The Mad & The Mentally Ill: Against The Diagnostic Model (Introduction & Part 1)

Hey everyone, I've been working for the last few months on a pretty big essay called The Mad & The Mentally Ill: Against The Diagnostic Model. It's getting really close to being fully written now and as I realised I hadn't posted anything on patreon in ages I thought I should drop the parts that are done and update as I finish the others. It's been taking forever in part because I've spent the last 6-9 months teaching myself psychology in order to articulate my points properly.

I'm aiming to get back to publishing new videos starting this month with one of the essays I posted here a few months ago and hopefully will be able to release fairly regularly into the rest of the year. Looking forward to your thoughts and comments on these first parts, which admittedly are mostly build-up to the meatier points of the essay.

Introduction: Justice Schreber has sunbeams in his asshole

Daniel Paul Schreber was born in 1842 in Leipzig in what was then Prussia. He became a judge and then ran for elected office in the German Reichstag in 1884 and lost. This loss drove Schreber into a prolonged psychotic break of many months where he experienced paranoid delusions and was diagnosed with “dementia praecox”. This term, “dementia praecox” or “premature dementia” is how doctors used to say “going loopy before you’re old”, but eventually the term “schizophrenia” was coined instead by Swiss psychiatrist Eugen Bleuler, and I don’t think that’s very relevant but I really like the name. Eugen Bleuler. Bleuler’s description of schizophrenia proved ultimately quite messy and was eventually disambiguated into paranoid schizophrenia, some psychotic disorders and the autistic spectrum.

Back to Daniel Paul Schreber: During his first psychotic break, Schreber was treated by a psychiatrist called Paul Flechsig, and returned to work in 1886. He continued his career as a judge, but in 1893 his wife gave birth to a stillborn child and Schreber went into a second psychotic period, this time much longer - he was in psychiatric institutions for 6 years. After release he published his book Memoirs of my Nervous Illness, in which he laid out his cosmology, the entire system of truth he had come to believe in his schizophrenia.

For Schreber, there was a system of human nerves in the world, people’s souls moving through thought and matter, and there was a parallel system of nerves beyond the observable world, which was the system of God’s nerves and of all the souls of people who had died, who returned to God when they were no longer living. Normally these two systems wouldn’t touch except in moments of divine intervention, but the same thing that had made Schreber aware of this all had also caused a disturbance in the order of the world. 

In his paranoia, Schreber believed that his initial doctor, Paul Flechsig, had made “nerve contact” with him, putting unusual thoughts in his head and putting in action the slowly unfolding problems across the world. The inciting moment for Schreber as he describes it in his Memoirs is the thought that he would like to “succumb” to sex as a woman: “One morning, while still in bed, I had a feeling which, looking back on it later when fully awake, struck me as highly peculiar. It was the idea that it really must be rather pleasant to be a woman succumbing to intercourse.”

This thought, he felt, was completely alien to his mind and must have been planted there by God via sunbeams as part of Flechsig’s plan. He was simultaneously deeply troubled by this thought but also thought it was his divine purpose, saying at another point “I consider it my right and in a certain sense my duty to cultivate feminine feelings, which I am enabled to do by the presence of nerves of voluptuousness.” - Nerves of voluptuousness are here a special kind of feminine nerve which Schreber thinks have been developed in his body by the feminising beams from God.

As Schreber’s condition worsened, he started to believe that nobody on earth was real any more except for him, and that the few people he still saw were “improvised people” - that God had created them as illusions for him. And to what end? God is trying to slowly turn him into a woman, the ultimate woman, the wife of God, so that together they can repopulate the Earth with real people again and restore the correct order to the world.

Despite its internal cohesion, this all seems quite incomprehensible, but when you start to understand Schreber’s trauma history, a lot of it begins to feel like an obvious mirror of the things that he had in his head.

