In Spiked, Sandy Starr reviews Gary Greenberg’s recently published The Book of Woe:
There is an inevitable contingency about diagnostic categories, particularly when it comes to psychiatry. Greenberg argues that for all the useful work that goes into constructing these categories, psychiatric diagnosis has a ‘self-validating nature…by which once you’ve created a diagnostic category, the fact that people fit into it becomes evidence that the disorder exists’. Greenberg reminds us that ‘while many diagnoses are made on clinical signs and symptoms rather than on lab tests or other external validators, only in psychiatry are all diagnoses made that way’.
It’s worth adding that this may be changing. As psychiatry seeks to predicate itself more and more upon genetics and neuroscience, there are expectations in some circles that biochemical diagnostic tests for psychiatric disorders will follow ineluctably. This prospect does not reassure me. Psychiatry is attempting the difficult feat of relocating its foundations without toppling its façade, and this involves elisions — several of which are discussed by Greenberg — that leave me feeling less persuaded of the profession’s credentials, not more.
That said, one can certainly appreciate the need for psychiatry to appear coherent and confident, given the far-reaching consequences of the DSM’s contents. Greenberg explains, for example, how the use of a single ‘and’ where an ‘or’ might have been used, in the definition of ‘paedophilia’ that made its way into the fourth edition, inadvertently made it far easier for US authorities to detain indefinitely (on psychiatric grounds) people who had been convicted of sexual offences against minors. In other words, a single use of the word ‘and’ in the DSM led to a complex domain of morality and law — the culpability (or otherwise) of people charged with sexual offences in various circumstances, and proportionate sentencing for their crimes — becoming subordinate to the considerations of psychiatry.
‘Once you start to think of your troubles as a disease, your idea of yourself, which is to say who you are, changes’, warns Greenberg. But while psychiatry gives a diagnostic imprimatur to our expectations of ourselves and of one another, psychiatry is not solely capable of bringing about a wholesale alteration of these expectations. To understand what else might account for a psychiatric turn in society, one needs to recognise that we live in a culture in which our adult capacities are constantly denigrated, in which victimhood has become one of the few widely recognised sources of authority, and in which we are constantly encouraged from all directions not only to put our problems on public display (rather than addressing them within the intimate confines of trusted friends, family or — in extremis — psychotherapists or even psychiatrists), but also to assume that our problems will most likely afflict us in perpetuity.
It’s not so much the case that psychiatry now seeks to colonise everyday life — rather, everyday life now invites colonisation by psychiatry. In circumstances such as these, even the most well-meaning and scrupulous psychiatrist might struggle to parse the suffering and idiosyncrasy they encounter, so as to partition it sensibly into the pathological and the normal. Greenberg’s barbs against psychiatry may be well deserved, and are certainly grounded in tantalising insider detail and no small amount of wit. But they represent an incomplete picture of the dynamics he sets out to get to grips with, which lie outside the institution of psychiatry as much as they lie within.