far from exhaustive, and we should not underestimate the effect of other critiques of psychoanalysis at this time, particularly those that concentrate on Freud himself. As Nathan Hale suggests, “Freud-bashers” advanced “four major criticisms: first, that Freud was no scientist and never devised a reliable way to test or prove his conclusions; second, that he lacked personal integrity and fudged his data to fit his theories; third, that he was a poor, inconsistent theorist; fourth, that he established a cult, not an empirical discipline” (1999, p. 236).
I discuss both the Rosenhan experiment and the homosexuality debate in further detail below.
With over 130 varieties of “psychosocial” therapy by the late 1970s (Hale 1995. p. 355).
In 1975, there were approximately 26,000 psychiatrists practicing in the United States and 15,000 clinical psychologists. By 1985, clinical psychologists surpassed psychiatrists, numbering approximately 33,000 to their 32,000. By 1990, the gap grew even more with 36,000 psychiatrists practicing in the United States compared to over 42,000 clinical psychologists. While this transformation is significant enough, over the same period the number of clinical social workers grew enormously, from 25,000 in 1975 to over 80,000 by 1990. Certainly this reflects the impact of the community mental health initiatives begun in the early 1960s. Moreover, marriage and family counselors, a little known specialty in 1975 with only 6,000 practitioners, grew to over 40,000 by 1990, indicative of the emerging “psychotherapeutic jungle” and the increasingly specialist and directed application of psychotherapy (Goleman 1990; Shorter 1997; Kirk and Kutchins 1992).
As he would later call them: “By the middle of the 1960s, American psychiatry was characterized by multiple ideological divisions in which little communication occurred between or among the various groups. While the biological psychiatrists tried to cling to their medical roots, they often became rigid in this defense and were not very persuasive. Limited as they were to unspecific medications and such treatments as ECT, insulin, and even lobotomy, they often found themselves regarded poorly within their profession and by the public at large. The psychoanalysts and social psychiatrists on the other hand … moved away from the medical model. Their demonstration of only minimal interest in epidemiology and in development of treatments based on nosology marked the nadir of psychiatrists’ demedicalization in the United States … it also marked a period of massive public confusion about the differences among clinical psychologists, psychiatric social workers, and psychiatrists” (Sabshin 1990, p. 1270).
The strategy worked for the NIMH, as the 1980s saw rapid increases in funding (Baldessarini 2000). In 1992, it once again became a branch of the National Institutes of Health.
Among other reasons, this was to prevent a similar embarrassment as the one that occurred with the US-UK Diagnostic Project (Kendell et al. 1971) in which the unreliability of diagnosis was revealed when US psychiatrists were shown to be far more likely to diagnose schizophrenia than their British counterparts (85% to 7% in one case).
As the introduction to the DSM-III stated: the “DSM-III is generally atheoretical with regard to etiology … and only rarely attempts to account for how the disturbances come about” (APA 1980, p. 7).
As Lakoff (2005) argues, much of the appeal of something like the DSM-III for interests external to the field lies in its ability to render something like mental illness “liquid.” The clarity and explicitness of the document enables a range of activities to develop around the practice of mental health, perhaps in much the same way as maps of the new world set the stage for the global expansion of economic activities and political control or what the human genome project might make possible in the future (see Wood 2004).
Kraepelin was known for devising the first clinically-oriented nosology system, dividing functional psychotic disorders into three major groups, each with its own subcategories: dementia praecox, manic-depressive illness, and paranoia. Though Kraepelin was masterful at describing symptoms, from which he created his nosology, he also speculated on the etiological basis of the diseases he classified, though maintaining the view that little could be known in this area until knowledge of the “normal” working brain became more comprehensive. This fed into his critique of psychoanalysis, which almost parallels later critiques developed by the neo-Kraepelinians: “We meet everywhere the characteristic fundamental features of the Freudian trend of investigation, the representation of arbitrary assumptions and conjectures as assured facts, which are used without hesitation for the building up of always new castles in the air ever towering higher, and the tendency to generalization beyond measure from single observations. … As I am accustomed to walk on the sure foundation of direct experience, my Philistine conscience of natural science stumbles at every step on objections, considerations, and doubts, over which the likely soaring tower of Freud’s disciples carries them without difficulty” (cited in Decker 2007, p. 340).
