Abigail Jane Mack //
In the past year, the diagnosis of mental illness has loomed large in US political debates about gun control and healthcare. We’ve seen the continued growth of individuals with mental disorders identified in the US prison and jail system. We’ve seen public commenters diagnose the president and celebrities from afar. At the heart of all these current events is what Jason Schnittker calls the “diagnostic system,” a complex of social and cultural ecologies of psychiatric diagnostic practice through which public, scientific and clinical articulations of mental disorders emerge.[1] Schnittker’s new book, The Diagnostic System: Why the Classification of Psychiatric Disorders is Necessary, Difficult, and Never Settled (2017) offers a timely, expansive and detailed interrogation of psychiatric diagnosis (mostly in the United States).
For me, reading this text as a Medical Anthropologist, Schnittker’s work raises fundamental questions about the relationship between psychiatric diagnosis, “the public,” and “culture.” Chief among these: What is this “public” that Schnittker describes? What are these “cultures”? And, most importantly, what are the consequences of Schnittker’s articulation of “public” and “culture” for our understanding of psychiatric diagnosis? How, for instance, does this illuminate or obscure our understanding about the gun control debate or the way we interpret celebrity behavior? We can begin to answer these questions by taking a closer look at the rhetorical framework that structures Schnittker’s new book.
The Diagnostic System seeks to answer three questions: “why the classification of psychiatric disorders is so difficult, why it is necessary to classify in the first place, and what problems (and solutions) follow from the kinds of classifications we create.”[2] These questions—broad but fundamental—are difficult to answer and (as Schnittker’s title suggests) any presumed answers remain tentative, unsettled. To tackle these questions, Schnittker takes a very methodical approach, beginning first with a history of the Diagnostic Statistic Manual (DSM), the “bible” of psychiatric diagnosis.[3] He focuses particularly on the production and revision of DSM-III and its impact on psychiatric practice. Here, he interrogates what psychiatric diagnosis is and can do. He observes its implication in political debates (e.g. the classification of homosexuality as illness or not). He observes that psychiatric diagnosis may be culturally informed. In the next four chapters, he conducts a “meta” analysis of the use of psychiatric diagnosis by clinicians, the public, scientists, and cultures. His final chapters explore contemporary nosology, the mobilization of genetic and neurological studies in the quest for validation of psychiatric diagnosis and concludes with suggestions for moving forward in developing the psychiatric diagnostic system. Organizing his text as such, Schnittker champions a dimensional approach to psychiatric diagnosis that recognizes the operation of social, historical, cultural phenomena in the construction of mental disorder. Tackling such a wide-breadth of ontological and epistemological problems, Schnittker offers his readers a much-needed, nuanced view of psychiatric diagnosis. Yet, from an anthropological perspective, the potential of Schnittker’s intervention is hindered by his limited articulation of public and cultural life.
It is important to remember that often, when we describe very big, abstract phenomena like “public,” we habitually rely on metaphor.[4] Schnittker makes use of Jürgen Habermas’s classic “sphere” metaphor. In their review of scholarship on publics, Daniel Brouwer and Robert Asen describe a wealth of literature on the “public sphere” which has productively facilitated critique of popular discourse. The “sphere” metaphor facilitates a useful delineation between public and private life. While this boundary between public and private may mostly be constructed for analytic purposes, it nevertheless reveals to us the inaccessibility of public life to many. Who can speak in public? Who is heard? Along these lines, Schnittker is concerned with the function of stigma and the mobilization of psychiatric diagnosis to public (i.e. not clinical) ends. However, Schnittker ignores the role of carceral and legal institutions in the enactment of public psychiatric diagnosis. He does not engage with racial, gendered, or class-based disparities in diagnosis. Instead, over the course of his statistical analysis—which addresses data from rural and urban areas of the US and abroad, effectively condensing distinction between these populations– what emerges is “the public” as a static, reified, unmarked group. We are left with very little insight into the function of stigma and the dynamic negotiation of mental disorder in public life.
In a similar fashion, Schnittker’s articulation of culture relies on an essentialist understanding that effectively positions psychiatric and biomedical practice as “cultures of no culture.”[5] What counts as culture in Schnittker’s perspective, then? While Schnittker does not define “the public,” he does define culture as “shared perspectives and assumptions, the foundational concepts that form the background around which individual beliefs are shaped.”[6] From this definition, Schnittker is satisfied with conducting a Google Books nGram analysis of various DSM phrases to chart their integration into popular culture over time. While he acknowledges that the analysis is limited to books and ignores other forms of written media or public discourse and therefore does not capture the entirety of culture as belief system, Schnittker attempts to remedy some of these limitations by also specifically charting how such DSM-related phrases emerge in contemporary fiction. This analysis can only be done from the perspective that culture is limited to individual beliefs which may be explicitly written. Rather we should remember that culture also acts at an implicit level and informs social action. It is present not only in our media, but in the foundation of our institutions and our communicative interaction. Culture is at the heart of articulations of social power, stigma, and belonging. It is through a nuanced understanding of culture along these lines that we may begin to understand the tensions and consequences when the DSM acts on, in, and with culture(s). The stakes become clearer. We see diagnosis as it operates in our social life–through gun control and healthcare debates, celebrity diagnosis, or the mass incarceration of people with mental disorders. Diagnosis as it is constructed in our social worlds
Having engaged with culture and public as dynamic, changing, phenomena which inform social action and the hierarchies of power in our society, we might look to Schnittker’s work as the product of a biomedical culture which frequently reduces culture writ-large to belief at the detriment of patients and clinicians alike. It is the task of those concerned with medical and health humanities to engage with these articulations of culture and the narratives they form as we move forward. Through this perspective, we may view Schnittker’s work as an invaluable narrative of psychiatric diagnosis and its history. Schnittker’s work can then be seen as a critical resource for developing psychiatric diagnostic measures in the future, a mirror for psychiatrists and clinicians which reflects back the very mechanics of culture and public it critiques.
[1] Schnittker, J (2017) The Diagnostic System: Why the Classification of Psychiatric Disorders is Necessary, Difficult, and Never Settled. Columbia University Press: New York. Pp. 18.
[2] Ibid, pp. 11.
[3] See for instance: Greener, M. “DSM-5: Rewriting the ‘bible.’” Progress in Neurology and Psychiatry. September/October 2013.
[4] Brouwer, D. and R. Asen (2010). “Introduction” In Public Modalities: Rhetoric, Culture, Media, and the Shape of Public Life.
[5] See for instance: Taylor, J. (2003) “The Story Catches You and You Fall Down: Tragedy, Ethnography, and ‘Cultural Competence’” Medical Anthropology Quarterly. 17(2)
[6] Schnittker, J (2017) The Diagnostic System. Pp 179.