Daniel Paul Schreber’s father was a man called Daniel Gottlob Moritz Schreber. (Please, call me Paul, the rest of my whole ass name is my father’s name.) Moritz Schreber was a famous and well-respected author and thinker on how to raise children in Prussia at the time. We don’t know a lot about Paul’s childhood directly, but Moritz’s expressed views on how to raise children don’t imply that it would have been a happy one. He felt that good posture and physical fitness were the basis of moral goodness and success in life, and to that end he invented a whole array of devices both for “remedial exercise” and for “correcting” posture, with an intensely strict regimen for their application. He tested his theories, and his devices, on his children, because Daniel Gottlob Moritz Schreber thought the best way to create productive successful prussians was to put his son in a series of contraptions.

At least one of his posture “correction” devices, the geradehalter, was used explicitly as a punishment for not having what he considered good enough posture, and would tightly and uncomfortably bind the child’s shoulders, chest and head.

For Paul Schreber however, there was never a possibility even in later life to call this abusive parenting what it was. In her introduction to Schreber’s memoirs, Rosemary Dinnage writes:

“In the asylum, it was a most irrational God that tormented him. His particular misfortune was to be reared not just by a stern father but by the famous child rearing expert, celebrated for his Orthopedic Institute, his books, his Schrebergarten. How could he be wrong?”

The case of Justice Schreber is one of the most well known and thoroughly discussed cases in psychiatric history, so I’m sure I’m going to have plenty of original shit to say here. There was an interesting confluence in Schreber’s case of his notoriety, the comprehensiveness with which he documented his delusions, and to be honest the degree to which Schreber’s delusion self-aggrandises him as the ultimate main character of the universe while he also runs from what he perceives as his destiny explains why it’s found both fascination by the psychiatric community and adaptation into one of the most famous animes of all time, Neon Genesis Evangelion.

No, I'm sorry this is only partly a joke. One analysis of Evangelion points out that SEELE and NERV, the governmental organisations in the story are german for “soul” and “nerve”, two basic elements of Schreber’s cosmology and when you think of Shinji as this unwilling main character at the centre of the universe with an overbearing father demanding perfection of him – it seems pretty fair to assume this was a deliberate reference - Evangelion is a complex masterpiece exploring the struggle to understand the meaningful subjectivities of others and connect with other people without losing yourself while at the same time taking responsibility for yourself and what you owe to other people, and I don’t mind calling an anime a complex masterpiece because this an essay about mental illness and I have simply never been well in my life.

Sigmund Freud, who never met Schreber but analysed his Memoirs, had a lot of stinky shit to say about his delusions. Freud saw the two gods in Schreber’s cosmology as being projections of his father and brother, which is probably a pretty reasonable understanding but then Freud says that the root of the delusions are repressed homosexual feelings that Schreber had for his family members.

A crucial positive element of what Freud brought to analysing the case of Paul Schreber was that he saw Schreber’s delusions not simply as a malfunction but as a protective mechanism, a way to make the world make emotional sense at the expense of reality.

This point really has legs. For example, in one part of Schreber’s delusions he felt that his chest was being compressed (the binding-of-the-chest-miracle) like it was bound in place in the same way it would have been in the geradehalter. This reads pretty straightforwardly as a trauma flashback, but not only did Schreber idolise his father, he wouldn’t really have any frame of reference for what this experience was. This was a time and place culturally where trauma was not only not understood, but where it was socially unacceptable to suffer in this way. Your mind would have to go to pretty extreme lengths to make sense of what you were experiencing with that little context to properly parse something like that.

It is important to understand that Paul Schreber found himself so detached from his body and his surroundings that he progressively saw everything happening around him as “miracles” which was his term for interventions by God, from food spilling down his shirt to the appearance of other people. His ability to centre himself as a subject in his own life had disintegrated.

