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 Selected Sharma Materials: Editor's Introduction to The Medical Model of Mental Illness Sohan L. Sharma, Ph.D.
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Nosology And Psychodiagnosis In Psychiatry And Psychology by Sohan Lal Sharma, Ph.D. Copyright 1998, Sohan Lal Sharma Nosology and psychodiagnosis have been central concepts in the development of both psychiatry and clinical psychology. Social and historical developments and the underlying assumptions of the concepts have rarely been explicitly examined. This failure has resulted in considerable confusion over the proper role and function of nosology and psychodiagnosis. This is evident in academic research, the graduate curriculum, practical training in psychology, and in the practices of psychiatry and clinical psychology. This paper attempts to examine: 1) the social and historical role of the "institutions" from which the concepts of nosology developed; 2) the logic of nosology in the context of psychiatry, and finally; 3) the meaning and utility of nosology in clinical practice. THE EARLY SOCIAL ROLE OF INSTITUTIONS As discussed in Chapter 1, the history of the development of social forces in Western societies shows that "mental hospitals" and their precursors preceded the emergence of psychiatry, both as a "scientific" discipline and as a profession (Grob, 1967). This fact is of paramount importance, for it means that psychiatric thought and practice was not the dominant influence in the shaping of the structure and function of these institutions. On the contrary, psychiatry to a very large extent grew out of the institutional and social setting within which it originated. Many of the dominant characteristics of psychiatric ideology and theory were simply rationalizations of existing conditions within mental hospitals and within the society as popular attitudes.* Mental hospitals, at +++++++++++++++++++++++++++++++++++++++++++++++++++ *An analogous situation would be if the institution of jail had developed first and then the theory of jurisprudence and law had later been created. +++++++++++++++++++++++++++++++++++++++++++++++++++least during the formative years, were created by society to deal with deviant behavior, particularly of the lower classes. The result was that psychiatry began in large measure to assume a role as an instrument of social control, rather than as a profession for the scientific study of behavioral and emotional problems (Grob, 1967). As European society began to shift from an ecclesiastical orientation to a more secular one, a need developed for institutions that would provide some sort of control of the indigent, the sick, the aged, the deviant, and the unemployed. During these centuries, the mercantilists, statesmen, and social philosophers began to emphasize the virtues of thrift, ambition, and efficiency in an attempt to create an administrative and financial structure capable of maintaining a high degree of social order in the emerging secular state. Consequently, problems of health and indigence began to fall within the province of the government. Thus, during the 17th and l8th centuries, civil governments began to develop a variety of institutions to cope with the increasing number of social problems (Grob, 1966) and deviant social behaviors. The French Hospital General of Paris is the historical model and social prototype for the mental hospitals. The purposes of this institutional system were threefold. In part they were economic: to increase [the] manufacture [of goods], provide productive work for the able-bodied, and to end unemployment; in part social: to punish willful idleness, restore public order, and rid Paris of beggars; and in part, religious and moral: to relieve the needy, the ill, and suffering, to deal with immorality and antisocial behavior, and to provide Christian instruction. A few years after its foundation, the Hopital General of Paris alone contained 6,000 persons, or about 1 per cent of the population. Who were these "mentally ill" people? According to regulations issued in 1680, "children of artisans and other poor inhabitants of Paris up to the age of 25 . . . girls who were debauched or in evident danger of being debauched . . . [and] wayward children. . . ." were among those listed as proper subjects for confinement. In addition, old people, persons with venereal diseases, epileptics, vagrants, prostitutes -- in brief, all of society's "miserables" -- were incarcerated in the Hopital General (Szasz, 1966a). The Hopital General is not a medical establishment. It is rather a sort of semi- judicial structure, an administrative entity which, along with already constituted powers, and outside the courts, decides, judges, and executes (Foucault, 1965). During this period, the field of medicine likewise accelerated in growth and became increasingly influential. Institutions, some of which were previously called poor houses, ³work houses," "retreats," or ³rest homes" all came to be known as hospitals. The historical transformation of such institutions into hospitals has been vividly discussed in numerous recent volumes (rain, 1964; Foucault, 1965; Grob, 1966). The development of institutions for social control and confinement in the United States is similar