Important for Spitzer’s view on this matter was Marcel Saghir and Eli Robins’s 1973 study Male and Female Homosexuality: A Comprehensive Investigation, which specifically tested the alleged pathology in terms of subjective impairment, and not according to a theory of etiology.
For example, consider the following statements: first, “He is a schizophrenic”; second, “He has schizophrenia.” The first reflects the analytic point of view; the second reflects the diagnostic. In the first, the patient is subsumed by the disease; in the second, he is attached to a disease. In the first, the patient is coupled to a diseased identity-type; in the second, the disease is an object definable on its own, which the patient possesses. It is detachable from him and not implicated in all of his behavior (like a broken leg). This illustrates Spitzer’s position. Here, we also see traces of what made diagnostic psychiatry seem more medical.
Except for the pseudo-patient diagnosed as manic-depressive, who Spitzer does not mention.
These include: Disorder usually first evident in infancy, childhood or adolescence; organic mental disorders; substance use disorders; schizophrenic disorders; paranoid disorders; affective disorders; anxiety disorders; somatoform disorders; psychosexual disorders; factitious disorders; adjustment disorder; personality disorders.
Like a placing an order from a Chinese menu: two of three items in Category A, one of four in Category B, one of three in Category C, and so on.
The significance of the structured “interview schedule” for clinical practice using the DSM classification would eventually lead Spitzer to argue that the burden was on clinicians to show that they weren’t “superfluous in the task of diagnostic assessment” in comparison to computers (Spitzer 1983).
For example, Task Force member Theodore Millon described the resolution of the dispute over “neurosis” as an issue “cleverly finessed by separating the concept ‘neurotic disorder’ from that of ‘neurotic process’ … or [separating it from] a sequence of intrapsychic conflicts” (1983, p. 807).
Perhaps indicative of concessions on the part of psychiatrists in the jurisdiction over psychotherapy, Thomas Hackett, professor of psychiatry at Harvard Medical School, suggested in 1977 that “apart from their training in medicine, psychiatrists have nothing unique to offer that cannot be provided by psychologists, the clergy, or lay psychotherapists. Our bread and butter—the practice of psychotherapy—has fragmented into multiple schools, all with uncertain boundaries” (1977, p. 434).
This is even despite the fact that the American Psychological Association initiated its own Task Force on Descriptive Behavioral Classification in response to the DSM-III (Smith and Kraft 1983, pp. 777–778). The Task Force was charged with exploring the possibility of developing an alternative manual for clinical, teaching, and research purposes. Significantly, only a third of clinical psychologists reported hearing of the initiative shortly after it began in 1981, and an even smaller percentage reported they would use the alternative manual if it were ever published (Miller et al. 1981, p. 388). The Task Force was terminated shortly thereafter.
Perhaps this explains clinical psychology’s sustained fascination with psychotherapy, and initiation of original therapy types when treatment is not contained within a holistic theory comparable to psychoanalysis, but concerned instead with realizing (“tweaking”) behavioral differences: “behavioral,” “cognitive-learning,” “cognitive-behavioral,” “humanistic,” “feminist,” “interpersonal,” “systems,” “existential,” even “psychodynamic” are among just a few among the toolkit of theoretical orientations (for therapeutic practice) available for clinical psychologists (Bloch 1996). Meanwhile, a 1988 lawsuit brought by clinical psychologists against the APsaA finally opened the doors of the most restrictive analytic training institutes to non-medical personnel. This was perhaps the last step in ending the “medical monopoly” over psychotherapy (Buchanan 2003: 244).
Most important was the Washington, D.C. metro area, which supported an unusually high number of psychoanalysts due to federal employee health benefits with generous mental health provisions, including ample support for analytic therapy (Bayer and Spitzer 1985, pp. 190–191).