Ultimately an all-consuming psychotic delusion can be your brain trying to make the sensations and experiences that your mind and body are going through make sense, and when some of those sensations and experiences are beyond your understanding, or shaped by people who are no longer present, the paranoid construction of an omnipotent force trying to fuck with you fits with your emotional understanding of the world. When that delusion and those experiences make you feel extraordinarily alienated from other people, seeing other people as manufactured or illusory makes more sense than it seems to at first. 

Schreber has been analysed and reinterpreted many times, but to jump to the exact opposite of Freud’s analysis for a second let’s talk about Anti-Oedipus, a direct refutation of Freud (and incidentally of Marx and Lacan and everything theory dorks hold dear) by Gilles Deleuze and Felix Guattari.

Deleuze and Guattari start from the place that shit models like the Oedipus Complex are too normative to be truly useful and because they break down in cases such as schizophrenics they don’t truly describe something inherent in the mind but something being imposed by society. Therefore they construct a model primarily of the schizophrenic mind, even using some of Schreber’s own terms for their model and then work backwards to show how all subjectivities can be understood the same way. In doing this they create a psycho-socio-political analysis of madness as being produced in capitalism’s subjects by the same things that it attempts to use to conform them into productive labour units.

Deleuze & Guattari map out the way that the mind works with a radically different phenomenology, so idiosyncratic and opaque that people who agree on the overall points and meaning of their work can debate endlessly on the ways that the specifics fit together. Foucault called Anti-Oedipus more of a work of art than of theory, while also saying that Anti-Oedipus is the “introduction to non-fascist life” saying it is “less concerned with why this or that than with how to proceed”.

Incidentally, there is also a deleuzoguattarian analysis of Neon Genesis Evangelion  you can read if anyone in my audience is subscribed to the Journal of Anime and Manga studies, I assume you’re out there.

The parts of the mind for Deleuze & Guattari that basically construct subjectivity in a moment-to-moment basis are the desiring machines of the body which connect to the things that are desired, the paranoiac machine which rejects them, the celibate machine that produces an intensive quantity out of this tension and a miraculating machine which convinces itself that it is a self and that the intensive quantity is a thing that it, itself, is experiencing. It’s okay if none of this makes sense, this isn’t primarily an essay about Deleuze and Guattari and unless you have a spare 2 days to explain it you find yourself talking and talking thinking that you’re making sense and then your partner looks at you and says “yes Sophie but what does that mean when they say the body without organs is an egg” and you say “I… need to poo”.

The part of this analysis that I want to talk about for Schreber is Anti-Oedipus’ various syntheses. You can synthesise information about two things in three ways fundamentally according to the book: the connective synthesis (this and this and this) puts things together in a set; the disjunctive synthesis (this is not that) differentiates between things; and the conjunctive synthesis (ah, so it’s) reveals that two things are actually one thing. When you have the language to explain these basic logical relationships you can explain delusions in terms that are frankly a lot less scary. Someone who is paranoid can often be seen experiencing an abundance of conjunctive syntheses - they think that everything is a coded reference to something else “ah so it’s a numerical code for chapters in the bible”, “ah so it’s predictive programming revealing what the illuminati are planning”, “ah so it’s gangstalkers watching me for the government”. In their critique of Freud and of Oedipus, Deleuze and Guattari show that the oedipal model is authoritatively forcing a conjunctive synthesis upon patients, demanding that they identify themselves with the characters in a story that doesn’t actually make sense for them.

Different models of the mind explain the basic processes that we use to think. Even models that don’t claim to attempt to explain psychosis can be mapped onto a case like Schreber’s.

For example, Marsha Linehan developed Dialectical Behavioural Therapy to help people like her who have Borderline Personality Disorder, which is characterised by unstable moods, insecure sense of self, dissociation, and can lead to or arguably develop into other conditions - more on this later. Linehan saw that people with BPD often develop similar skills to manage their own disordered thinking and in codifying those skills as a clinical treatment she developed a model of the mind based in dialectics between things and their syntheses or resolutions.

