what on Earth has this to do with psychiatry I hear you ask.
Firstly, I take it as a given from my own experience that psychiatry has no faith or sincere interest in objective transcendent truth, never mind the good or the beautiful.
Secondly, I take it as a given that contemporary psychiatry is dominated by North America, its publication machine and the DSM. To the extent to which it exports its ideology beyond its borders and to the extent psychiatry is bio-political (as is certainly the case), American psychiatry colonizes other nations. It does this under the guise of caring words just as it does using propaganda words such as democracy, rights etc. And these other nations welcome becoming colonies.
Thirdly, when the effects of a various philosophies are found to be existing in an Anglo nation and can be attributed either to being manufactured locally or to have been imported from the European continent, it is the more parsimonious conclusion that the effects are from the local philosophy (i.e. pragmatism), though this of course is not to imply other influences are impossible (Marxism, postmodernism, other isms).
Fourth, Pragmatism qua truth being what is useful was an invitation to a power hungry hedonistic epistemology that was too much for modern (and post-modern) Americans to resist. It seeped into all areas of its culture and indeed even into psychiatry. It is evidenced by the words psychiatrists use. It placed a perverted epistemology in an unholy marriage with an ethics that would be unable to resist becoming perverted in kind. It is a question of human drives and motivations as to what people wish the truth to be in being directed to a desired end, ends often impacting upon other persons. In this sense pragmatism is necessarily a political philosophy. And the will towards a desired truth is the manifold upon which psychiatry can slide incoherently and effortlessly between appeals to reified truth as a science of the objective world (an appeal to scientific legitimacy), and also an appeal that the truth can be whatever is according to some other self serving end that it wishes (the continuance of power cloaked in the language of care, patient values etcetera). The truth is my truth. And who am I? I am the psychiatric guild. And the truth I trade in derives its “cash value” from verification. And who verifies? It is the guilds of psychiatry that verifies. If psychiatry verifies its own truths, it creates its own capital. And who owns the capital? The guilds do. Domestically they are monopolies. Internationally they are oligarchies. And then the public take these false “truths” as fact, via a focus on what the guilds call science at the time in a game when the doublethink makes opportune to invoke the word “science”. Surely this is an economy that can only survive as long as the metaphorical mint keeps printing the metaphorical cash, always borrowing on a future that never arrives, a society where the will to real truth has lost the “cash value” of a former age. This is the age where Oprah can speak of “my truth” and “your truth” with nary anyone taken aback at the horror of three hundred million truths, and few wishing to champion even the notion of “the truth”. This is the age where psychotherapies are more concerned with what “works for you”, as opposed to a confrontation with “what you are” or “who you should be”.
Fifth; Take a critical look at all the uses for the words pragmatic and pragmatism and their variants or subtexts in the psychiatric literature. It is everywhere. What follows is but one particularly egregious example from the Australian literature, a country where I once worked for a time, citing American psychiatric intelligentsia of course, this being consonant with my thesis.
The 2013 Royal Australian & New Zealand College of Psychiatrists (RANZCP) Mood Disorder Guidelines is the specimen to be studied, at its time the most up to date international guidelines in print. It remains perhaps the largest undertaking into mood and its disorders, so long in the planning that the previous guidelines were published a full decade prior. Weighing in at greater than one hundred pages, with more than a thousand references and a few dozen committee expert authors and advisors, it includes the claim to have consulted widely with many stakeholders including the laity.
The first section titled “Classification of mood disorders” opens with subtitle
“A pragmatic approach to mood disorder classification.”
It continues; “There is growing consensus that psychiatric diagnoses are akin to social constructs (Insel, 2014; Zachar and Kendler, 2007). It is nonetheless appropriate for the structure of this guideline to adopt an accepted mood disorder taxonomy because, (i) there is broad agreement about definitions, and (ii) diagnostic terms have accrued valuable meaning through scientific (e.g. clinical trials) and social processes (e.g. advocacy). (See: Figure 1). Using the terms as pragmatic organising constructs should not translate into their reification – the optimal classification of disorders must await a quantum leap in our understanding of the aetiology and pathophysiology of abnormal behaviour.”
The references are these.
Insel TR (2014) The NIMH Research Domain Criteria (RDoC) Project: Precision medicine for psychiatry. American Journal of Psychiatry 171: 395–397.
Zachar P and Kendler KS (2007) Psychiatric disorders: A conceptual taxonomy. American Journal of Psychiatry 164: 557–565.
We will dispense at the outset with the words “akin to”. This is written I suspect to allow one to evade critique by denying having made a definite statement, only something akin to the statement. The same is the case with the word “consensus”, as I suspect were I to say the consensus is the RANZCP they would say “no not us”, and have me running down labyrinthine alleys searching for the target.
The RANZCP guidelines are a lesson into the dangers of secondary reading and that bloating an article with references (or a book, hence my refrain) neither adds to the weight of scholarship or the strength of argument. You see neither the Insel or the Zachar and Kendlar articles state anything like approaching that diagnoses are akin to social constructs. Insel speaks of the DSM, “like other medical disease classifications”. His article is thoroughly wedded to the so called medical model and it would dishonour the man to suggest a social constructivist subtext that clearly is not present. It simply posits that medical science (under the RDoC framework) will grant the tools to reorganize a taxonomy of mental illness that would be an improvement on the existing one. There is not one single mention of any psychiatric disorder being etiologically either a psychological or social phenomena, much less specifically a “social construct” designed by a consensus group of powerful stakeholders.
And what of Zachar and Kendlers paper? Having been published pre DSM 5 in 2007, it’s a curious choice, with both authors publishing widely since. For Zachar this has reached its peak as a contributor in a multi-perspective wonderful series of articles in 2012 in Philosophy and Ethics in Humanities and Medicine. Suffice to say for now, Zachar sides with the American psychiatric guild and its colonies (Australia included) on the side of philosophical pragmatism. To use Allen Frances baseball metaphor of truth, he thinks the reality of an umpire’s call lay in how he uses it (Frances was chair of the various DSM IV committees). Or to speak of psychiatry, he considers models and explanations as more or less as a means to an end. For Kendler, he was a task force member of DSM IV and a member of the psychotic disorder working group, the group in which one hundred percent of its membership were in receipt of monies from the pharmaceutical industry. He also was part of the DSM 5 mood disorder working group 2007-2010. His views on the DSM are sympathetic at the very least, even whilst paying lip service to their imperfection. The cited 2007 article speaks of a need to revise the DSM for sure, though posterity has shown this revision to the DSM 5 be modest, to capture more people under diagnostic umbrellas than in earlier editions, and the DSM has continued to underwrite psychiatric diagnoses as bona fide medical illnesses. The article takes us on a journey not of consensus to social constructs but of many ways in which psychiatric classification may be considered. The authors do this by comparing 6 sets of dipoles as dimensions of categorization. (Causalism vs descriptivism, Essentialism vs nominalism, Objectivism vs evaluativism, Internalism vs externalism, Entities vs Agents and Categories vs Continua). Nonetheless at the end of the