to that in Europe. In the United States between the end of the 17th Century and the time of the Civil War, many institutions cared for the mentally disturbed, but were not called hospitals. Then, after the end of the Civil War, practically every state had a mental hospital, while other institutions charged with the care of the mentally disturbed were being transformed into hospitals. These institutions incarcerating the poor, the aged, deviants, and miscreants became hospitals. As psychiatry developed, a great deal of emphasis was placed on extra-scientific factors (Grob, 1967). Hundreds of reports, books, articles, and speeches listed what to the psychiatrist of that period seemed to be leading causes of mental "disease." These included intemperance, overwork, domestic difficulties, striving after wealth, etc. (Grob, 1966). These were all manifest social behaviors, which, according to the social climate and moral judgment of the day, were unacceptable to the [middle class] society. The institutional label of "hospital," together with the rapid development of medicine, culminated during the 19th century in the psychiatrist assuming more and more that mental illness was somatic illness, usually involving lesions of the brain, which was regarded as the organ of the mind. Yet psychiatrists could offer no empirical evidence to substantiate this assertion. Consequently, "mental illness" was identified through a person's manifest behavior. This, then, required some normative standard by which to judge or evaluate behavior. The norm that they used (and it was generally an implicit, rather than an explicit, one) was the norm of their own reference group. The standard used was no longer a physical one (one that involved proper organic functioning), but, rather, was culturally defined: it was a standard that implicitly adopted middle- class, Protestant, agrarian values. Defining mental illness in terms of outward behavioral manifestations, while yet claiming that it was organic in nature, of course, created serious theoretical problems (Grob, 1967). Since "mentally ill" people were sent to institutions called "hospitals," classifying and labeling their social behavior became necessary. This act of classifying behavior was traditionally a function performed by a physician in the institution called a hospital. Thus, the social behavior of the inmates came to be categorized and labeled (judged) no longer as a form of social behavior, but now as a disease entity (Robbing, 1966). Such classification, in the medical tradition, was taken to be an essential preliminary step for the future discovery of a biochemical agent or a neurophysiological basis for these social or mental diseases. Due to these historical and social developments, the nature of diagnosis was obscured, while the underlying assumptions and the logic of psychiatric nosology were not confronted (viz., the raison d'être of labeling social and interpersonal behaviors as a disease form). The confusion developed first when the detention institutions came to be called "hospitals" and then when the different forms of behaviors were regarded as "sick" or "ill." It can be seen that the true nature of the problem is obscured by the implicit moral judgment submerged within the context of an institution where the labels "sick" or "ill" must be applied. Such a distortion has indeed not been limited to the l8th and 19th centuries. Today, the conceptual basis of nosology and diagnosis is much the same. It is still generally ac the patient's behavior is the sole basis of classification of mental disease or diagnosis (Zubin, 1966)." Yet, like our l8th and 19th century predecessors, the search for and the hope to find a neurological basis or a biochemical agent in mental disease still operates. One authority in nosology and diagnosis, for example, has recently written: --- there may be more to mental disorder than this externally observable deviant -- it may be a hereditary basis, or it may develop as a result of trauma producing experiences very early in life or perhaps even in intrauterine existence (Zubin, 1966). The conclusion, based on historical evidence, that social institutions first developed to detain and isolate disturbed individuals whose behavior was distasteful to the community, and then became the focal point and locale for the classification of "mental illness" thus appears warranted. This development was chiefly responsible for instituting the methods of modern psychiatric nosology. PSYCHIATRY AND THE LOGIC OF NOSOLOGY It has been mentioned that psychiatry developed as a branch of medicine to deal with deviant behaviors which, because socially unacceptable, came to be labeled as sick or ill (Foucault, 1965; Grob, 1966; Szasz, 1961). Because the emotionally and behaviorally disturbed were designated as sick or ill, it was assumed that the physicalistic qualities applicable to physical illness could also be attributed to interpersonal behavior and emotional problems. Personal distress and social deviance were then comprehended in the same terms as those of physical illness (Szasz, 1961). Psychiatry is the study of mental disease or disturbance. Nosology is, then, the classification of such diseases (Szasz, 1959). When emotional disturbances are conceptualized as illnesses or