In Linehan’s model, because everything is processed dialectically, the times when we find ourselves stuck are because we can’t resolve a dialectic, either because we constructed it wrong, or with a missing piece of information, or we lack the skills to properly resolve the dialectic. This is known as a dialectical failure, which is what I like to call Max Stirner (sometimes you write jokes just for you and that’s okay)

Through the lens of dialectical failures, you can see the tension between the expectations Daniel Paul Schreber had on him to be a perfect successful man and the grandiose fantasy in which he is going to be made into a woman with whom God will repopulate the Earth with real people. The missing piece that makes the resolution of this dialectical failure so hard is that it’s okay for Schreber to fail, to be imperfect, to be normal. As for wanting to become a woman, there is no psychological explanation for that. Science has no answers.

The first basic error that one can make and that lots do make is to assume that to be insane is a fundamentally different state and that the basic processes of thoughts in a mad person’s mind are not those found in the minds of everyone else. As Foucault puts it, it is “The marvellous logic of the mad which seems to mock that of the logicians because it resembles it so exactly, or rather because it is exactly the same, and because at the secret heart of madness, at the core of so many errors, so many absurdities, so many words and gestures without consequence, we discover, finally, the hidden perfection of a language.”

There are two lines of thought on madness that have been taking up space in my head for a while now. One is a cultural fear about madness that Foucault highlights in Madness & Civilisation, that madness in some sense presages the end of the world, the idea we see culturally expressed by traditionalists and conservatives that “the world today has gone mad”. The other attitude is Thomas Sankara’s famous line that fundamental change requires “a certain amount of madness”. As I’m describing these I realise that they might actually fit together quite simply, and that they provoke a set of questions about a world different to how ours is now in how it treats the idea of madness. We don’t yet have those questions, let alone their answers, but I think asking them requires that we look at the way our society thinks not just about the mad, but about everything.

The Mad & The Mentally Ill: Against the diagnostic model

i. Getting better, getting free

I was talking to a friend and comrade about a year ago and we were outlining what we considered to be the fronts of liberation that need the most effort and energy to make a better world. I have a list of 6 that I use as a bit of a rule of thumb, and after I listed them off they said to me “yes, I suppose, but i think there is also getting better, understanding your psychology. I think that’s the internal front” and I agreed, said this was a very important front to fight for liberation on, and they said maybe it’s the most important one.

Since then, and as I’ve been in therapy and taking my mentle elf more seriously, I’ve been thinking about this kind of psychological liberation and in doing that I’ve put together my thoughts on the sociological class of the mad, the liberal identity class of the mentally ill, the mind, neurodivergence and how it all relates to leftist values. As I’ve approached finishing this essay I’ve felt in turns wretched, annoyed, dreadfully depressed - go figure, thinking very hard about how crazy you are isn’t a particularly pleasant experience. Very rarely I’ve felt like I’m onto something I really really like and very often like I just desperately want to be done with the fucking thing. There is already a long tradition of class consciousness leading writers into exploring psychology and I’d like to invite others into a conversation here about building a model of the mind that helps us build the world we want to see.

I am obviously not a therapist, psychologist or psychiatrist. My experiences with mental health are those of my own mind and of being in community with people who experience poor mental health and whose minds work in a huge variety of ways. Therefore I’m talking about everything at a distance because I’m not looking to either have my perspective disregarded on the grounds of my own pathology or to walk my audience through the ins and outs of the depressive, dissociative, psychotic, even schizophrenic mental health crises of my friends and comrades. I believe in the capacity for people to truly heal and to help each other heal having seen it firsthand. I have also seen firsthand how an inability to foster healing can turn communities in on themselves and completely frustrate their ability to organise.

Getting better is an essential part of getting free.