Among the most prominent drugs used prior to publication of the DSM-III, and before the subsequent emergence of Selective Serotonin Reuptake Inhibitors (SSRIs) like Prozac, Paxil, and Zoloft, were the meprobomates Milltown and Equanil, the benzodiazepines Valium and Librium. This was the beginning of a trend that would eventually make psychiatrists the most frequent prescribers of medication among all medical practitioners (Shorter 2009).
Spitzer later recalled, in response to the question of whether pharmaceuticals influenced the DSM-III: “Absolutely no. I mean in what specific way? Some people would have said that with panic disorder we were trying to make [the pharmaceutical company] Upjohn happy. That’s not why we had panic. We had panic disorder because [Task Force member] Don Klein convinced us that it was different from generalized anxiety disorder. Alprazolam [i.e., Xanax] was never part of our discussion and I don’t see how psychopharmacology would have influenced the DSM. I know it was never part of any discussions” (2000, p. 426)
The coding system is now included as part of the CPT (or Current Procedural Terminology) Handbook.
For his part, Spitzer contests that “insurance issues had no effect. They never came up in discussion. The insurance people were always happy with DSM-II, they never complained about it. I suppose they like DSM-III, maybe more, but there was never any way in which we tried to fashion the manual to make it more acceptable for insurers” (2000, p. 426).
This process can be conceptualized in terms of Andrew Abbott’s (1988) systems model of the professions as a new “jurisdiction” or “form of work” opening up, and psychiatrists filling it. However, while this provides a way to understand the success of diagnostic psychiatry, it still does not account for why diagnostic psychiatry or, in particular, why the DSM-III emerged, apart from crediting the outcome—or they emerged to “fill a jurisdiction.” In this respect, Abbott’s model falls victim to the same problems as explanations that rely on the power of pharmaceuticals and insurance companies to explain the case.
In his review of the changing role of psychotherapy in mental health care, the veteran psychoanalyst Robert Wallerstein reports that, in the 1940s and 1950s, at the brink of psychoanalysis’s dominance over the field, 40% to 50% of the time spent in psychiatry residency programs was devoted to training in the application of psychodynamic psychotherapy. This number would, of course, grow over the coming decades as the influence of psychoanalysis in psychiatry grew. But it would begin to decline in the mid-1970s and early 1980s, reaching the point, by the early 1990s, when psychotherapy training took up only 200 h of the total time spent in psychiatric residency, or a paltry 2.5% in comparison with the earlier numbers (Wallerstein 1991). Clearly this was a move away from the old concerns of the profession, pressed by the influence of the DSM-III and subsequent manuals, which, as one of the psychiatry resident informers in T.M. Luhrmann’s recent ethnography suggests, made therapeutic training during residency seem a waste of time: “[If] we don’t go into research we’ve failed somehow” (2000, p. 158).
These responses also suggest practices indicative of what Bowker and Star (2000: 159) call “work-arounds” or the way practitioners adapt to formal standards like classifications by devising informal ways of meeting the requirements they impose, while still retaining autonomy of practice. They offer the example of a psychoanalyst arbitrarily classifying a patient as receiving treatment for “obsessive-compulsive disorder” in order to meet health insurance reporting requirements and thus retain benefits that include psychotherapy treatment (2000, p. 47).
This is in addition to the persistence of significant income differences between psychiatrists and other mental health professionals after publication of the DSM-III (Dodosh 1981).
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Acknowledgments
I give special thanks to Omar Lizardo and Lyn Spillman for their advice, criticism, and encouragement since the very beginning of this project. I also thank Gene Halton, David Hachen, Ellen Childs, Sara Skiles, Isaac Reed, Nina Eliasoph, and John R. Hall for their comments on earlier versions of the article. Finally, I thank the Theory and Society Editors and reviewers for their insight and criticism.
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Strand, M. Where do classifications come from? The DSM-III, the transformation of American psychiatry, and the problem of origins in the sociology of knowledge. Theor Soc 40, 273–313 (2011). https://doi.org/10.1007/s11186-011-9142-8
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DOI: https://doi.org/10.1007/s11186-011-9142-8