diseases, it becomes necessary to classify them in the same ways as physical disease is categorically described (Robbing, 1966; Sharma, 1967). A physical disease, however, has a certain fundamental difference from emotional disturbance. It has a causative agent: it produces physiochemical changes in the body which can be described as symptomatic of illness. This physical illness is experienced by the individual without his willing participation and the form it takes is universal or independent of the individual or society in which he lives (Szasz, 1961). Cancer, for example, is diagnosed and treated in the same manner in whatever society it is found. An emotional or mental disturbance, in contrast, is the whole person acting in a social role. It is necessarily defined by the social and cultural conditions in which the individual lives, and can be understood essentially in this context. Thus, mental illness refers to the identity or the being of the person and not anything apart from him. A person can assume only one identity at a time, that is, he can either be a neurotic or a psychotic at any given time; he cannot be both (i.e. he cannot have neurotic and/or psychotic features) any more than a person can be Chinese and America-standing controversy as to whether or not one can have both the neurotic and psychotic symptoms appears to be based upon fallacious assumptions underlying the medical model. When an equivalence of structure between mental and physical illness is assumed, or that physical and emotional disturbance (disease) are similar in nature, the essential differences are ignored. This faulty premise of equivalence was assumed, and the classifying and diagnosing of mental illness as a disease entity, which was independent of the person and his social role, became intrinsic to psychiatric practices. Table 1 summarizes the fallacy of such thinking and the source of logical confusion.
Table 1. Logical Fallacies in the Nosology of
"Mental Illness"*
+++++++++++++++++++++++++++++++++++++++++++++++++++
Item Label Observable Sick Role
+++++++++++++++++++++++++++++++++++++++++++++++++++
1 Sick Yes Assumes
(physically)
2 Superstitious Yes Does not
or assume
Christian
Scientist
3 Mentally ill No Assumes
or
Hypochondriac
4 Well No Does not
assume
*Borrowed from a lecture by Professor Thomas Szasz
Item l of the table shows that to be labeled physically sick, an observable physical condition must be present and the patient be labeled something else. For example, in Item 2, where he does not assume a sick role, even though having an observable physical condition, he may then be labeled as "superstitious" (or a "Christian Scientist"). The label of "mental illness" (Item 3) is applied to what is essentially a social role without an observable physical condition. To equate mental illness with physical illness is to ascribe an observable physical condition to mental illness, which, per se, does not exist. Such "category mistakes" (Ryle, 1946)* have +++++++++++++++++++++++++++++++++++++++++++++++++++ *To represent the facts of mental life as if they belong to one (physical) logical type or category (or range of types or categories) when they actually belong to another. +++++++++++++++++++++++++++++++++++++++++++++++++++resulted in the difficulties now being experienced in the fields of mental health and clinical psychology. A physical disease is a closed system, which follows a pre-established pattern of unfolding. Personal distress and emotional disturbance, however, are essentially open systems which do not follow a pre-determined sequence (Marzolf, 1947). By conceptualizing emotional disturbances as diseased entities, however, it also became necessary to chart the course of the unfolding of mental illnesses. Patients institutionalized and incarcerated in mental hospitals were observed for periods of time to study the growth and development of mental illness in order to develop a nosological system so that symptom clusters could be correlated for diagnosis (Zilboorg, 1941). These early "patients" constituted the population sample upon which the current diagnostic system is based (Szasz, 1959). A closed system of physically closed environs is a state mental hospital. The pseudo-equivalence of physical and mental illness was thus established. The effect of almost total confinement over an extended period of time on an individual's behavior was simply interpreted as the characteristically prolonged nature of "mental illness." As subsequent studies were to suggest, such a view of emotional disturbances as a closed system produced a profound bias for the investigator. Many of the symptom clusters which were attributed to what was termed "mental illness" were indeed a product of the hospital socialization process itself, and the effects of the institutional structures and policies upon the behavior of the individual (Stainbrook, 1965). In viewing personal distress and emotional disturbance as illness, it followed that nosology and diagnosis were necessary tools in treatment, just as they were for any other illness. Assigning a person to a class of things that are "ill" indicates that a recognizable disease has been identified which has objective symptoms (Sarbin, 1967). It further followed that specific symptoms and syndromes were required for