Madness & Civilisation by Michel Foucault is considered a classic of leftist analysis and of understanding the history of madness and the development of psychiatry. It completely upended the way that people discussed mental illness by presenting the development of sciences of the mind as a story of a loss, a sort of flattening. Foucault argued that alongside the progress in treating patients, the emergence of asylums meant the confinement of the mad to the edge of society so that the general population could be considered purified, cleansed of madness, a thing that had previously been understood as something that everyone would encounter at some point in their lives.

In the preface to the 1961 edition of the book, Foucault wrote this:

“There is no common language [between the sane and the insane], or rather, it no longer exists; the constitution of madness as mental illness, at the end of the eighteenth century, bears witness to a rupture in a dialogue, gives the separation as already enacted, and expels from the memory all those imperfect words, of no fixed syntax, spoken falteringly, in which the exchange, between madness and reason, was carried out. The language of psychiatry, which is a monologue by reason about madness, could only have come into existence in such a silence.”

Now, how valid is Foucault’s perspective on all this?

Critics of Foucault argue that his history of madness is told selectively, that it makes earlier periods appear kinder to the mad than they actually were, and this critique does align with the nature of Madness & Civilisation - ol’ Michel is making a somewhat reactionary appeal to the idea that the mad used to be considered wise and possessing hidden truths. This same appeal is present in his idea of a “lost common language” between reason and madness, but the underlying argument holds nonetheless. There is a felt absence of communication, and a discarding of the perspectives of those deemed mentally ill, and both of these are caused by the structure of the modern attitude that the mentally ill should be confined and treated until they are made well enough to contribute.

The felt absence of a common language for talking about how the mind works, I would argue, drives the popularity of pop-psychology. People feel alienated and misunderstood by the way that psychiatry and clinical psychology tells them that their minds work. A lot of people, both in bestselling books on psychology and social media discourse around neurodivergence, are looking for if not a language, a clear explanation of the rules of engagement - a way to connect with people who think differently. So although there are many competing frameworks out there, usually sold on the basis of self-improvement, in striving for liberation on this “internal front” we should look to find a common way of understanding each other.

In the 1960s period drama show Mad Men there is a character called Michael Ginsberg who appears as a creative prodigy within the advertising firm whose ideas are reliably excellent and astonishing to others. He is quirky and eccentric throughout the show, sometimes saying things or acting in ways that mark him out as strange, and then almost seemingly out of the blue he suffers a psychotic episode where he believes a persecutory delusion and engages in an act of extreme self harm. Immediately following this he is committed, we see him wheeled away strapped to a gurney and he is never seen or heard from again.

Ginsberg’s arc in the show is very illustrative of the way that the mad are disposed of without further discussion, introducing a character who is charming and often more relatable and likeable than lots of the others around him, who through his quirks is always earnest, fun and generally cheerful and then showing how his madness is so disruptive that everyone in his social context would rather pretend that he never existed than try to reconcile what happened beyond “he went crazy” or “he was crazy all along”.

Even between those two possibilities though, there is a tension - and it’s worth examining. Did Ginsberg “go crazy”? Well, one day after a period of mounting stress and shifting circumstances that provoked anxiety about his place in the world, he was quite noticeably less well: he believed in an imminent threat that wasn’t there and his actions were nonsensical, scary to people around him and harmful to himself. On the other hand, there were moments in the long lead up to this where he expressed beliefs that were taken as whimsey or misdirection away from his trauma, that if we assume he authentically believed were actually quite significant delusions (he believed that his birth in a Nazi concentration camp and the death of his parents was a fabricated story and that he was actually sent to Earth from Mars on a secret mission). These delusions weren’t affecting his behaviour on a day to day basis until this period of extreme stress drew him deeper into them, and then into his more obviously defined episode of psychosis. It’s obvious and was always obvious that Ginsberg was different, and were he to have confronted and processed his past trauma, it wouldn’t have made him less so.

