The Politics of Psychiatric Classification

Scott Alexander discusses the incoherent wish for an apolitical psychiatric classification in a recent blogpost on

Astral Codex Ten

. His post is in response to assertions that it is better for classifications to eschew social and political influences because when they don’t do so, it results in errors like the DSM classifying homosexuality as a disorder. Alexander argues that “The people asking for apolitical taxonomies want an incoherent thing. They want something which doesn’t think about politics at all, and which simultaneously is more politically correct than any other taxonomy.”

You Don't Want A Purely Biological, Apolitical Taxonomy Of Mental Disorders

I agree with Scott Alexander on this point, but I'll take this opportunity to clarify some aspects of the debate, especially since they usually aren't well explained in popular discussions.

The fundamental thing to appreciate is that we are looking at two different but interacting classification questions:

1. Is this condition in the class of mental disorders or not? Is this state psychopathological? Is this cluster of problems a psychiatric condition?

2. How do we distinguish between conditions within the class of mental disorders? How do we map the territory of psychopathology? Where do we set thresholds? How do we differentiate one problem from another?

The reason this is important is because the two questions require very different sorts of answers.

Here’s how I understand these issues:

There is no value-free answer to the question of what makes something a disorder.¹ Disorder judgments – the way they are employed in medicine and psychiatry – cannot simply be answered by statistics or neurobiology or evolutionary history or something of the sort. These judgments are enmeshed with sociocultural and sociopolitical considerations. Disorder status is not a fact of nature that can be scientifically discovered. It doesn’t mean that scientific facts aren’t relevant. Scientific knowledge of how the brain and mind work is very important and helps us make decisions, but it isn't enough. It also doesn’t mean that disorder attribution is arbitrary or purely relative, nor does it mean that there aren’t good or bad answers. If we call something a disorder because of social prejudice, we have made an error. The nature of this error is normative. We have misunderstood and misapplied the norms for disorder judgments. These norms include judgments of typicality, rationality, adaptiveness, distress, disability, harm to others, and impediments to well-being in various conjunctions and combinations. Over time, we've learned that it's not enough to say that something is out of the ordinary, abnormal, irrational, or strange; it also has to be linked to the right kinds of harm. Disorder judgments are intended to identify states that threaten an individual’s adaptive functioning. Since this functioning is always in a particular social context, the judgments inevitably have a social and political dimension. When conditions involve a risk to others (e.g., pedophilia, pyromania, etc.), the needs of the individual have to be balanced against the needs of society. Disorder judgments, therefore, require a formal or informal process of negotiation among stakeholders. People with the condition are the most important stakeholders, but there are others as well, such as their families, clinicians, funders who will pay for healthcare and research, the legal system, etc. Just to make it clear: the process is, under ideal circumstances, constrained by the relevant considerations. It is not whimsical; it is not anything-goes relativism, where anything can be a disorder just because we want it to be.

Once we have identified a domain of disorders, or psychopathology, or psychiatric conditions, there are many different ways in which we can describe, categorize, and classify it further. And some of these ways may be as close to objective and apolitical as any method can be. Quantitative factor analytic methods can reveal the factors that underlie symptom co-variation. We can classify based on genetics, or functional neuroimaging, or neuropsychological testing, or a variety of other ways. Since psychiatry and clinical psychology are applied fields, the most important thing about a classification is how well it helps guide clinical practice. The classification is ultimately pragmatic. What method of categorization we prefer will depend on what we want to accomplish and how we can accomplish it. In situations where we are dealing with “natural kinds” — such as chemical elements in the periodic table — identification of natural kinds offers the best categorization. But when there are few or no natural kinds, as is the case in psychopathology, we have to deal with classification pluralism based on our pragmatic goals. Once we have identified certain goals, we have to undertake the process of discovery. If we want a classification based on patterns of symptom co-variation, we cannot simply make up the results. We have to do the scientific and statistical work and see what factors emerge. If we want a classification based on genetics or brain circuitry, again, we have to do the empirical work and follow the science.

Classifications like HiTOP and research frameworks like RDoC operate at this second level. They are working with implicit notions of psychopathology, or implicit notions of what constitutes conditions of medical/psychiatric interest, but they do not articulate what these notions are. In a narrow sense, they are objective and apolitical, to the extent that decisions are guided by empirical data or statistical findings. But in a broader sense, their objectivity is an illusion; they already assume an answer to what is included in the class of mental disorders. When HiTOP is contrasted with DSM, the contrast is usually intended to highlight DSM’s commitment to practical considerations. That is, considerations of insurance and reimbursement, or how thresholds are set to minimize inappropriate diagnosis, or how user-friendly the classification is. Classifications that are unconcerned with practical and pragmatic issues are also poorly equipped to serve those needs, and it is both an advantage and a disadvantage.

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See also:

Psychiatric Diagnosis: A Reintroduction

Psychiatry and Medical Authority: Part One

1. An answer that also adequately captures what we clinically and practically mean by “disorder.” Philosophers interested in natural functions in the abstract can work with weakly normative notions of dysfunction, but in my opinion, those notions don’t translate well into the clinical realm.