each of the nosological categories. To achieve this end, much of the conceptual lexicon of physical disease was transposed to psychiatry and psychology (viz., patients, epidemiology, etiology, symptoms, chronic, diagnosis, prognosis, cure, hygiene, treatment, etc.) (Adams, 1964). The task of psychiatry and psychology became one of assessing and categorizing interpersonal behavior and personal distress according to definitive physicalistic categories. In physical medicine, a diagnosis is of value in indicating the etiology (origin or causation), treatment, and prognosis of the disease. Mental illness, therefore, required a correct diagnosis of the disease to provide etiologic significance, treatment, and prognosis. Another factor of physical illness is the specificity of causative agents, such as bacteria, virus, etc. These have specific treatment procedures. It was, therefore, assumed that by developing an accurate nosological system and diagnosis of mental illness (viz., neurosis [hysteria, obsession], psychosis, etc.) that specific treatment procedures could also be specified for these (Sharma, 1968). The system of classification and diagnosis of mental illness was fundamentally based and developed upon the hospitalized patients. It was then hardly applicable to populations outside the confines of a mental hospital. For example, during World War II . . . only about 1O per cent of the total cases seen fell into any of the categories ordinarily seen by public mental hospitals; . . . "therefore] psychiatrists found themselves operating within the limits of the nomenclatures specifically not designed for 90 per cent of the cases handled (Diagnostic and Statistical Manual of Mental Disorders, 1965). In order that a system in the classification of mental diseases might be applicable to a larger segment of population outside of mental hospitals, it was deemed imperative to extend the scope of the nosological system and broaden the already-existing categories. This was generally achieved by such means as attaching a prefix or a suffix to already- existing categories (e.g., "pseudo-psychopath"). In such a way, the classification of mental illnesses could now be applied to the remaining 90 per cent of the population outside mental hospitals. As the field of clinical psychology developed with emphasis on psychological testing for assessment of emotional and behavioral disturbance, it was expected that more accurate and objective methods could be employed in the classification of "mental disease." Indeed, classification and diagnosis of "mental illness" within the prevailing framework of psychiatric thought and ideology became a prime task of the clinical psychologist. The prevailing assumption and existing logic of "mental illness" was accepted almost without reservation. THE MEANING AND UTILITY OF CLASSIFICATION AND DIAGNOSIS One should ask, "what is classified and diagnosed as mental illness?" Unlike other diseases, we have seen that mental illness has no observable causative agent, nor observable alteration of a physical organ, nor is there necessarily any change in the physiochemistry of the body which can be used as a basis for a classification scheme (Szasz, 1961; Albee, 1966). The conclusion is that it is social and interpersonal behavior that is classified and diagnosed (Szasz, 1966b). Social and interpersonal behavior, as such, cannot be ill or sick (Sartre, 1957). Only for a given social context and for certain purposes can behavior be labeled as sick (Szasz, 1966b). Classification of social behavior necessarily involves valuative and judgmental assumptions; such classification carries relational assumptions about a person. Therefore, nosology and diagnosis in psychiatry and psychology are, at best, social-judgmental acts of attaching a label to behavior (Szasz, 1959); at worst, such classification may be a moral indictment of an individual and his way of life in a given social situation. Nosology emerged as a form of moral indictment and social control for the behaviors deemed desirable. When existing classifications or prevailing labels failed to encompass a behavior in question, a new prefix was attached to an existing label. Schizophrenia is a case in point. In addition to the four original categories described by Bleuler, the term now carries a dozen or more subcategories, e.g., Ambulatory Schizophrenia, Alpha Schizophrenia, Borderline Schizophrenia, Circumstantial Schizophrenia, Incipient Schizophrenia, Latent Schizophrenia, Pseudo- Neurotic Schizophrenia, Residual Schizophrenia, etc. Yet the subcategories carry the same pejorative meaning as the generic label. Prefixes are now attached to practically all the existing diagnostic categories, with the result that almost any form of behavior (e.g., political activism, intense personal involvement, etc.) may be labeled for purposes of social and moral indictment and control.* +++++++++++++++++++++++++++++++++++++++++++++++++++
*This trend is particularly noteworthy in the new
Diagnostic and Statistical Manual {of the American
Psychiatric Association) which became official on
July 1, 1968. The new manual adds thirty-nine
diagnostic categories to those listed in the
International Classification of Diseases, usually
by subdividing existing categories (Spitzer
and Wilson, 1968).