I’m using Ginsberg’s case as a way in to talking about psychosis, a group of mental symptoms linked by a loss of touch with reality. Psychosis can be induced by lack of sleep, drug use, extreme heat and dehydration - we’ve not gotten to climate change yet but we will - destabilising life events and simple overwhelming stress. The kind of stress that can lead to psychosis can be related to previous trauma and the way that it creates tensions with living in the wider world, but there’s an important distinction to make here. Great news: Psychosis can happen to anyone! Yay!

We always begin in these conversations by discussing the kind of madness that Foucault would call “a blindness to physical truths”- hallucinations, false sensory information generated in the brain. Foucault said that society discussed madness using two broad and overlapping categories, a blindness to physical truths and a blindness to moral truths: “”Moral truth”, on the other hand, “consists in the exactitude of the relations we discern either between moral objects, or between those objects and ourselves.” There will be a form of madness consisting of the loss of these relations; such is the madness of character, of conduct, and of the passions.”

Madness as a social class, if it is defined in Foucault’s “blindness to physical truth or blindness to moral truth” is defined in a lack of coherence with reality, but moreover with the realities of productive life in society. In other words, “who’s truth?” Madness is defined in incoherence and in inconvenience. Addicts are considered mad. Rough sleepers and beggars are implicitly considered mad if the observer assumes they refuse services that would improve their situation, which they are assumed to have done since their situation hasn’t improved. Many a kafkaesque fantasy imagines people placed in mental institutions because they know something that they shouldn’t about the way that the world works or because they’ve become inconvenient to some powerful group’s social truth, mirroring Foucault’s thesis.

In the framework given by Madness & Civilisation, the mad have been confined to a limbo not quite in nor fully out of society, through the logic of treatment. The conversion of the mad into the mentally ill has been performed to allow the idea that madness is not the end of someone’s life but rather more comparable to bodily sicknesses all the way from the flu to chronic pain.

There is a saying that all models are wrong, but some models are useful. 

Well, I have a bone to pick with the diagnostic model - I am going to be critiquing the diagnostic model, not arguing for its abolition. We have had arguments for the abolition of the carceral psychiatric system for a long time now, but I want to look at the deep problems in the diagnostic model itself. I’m sure that it sounds whacky to some people to say that the system of classifying and treating mental illnesses is what I have a problem with, but I’m also sure that for people who have multiple mental health diagnoses it sounds like a conversation they’ve been waiting for a long time to have. This essay began in the question of how we get better in order to get free, and as I wrote more of it, the system of diagnosis - not just the way it is done but the philosophical underpinnings of how the mind is treated - came up again and again as a point of frustration.

I think that to quickly run through defences of the diagnostic model is a useful exercise, because if we can see what is useful about this model we can see firstly why it doesn’t need throwing out entirely, secondly where its scope should be which will help us define where it overreaches, and thirdly what are worthwhile and positive outcomes that would be worth recreating in the places where the diagnostic model should be withdrawn. 

So firstly, some models are useful: the model is useful in that it is used for understanding and treating poor mental health. There are treatments that work and help for specific issues of poor mental health and furthermore, getting specific features of poor mental health diagnosed can help relieve shame for someone who would otherwise just think the same things were inherent and integral features of their existence.

Secondly, what is the scope: the diagnostic model is for identifying poor mental health for the sake of treatment, and I am leaving a lot unsaid about that which we will get to later, but for now we can appreciate the positives of having a model that fits that scope. While it leads us straight to critiques like the presence of queer and kink identities as diagnoses in the DSM which point at the DSM exceeding its scope, we can still see that within the purview of identifying and treating poor mental health, identifying things that cause people problems in everyday life like addiction, depression, lack of executive function and so on, the study and classification of poor mental health can help people.

Thirdly, therefore: if the diagnostic model can appropriately distinguish what is poor mental health, identify it and offer treatment, it can help people to understand themselves better, find solidarity with others like them and live happier, fuller lives. There is critical overlap here however, between the diagnostic model and something social beyond its scope, because knowing that you share the same diagnosis as others can make you feel less alone and more understood, and sometimes finding community with other people who share that diagnosis can help in healing in ways that benefit people even beyond the treatment that they can in theory be offered after being diagnosed.

