3 June 201311 June 2013 Politics Debating DSM-5 Stephen Wright Last month the British Psychological Society’s division of clinical psychology (DCP) issued a statement attacking the dominant bio-medical models of mental illness. Lucy Johnstone, a clinical psychologist who was one of the architects of the DCP’s statement, said: ‘There is now overwhelming evidence that people break down as a result of a complex mix of social and psychological circumstances – bereavement and loss, poverty and discrimination, trauma and abuse.’ The DCP’s statement was a pre-emptive strike on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was published a couple of days later. The categorisations of human experience promoted by the various editions of the DSM have been immensely influential across the world. If you visit a shrink for reasons to do with what you might refer to as your ‘mental health’, it’s quite likely that he or she will be working within DSM diagnostic criteria and may even have one in mind for you. GPs, never afraid to diagnose and medicate mental states, can use DSM definitions pretty freely too. Given the modern history of the US in establishing political hegemonies and practices of cultural dominance, this is something of a worry. Millions of people are diagnosed, treated and medicated according to imperial American psychologies. The DSM-5’s publication has generated something of a backlash, as professionals and non-professionals – using an internet that wasn’t available when DSM-4 appeared – articulate what everyone has known for yonks: that the DSM is unreliable, unsafe and promotes models of mental health that look positively Orwellian. Lucy Johnstone’s implicit definition of mental illness foregrounded poverty, discrimination, loss and abuse; all states that neoliberalism facilitates and perpetuates. These are not factors that classical taxonomies of pathology have sought to embrace. And for good reason. Descriptions of mental illness can very often be typologies of cruelty, an interpretation of someone’s identity that they haven’t participated in but have to submit to. The mental health profession has historically been ridiculously easy to recruit by totalitarian or colonial systems seeking to pathologise dissidence or difference. Even as a diagnostic tool, biomedical models such as the DSM can be worse than useless. Anders Breivik was examined by two different psychiatric teams who came to completely different conclusions. They couldn’t agree if he was psychotic or not. They were asking a question that was beside the point. Even Noddy could tell you that murdering 77 defenceless children and adults is probably not a sign of sanity. But it is the political conditions that enabled Breivik, and how they fired up his personal pathology, that are of critical interest. As the Lacanian psychoanalyst Darian Leader wrote in a piece on Anders Breivik, ‘Paranoia has three classical components. The paranoiac has located a fault or malignancy in the world, he has named it, and has a message to deliver about it. For Breivik, the conviction is that Europe is rotten, that the name of this rottenness is Islam and that it is his mission to expose and excise it.’ The other night I was listening to Benjamin Britten’s opera Peter Grimes (violent child-abusing fisherman battles with toxic bigoted villagers) one of the three operas of which I am quite attached. In opera, when protagonists are faced with an irretrievable loss or a dilemma that cannot be resolved, they often go mad. As ridiculous as the plots of operas can be, there’s some kind of truth and pathos in their use of madness. In our domestic, neoliberally constructed lives we can confront these dilemmas continually: my iToy was made by slaves/I’m dependent on it; daddy does that thing to me/daddy says he loves me; if I love my partner I have to have sex with him/if he wants sex with me that means he loves me; a career gives my life meaning/a career is chewing up my life. Unlike popular depictions of madness, it is rarely actually operatic. But the consequences of competing and conflicting states of existence can be devastating. And, of course, these are the states that neoliberal capitalism specialises in both creating and managing. These can take an infinite number of forms. After all, creating an endless variety of subjectivities is what capitalism specialises in. They are always fractured subjectivities, or to use a DSM term: dissociative identities. Capitalism creates intense desire and insists those desires can only satisfied by engaging in a process of destructive and voracious acquisition that is both endless, and dependent on compliance and silence. Nobody orders us to compete in an increasingly punitive workplace, plunge into the wasteland of a 30-year mortgage, rear our children in fractured nuclear families and fill our lives with possessions made by slaves in countries we prefer to visit as tourists. But we do, largely because we often have little choice. The DSM format of mental illness is one shorn of any political context. The idea that what is called ‘mental illness’ is actually an effect of ordinary, sanctioned practices of relationships, gender identities and economic worth is one that needs more attention. Those of us in what are sometimes called the ‘helping professions’ rarely consider that what we are doing in working with those designated as mentally ill is cleaning up the endless devastation caused by neoliberal capitalism and, not unusually, enabling a kind of pathological neoliberal framing and labelling of the helped. That is why behavioural cognitive-based therapies are so attractive to politicians and functionaries of the neoliberal state; it avoids any analysis of the context around the diagnosed condition, it gives them an out in demonstrating their compassion, and promises a definite quick fix, like sending a car to a mechanic. In his new essay-length book Strictly Bipolar, Darian Leader points out that the surge in diagnoses of bipolar disorder ‘occurred precisely when the patents began to run out on the biggest-selling mainstream antidepressants in the mid-90s [and] bipolar suddenly became the recipient of the vast marketing budgets of the pharmaceutical industry’. The diagnostic mechanisms of the DSM dovetail neatly with the massive US insurance and pharmaceutical industries. The designation ‘mental illness’ is also a way that those working in the field of mental health can use to manage out their perceptions of trauma, of the terror that interacting with the distressed can bring, and nullify any political causes. Trauma has of course, a traumatic history. And part of that history is trauma’s ineluctable links to the political, links that are often effaced or forgotten. The history of trauma’s descriptions – hysteria, melancholia, nerves, shellshock – are all linked to oppressive cruel social orders: misogyny, child abuse, war, colonial occupation, neoliberal economics and so on. To trace the etiology of trauma is to map the history and topology of social unrest, oppression and political cruelty. ‘Is mental illness culturally determined’, the Guardian cautiously asked last week, positing a question that Frantz Fanon chewed up decades ago. Physical trauma is a wound; a damage to tissue. The physical organism has been breeched. When we talk about (what is termed) ‘psychological’ trauma, something else has been breeched, something difficult to quantify. What has been damaged is the sense of meaning-making – the actual building blocks of one’s personal experience; the thinkable-about, the dreamable-about, the actual way we remember things. This is the membrane that contains us. Something breaks down as though a violence has happened internally as well as externally. Nothing is predictable anymore. There has been an internal loss as well as an external loss. What was coherent internally is now fragmented and chaotic and terrifying. What has happened becomes unspeakable via the primary method of symbolising language. It gets spoken in other ways, a so-called ‘symptom’. Of course these take many diverse forms. In the introduction to his lecture ‘Air War and Literature’ contained in his book On the Natural History of Destruction, WG Sebald wrote of the affect that the Allied bombing of Germany had on his writing. Sebald was born a few weeks before D-Day; that is, after the firestorm of Hamburg but before that of Dresden. I am one of those who remained almost untouched by the catastrophe then unfolding in the German Reich [but] I tried to show, through passages of some length taken from my own literary works, that this catastrophe had nonetheless left its mark on my mind. The staggering numbers of traumatised US combat veterans, dumped back in the middle of the most rapacious neoliberal economy on earth, is both a reality and a metaphor for how capitalism creates and discards its subjects. The trauma experienced by US combat vets is of two orders: first, there’s the overwhelming psychological trauma produced by continual states of terror and hyper-anxiety and exposure to, or commission of, the bloody destruction of other human beings. Second, those recruited for the patriotic wars against freedom-haters often really believe that’s what they are doing – making the world a purer place by killing bad guys. The realisation that their struggle against evil was actually a meaningless slaughter for the benefit of a few oligarchs or multinationals can be unspeakably bitter and again contribute to that bicameral state of mind I mentioned earlier: my country is the greatest nation on earth/I murdered children in its name. I’m not arguing that combat vets routinely experience epiphanies into the dark heart of capitalism. But the pernicious thing about capitalism is that the only way to come to understand one’s complicity with it is to gain an understanding that is, in a sense, traumatic. There is no DSM of Normal States. In fact a desire to have one would probably be worthy of a category for DSM-6. But in definitions of madness there is always an implicit idea of the normal. It’s just that no-one ever says what it is. Mostly that’s because no-one knows what it is. But everyone pretends – or perhaps ‘conspires’ would be a better verb here – to know. Lacan said one can only be neurotic, psychotic or perverse. As interesting an idea as that is, the investigation of what might constitute versions of sanity, is something that could do with a better political grounding. The Left has historically had many omissions in its political projects, and it’s never been great with psychologies. But perhaps a discussion