+++++++++++++++++++++++++++++++++++++++++++++++++++
Psychiatric nosology and its communicative value is
essentially social institutional in nature. It
derives meaning from social-institutional contexts
and can be understood only in these contexts. For
example, within the sociological context of a state
institution, the relevant category to which a
patient is assigned is principally one of psychosis
vs. non-psychosis. The former tends to justify
forcible retention in the hospital, giving the
physician power over a patient; the latter does
not. The diagnosis of psychosis also legitimizes
the use of various, sometimes drastic, therapies
(Szasz, 1959). Other diagnoses, such as character
disorder, have little utility and significance in
this setting. In state institutions, psychological
testing is essentially used for the purpose of
classification of psychosis vs. absence of
psychosis. Psychological tests which easily and
quickly differentiate these two groups are
preferred.
Another context is the psychoanalytic situation. Within this framework, the same term, psychosis, refers only to certain mental mechanisms or patterns of human relationship; it does not refer to overt behavior (Szasz, 1959). Here, the utility and significance of testing does not lie in classifying or diagnosing, but rather in describing the mental life and dynamics of a patient. Psychological tests geared to produce fantasy and to describe psychical life are found more meaningful in this situation. In a legal setting, psychiatric diagnostic terms must also be categorized in terms of two mutually exclusive classes: "those who are, and are not, punishable." Psychological tests are employed to determine whether or not a person's psychological faculties are functioning reasonably well and whether he is able to stand trial and to assume responsibilities for himself. Thus, it can be seen that the use of psychological tests and the interpretations imposed (i.e. the meaning derived) is not independent of the contextual social situations. The meaning of test results and their communicability is dependent upon the social context in which the testing is done. Those tests done within a legal context, for example, would have little meaning within the psychoanalytic framework. The extent to which tests are explicitly constructed for nosological purposes determines their function as instruments of labeling. The categories of the M.M.P.I., for example, are based on psychiatric diagnostic labels. Even when administered to so-called "normal" people, the test requires a psychiatric diagnostic label is then attached to the scores on the tests. The usefulness of psychological testing is not meant to be negated by this discussion. On the contrary, tests have made significant contributions. First, tests have introduced a corrective measure by providing a basis for objective comparison of the individual with his group: this introduced a social context in psychology and psychiatry which had been lacking thus far. Second, numerous tests are not constructed upon psychiatric assumptions. These provide measures of various abilities, interests, etc., which provide an assessment without a pejorative connotation. Third, many "personality tests" provide a meaningful understanding of one's mental and emotional functioning. Finally, the use of tests in schools, industry, and similar situations where social context does not impose a derogatory meaning on the test scores have also proved useful. In the early history of emotional and mental disturbance, during the period of moral therapy, a disturbed person was neither labeled nor classified as ill or sick, nor was he given a diagnosis (Bockoven, 1963; Foucault, 1965).* His actions and behavior +++++++++++++++++++++++++++++++++++++++++++++++++++ *During this period, it was assumed that a person becomes insane because he has led an "immoral" life. His rehabilitation, therefore, consisted of providing moral therapy. +++++++++++++++++++++++++++++++++++++++++++++++++++were accepted at face value. Perhaps because such labeling was not practiced, the individual was not relegated to a less than human status, and an atmosphere of equality and acceptance was more easily created. The studies suggest that the recovery rates then were at least as promising as at present (Bockoven, 1963; Dain, 1964; Grob, 1966). With the rise of physical medicine, the classification procedures, diagnosis, and labeling of the emotionally disturbed became established practice Psychological tests and other techniques were introduced for this purpose. It was believed that deviant behavior was caused by an illness. The struggles, joys, and tribulations of an individual's existence are then interpreted as symptoms that are classified and diagnosed. The difficulty in finding a sound logical basis for nosology, the current confusion regarding nosology, the lack of success of classification and psychodiagnostic procedures in achieving better results with the emotionally and mentally disturbed, and the increasing reluctance on the part of many of the mental health professionals to use diagnosis and tests, all tend to suggest an urgent need for reexamination of the assumptions upon which classification, nosology, and diagnosis of mental illness are based, and the purposes for which they are used. BIBLIOGRAPHY
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