But on to the direct critiques:

To repeat what we’ve already said, being gay used to be a diagnosis in the DSM, being trans still is, and so is having fetishes. The diagnostic model is used beyond its scope to classify behaviour that psychiatrists or rather psychiatry as an institution considers strange, which is informed by what society considers strange. This critique is the implicit normativity issue - here our “blindness to moral truths” comes back to bite us. The moral truths for one person that “it’s wrong for men to have sex with men” or that “there are only two genders and they are immutable from birth” is in conflict with the moral truths for another that “shut the fuck up dickweed”.

Next: the diagnostic model problematises - it treats the patient population as necessarily having a problem that needs solving because such is the nature of treatment. However, it also invents problems due to the assumption of otherness or wrongness given to patients. 

The name “autism” originally derives from the idea that an autistic person is completely turned inwards, alone and isolated from others in a fantasy world in their head. This turns out to be a perfect example for understanding Foucault’s “lost common language” issue because for a long time a diagnosed symptom of autism has simply been that autistic people are bad at making friends, rather than the reality autistic people were aware of and psychiatrists only cottoned onto recently, that autistic people are just as capable of making friends with other autistic people as non-autistic or allistic people are with one another. There is an observable difficulty in communication between autistic and allistic people, but neither group actually suffers from the inherent characteristic of being bad at making friends.

What psychiatrists were observing was a social issue around autism and blaming the autistic patient. This is a systematic problem of the diagnostic model because once a person becomes a patient everything about their life is under a microscope. In the case of autistic people, the problematisation of autistic behaviours has led to the development of Applied Behavioural Analysis or ABA, a method of systematic child abuse intended to train autistic children like dogs into behaving how allistic parents want and expect them to behave.

When psychiatrists observe a whole host of social problems around a patient population, psychiatric stigma can combine with the general societal stigma to produce what are commonly understood as “evil diagnoses”. The key examples here are disorders like the Cluster B Personality Disorders which psychiatrists have only recently stopped defining in “manipulative” behaviour and compromised on the polite metaphor of “maladaptive behaviours”. Among them, Borderline Personality Disorder - see also Beautiful Princess Disorder, Bad Person Disease, Brain Please Don’t - Narcissistic Personality Disorder - named after a Greek myth about being a twink - and Anti-Social Personality Disorder - which literally has the listed risk factor of being poor. 

As an aside, the diagnostic model operates in close relation to statistical analysis, looking at what is statistically unusual but common enough to constitute a disorder or diagnosis. The DSM is, after all, the Diagnostic and Statistical Manual. If psychiatrists won’t diagnose these because of stigma they won’t show up in statistics as frequently which creates a feedback loop telling everyone involved that these behaviours, this personality type are unusual, abnormal, pathological et cetera.

We need to think a bit more about how mental health diagnosis and treatment works to talk about the next critique.

Not exactly a positive, but a common defence made of the diagnostic model would be a general defence against specific criticisms, because it is of course updated all the time. If what we had to say against the model boiled down to “you are misdiagnosing this or that”, the diagnostic model would happily swallow this criticism and adjust. Conditions have their names changed within the model frequently, like “dementia praecox” to “schizophrenia”, but also categories change, relationships between conditions are reevaluated and so on. The term neurosis for example, which used to classify all mental conditions such as depression and anxiety which do not include a radical departure from reality - are not psychotic - is no longer used in clinical diagnosis.

Let’s look at an example.

In the video It's Time To Revisit Dissociative Identity Disorder by Neuro Transmissions, Micah (one of the channel’s presenters) argues that Dissociative Identity Disorder, often colloquially known as Multiple Personality Disorder, should be eliminated as a diagnosis. His argument is that the diagnostic criteria for DID essentially already contain the criteria for PTSD, and so everyone diagnosed with DID could be diagnosed with PTSD, and that most people with DID also receive diagnoses for Borderline Personality Disorder, which involves sudden swings between different moods and often dissociation around this emotional rollercoaster. 