of what versions of sanity we could usefully inhabit could be one project to put on the table. There are endless descriptions of madness and almost none of sanity. One could argue that even the relentless categorising of madness is a kind of madness itself. It’s interesting to read the DSM as a madman’s dictionary, written by a kind of obsessive butterfly collector who broods endlessly on the dark minds of others, and attempts to build a master-template to describe them all, without omission. In other words the DSM reads like it was written by someone in the throes of a deep and irretrievable psychosis. If ‘mental illness’ is actually a label we use to disguise the presentation of trauma and stop thinking about it, and one of the characteristics of a traumatised state is the struggle to think about the unthinkable from a state where the process of thinking has been ruptured, then perhaps a politicised sanity needs to recover the idea of thinking. To talk about thinking is to learn to do it. And whatever it is you do when you are thinking will, by default, shape your definition. Thinking about thinking has a long history – and a long history of paradoxes too. How does the mind think about the mind? Is that like a finger touching itself? To try and debate these things with someone is to want to tell them to stop thinking so much. Before you know it you’re bogged down in debates that make the Pinocchio Paradox look pretty simple. So rather than asking ‘what’s the definition of thinking’ and find ourselves arguing with people like John Searle, perhaps there’s a way we can outflank ourselves a bit, which after all, is the only way to engage with your own politics of who you are – try to find creative and attentive ways to see ourselves as others might. Maybe thinking is tied up with the capacity to hold in our minds the minds of others; to think about the thinking of others. If that’s the case, then thinking is not just the ability to cognitively plan, to get from Brisbane to Melbourne or to build a better land mine. Anyone who considers that others have minds is never going to be able to rejoice in the construction of a more effective way to chop other living human beings into bits. One of the most unnerving characteristics of our political representatives is that they so often seem to demonstrate their lack of ability to consider others as persons. One can only learn to think in the presence of other beings who think. No child is ever going to be successfully reared by a robot, even one that passes the Turing Test. One can mimic thinking, but it’s not really going to get you anywhere. The scary thing about the push for AI is not that we might actually get human intelligence inside a machine, but that we’ll get something that mimics it. Of course, the capacity to hold the mind of another in your mind wouldn’t be the end of thinking, it would be the beginning. It would commit one to an ethic of more thinking, of working out one’s stance in relation to others, to be situated within politics: what is done and who gets to do it, what gets said and who gets to say it, what gets felt and who gets to feel it, who gets paid and who gets to pay them, what gets gendered and who gets to gender it, and so on. Capitalism facilitates the cult of individuality and this is often posited as the antidote to fascism. But sovereign power requires the eradication of plurality, not individuality. Of course a fascist political architecture also needs external structures to make it possible; compliant media keen to sensationalise and demonise, continual surveillance of the population, civil liberties available to only a few, continual war or the threat of war, a population disillusioned with the protocols of democracy, resurgence of a militarist nationalism, creation of a series of internal threats to the nation etc. The injunction of the fascist is not only Do Not Think, but also a demand that the subject substitute primitive ideologies and desires instead. Whenever ‘thought’ is required it is instantly expelled into a demonic other: Jews, Muslims, teenagers, women, refugees etc. The fascist is always paranoid and if there’s one thing that can be said to characterise political life post-9/ll and post-financial crisis, it’s paranoia and the demand that we leave thinking to others. Stephen Wright Stephen Wright’s essays have won the Eureka St Prize, the Nature Conservancy Prize, the Overland NUW Fair Australia Prize and the Scarlett Award, and been shortlisted for several others. In 2017, he won the Viva La Novella Prize. His winning novel, A Second Life, was published by Seizure, and also won the Woollahra Digital Literary Prize for Fiction. More by Stephen Wright Overland is a not-for-profit magazine with a proud history of supporting writers, and publishing ideas and voices often excluded from other places. If you like this piece, or support Overland’s work in general, please subscribe or donate. Related articles & Essays First published in Overland Issue 228 24 November 202225 November 2022 Politics ‘Sir, please get me the Manager’: Brazil before and after Bolsonaro Guido Melo By then, although young in age, I already knew about those rituals of humiliation and how they were part of my Black family's lives. 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