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Descriptions and Prescriptions
Descriptions and
Prescriptions
Values, Mental Disorders, and the DSMs

 
 . , ..
Professor, Department of Psychiatry
University of Texas Southwestern Medical Center at Dallas
Dallas, Texas

The Johns Hopkins University Press ■ ■ Baltimore and London

©  The Johns Hopkins University Press
All rights reserved. Published 
Printed in the United States of America on acid-free paper


The Johns Hopkins University Press

 North Charles Street
Baltimore, Maryland -
www.press.jhu.edu

   -- 

Descriptions and prescriptions : values, mental disorders, and the DSMs
/ edited by John Z. Sadler.
p. cm.
Includes bibliographical references and index.
 --- (hardcover : alk. paper)
. Mental illness—Classification—Social aspects. . Mental illness—
Classification—Moral and ethical aspects. . Diagnostic and statistical
manual of mental disorders. I. Sadler, John Z., – .
[DNLM: . Mental Disorders—classification. . Social Values.
   ]
c.. 
.⬘⬘—dc


A catalog record for this book is available from the British Library.
Contents

List of Contributors ix
Acknowledgments xi

Part One Introduction and Background

 Introduction 
 . 
 The Limits of an Evidence-Based Classification of
Mental Disorders 
     
 Values, Politics, and Science in the Construction of the DSMs 
 . 

Part Two Conceptual and Methodological Considerations

 Values and Objectivity in Psychiatric Nosology 
 . 
 Survival of the Fittest? Conceptual Selection in Psychiatric
Nosology 
 
 Technical Reason in the DSM-IV: An Unacknowledged Value 
 
vi Contents

 Implications of a Pragmatic Theory of Disease

for the DSMs 
 . 
 Rethinking Normativism in Psychiatric Classification 
 

Part Three Diagnostic Categories and Values

 Evaluation and Devaluation in Personality Assessment 
  
 Values and the Validity of Diagnostic Criteria: Disvalued
versus Disordered Conditions of Childhood and
Adolescence 
 . 
 Implications of an Embrace: The DSMs, Happiness,
and Capability 
 . 
 Why Criteria of Involuntary Action Are Value Laden 
 

Part Four Personal and Collective Interests

 The Hegemony of the DSMs 
     . 
 What Patients and Families Look for in Psychiatric Diagnosis 
  
 Softened Science in the Courtroom: Forensic Implications
of a Value-Laden Classification 
 . 
 Speaking across the Border: A Patient Assessment
of Located Languages, Values, and Credentials
in Psychiatric Classification 
 
 Psychotherapists as Authors: Microlevel Analysis
of Therapists’ Written Reports 
    . 
 Contents vii

Part Five Visions for the Future

 Clinical and Etiological Psychiatric Diagnoses:
Do Causes Count? 
 . 
 Defining Genetically Informed Phenotypes for the DSM-V 
 . 
 Values in Developing Psychiatric Classifications:
A Proposal for the DSM-V 
 . 
 Report to the Chair of the DSM-VI Task Force from the Editors
of Philosophy, Psychiatry, and Psychology, “Contentious
and Noncontentious Evaluative Language in Psychiatric
Diagnosis” (Dateline ) 
. . . 

References 
Index 
Contributors

G J. A, Ph.D., F. J. O’Neill Chairman, Department of Bioethics,

Cleveland Clinic Foundation, Cleveland, Ohio
C B, Ph.D., Professor of Rhetoric, Department of Hu-
manities, Michigan Technological University, Houghton, Michigan
L A C, Ph.D., Professor, Department of Psychology, University
of Iowa, Iowa City, Iowa
K. W. M. F, D.Phil., F.R.C.Psych., Professor of Philosophy and Men-
tal Health, Department of Philosophy, University of Warwick, Coven-
try; and Honorary Consultant Psychiatrist, Department of Psychiatry,
University of Oxford, Oxford, United Kingdom
I I. G, Ph.D., Sherrell J. Aston Professor of Psychology
and Professor of Medical Genetics (Pediatrics), Department of Psy-
chology, University of Virginia, Charlottesville, Virginia
L L H, Ph.D., former Director of Research, NAMI (National
Alliance for the Mentally Ill); biomedical and health care analyst and
writer.
C L, Ph.D., Visiting Instructor of English and Women’s Studies,
Empire State College, State University of New York, Rochester, New York
C M, M.D., M.R.C.Psych., Senior Lecturer in Psychotherapy,
Department of Psychology, University of Warwick, Coventry, United
Kingdom
L MQ, M.S.S.W., DSM Project Manager, American Psychi-
atric Association, Washington, D.C.
x Contributors