Therefore, he concludes, DID should be reclassified as PTSD Dissociative Type and BPD with Dissociative Amnesia. The mechanisms here being that someone with PTSD experiencing long term repeated flashbacks to their trauma essentially presents different personality states, as does someone whose radically different emotions leads to a divided sense of self with dissociative amnesia between the emotional extremes.

As a diagnostic suggestion, I don’t hate this - It reduces comorbidity, that is it turns more diagnoses into fewer diagnoses, which is essentially one of the things the diagnostic model wants to do whenever it can, and the mechanisms for how different personality states would come about within the logic of this model make sense.

There are problems with his arguments however. Firstly, a part of his scepticism toward the existence of DID is expressed through the common psychiatric concern that portrayals of DID in the media is leading to people identifying with the condition - graph of left handedness here please. Secondly, his discussion doesn’t actually account for the currently diagnosed types of dissociative disorders, which include not only DID but also OSDD types 1a, 1b, 2, 3 and 4. Vitally here, Otherwise Specified Dissociative Disorder (OSDD) type 1b is essentially DID without dissociative amnesia, so it wouldn’t have a place in Micah’s new diagnostic schema.

These issues are relatively trivial however, because as I say, when we are sticking to the logical framework of the diagnostic model, it is simple enough to make small adjustments to fold in discrepancies like this. The problem really emerges at the patient end.

At one point in his conclusion, Micah says “All models are wrong but some are useful” Woah! He says the thing I said! I’m messing around. Obviously I saw his video first and I’ve stolen it from him. I like this as a way to process what the issue is here though. What is this model useful for? What is it being used to do?

Here, the model is being used to cement the patient’s existence as a symptom of a deeper illness. The existence of alters, personalities, headmates, personality states, or however else we choose to describe the parts present in the psyche, remains a symptom of a disorder whether it is causing the patient distress or not.

From here we have derived a specific critique: the diagnostic model abstracts and alienates its subjects from their context. We are moving through a topic here that has to do with how people relate to themselves and others, and we do that primarily through stories. There is a story of self that you tell to construct who you are and the diagnostic model wants to introduce conditions, syndromes and acronyms into that story as alien parts. This isn’t just problematising the patient but internally problematising parts of the patient.

In her TED talk The Voices In My Head, Eleanor Longden tells the story of how she started experiencing auditory hallucinations while in college, and though the voice she was hearing at first was totally neutral, narrating her experiences as though observing from the outside, when she talked to people about what she was experiencing and was met with concern and alarm, the voice and then multiple voices became hostile to her. It was only eventually through reconciling with these parts of herself that she became well again - she came to see the voices telling her that she’s in danger as a part of her being anxious, the scared and angry voices telling her what her trauma was making her feel, she saw that the parts of her were still parts of her whole self and that they wanted to help her when she wasn’t hostile to them.

Here I think we have a curiosity and a conflict. By Foucault’s definition, hearing voices is a blindness to physical truth. If we were to interrogate society’s normative notion of the self as a cohesive and singular object, it is a blindness to moral objects too. Therefore, by those definitions, it is madness, but Eleanor is not mentally unwell.

Vitally, the mind is reflexively shaped and affected by the story through which you understand yourself, and the body and mind are in a constant interrelation that can drive symptoms to emerge in either because of the state of the other. It just isn’t as simple as mechanical analogies of the body, brain and mind would make us think, and at this point we find that we have people who are not obviously experiencing distress or problems in their day to day lives, but whose qualities reveal a contradiction. If we have people who feel that they are fine but who psychiatry insists have a problem, we can see how quickly treating them as patients rather than people could lead to serious harm, because the contradiction here is an existential one.