C P, Ph.D., Assistant Professor, Department of Philoso-

phy and Religious Studies, Dowling College, Oakdale, New York
J P, M.D., Clinical Associate Professor, Department of Psy-
chiatry, Yale University School of Medicine, New Haven, Connecticut
H A P, M.D., Professor and Executive Vice Chairman,
University of Pittsburgh School of Medicine; and RAND Senior Sci-
entist and Director, RAND–University of Pittsburgh Health Institute,
Pittsburgh, Pennsylvania
J H. R, D.Phil., Professor, Department of Philosophy, Uni-
versity of Massachusetts at Boston, Boston, Massachusetts
D J. R, M.A., L.L.P., Instructor of Psychology, Department of
Education, Michigan Technological University, Houghton, Michigan
P A. R, Ph.D., Assistant Professor, Department of Philosophy,
and Resident Fellow, Minnesota Center for Philosophy of Science, Uni-
versity of Minnesota, Minneapolis, Minnesota
J Z. S, M.D., Professor and Director of Undergraduate Psychi-
atric Education, University of Texas Southwestern Medical Center at
Dallas, Dallas, Texas
K F. S, M.D., Ph.D., University Professor of Medical Hu-
manities and Professor of Philosophy, George Washington University,
Washington, D.C.
M A S, M.D., Professor, Department of Psychiatry,
Tufts University School of Medicine, New England Medical Center,
Boston, Massachusetts
D W. S, J.D., Professor of Law, Southern Methodist Univer-
sity, Dallas, Texas
A S, Ph.D., Department of Philosophy, York University, To-
ronto, Ontario, Canada
J C. W, D.S.W., Professor, School of Social Work and In-
stitute for Health, Health Care Policy, and Aging Research, Rutgers
University, New Brunswick, New Jersey
T A. W, Ph.D., Professor, Department of Psychology, Uni-
versity of Kentucky, Lexington, Kentucky
O P. W, Ph.D., Professor, Department of Philosophy, Uni-
versity of Louisville, Louisville, Kentucky
Acknowledgments

L  edited scholarly books, this one was conceived in concert with
a conference. I am grateful to the people and institutions that contributed
funds to support a large and diverse meeting. John W. Burnside, associate
dean at the University of Texas Southwestern Medical Center at the time,
conveyed, as always, unabashed enthusiasm for this project and managed
to scrape up some money from here and there for it. William F. May, then
the Maguire Professor of Ethics at Southern Methodist University, was a
personal inspiration as well as essential in helping me secure grant fund-
ing for the meeting and, ultimately, this book. William Stubing and the
Greenwall Foundation were essential sources of support as well as encour-
agement about the importance of values in mental disorder classification.
My colleagues in the Association for the Advancement of Philosophy and
Psychiatry were generous as well, both in checkbook and in spirit—and,
of course, ideas. Danny and the anonymous others who, in large part, sup-
ported the conference deserve great thanks; without them it could not have
happened, at least not in the grand manner in which it did. My chairman,
Kenneth Z. Altshuler, as always, was a significant source of encouragement
and support as well. I’m aware, and therefore doubly appreciative to all, of
the novel, perhaps idiosyncratic vision of the conference at the time. Partly
because of all the individuals who were involved, the whole “values” mat-
ter is less novel and considerably less idiosyncratic at the time of this book’s
completion.
Showing her characteristic enthusiasm and tenacity, Linda Muncy, my
xii Acknowledgments

assistant, deserves much of the credit for pulling this off, from the initial
exploration of the idea, to the preparation of proposals, letters of invita-
tion, and reports, hosting visitors, and, ultimately, this book’s manuscript.
I salute her flexibility and commitment and am ever grateful.
Who could ask for a more congenial, constructive, and thoughtful
group of contributors? The positive attitudes and active listening of all, es-
pecially in the face of often substantial disagreement, were key outcomes
of the conference, and ones that I hope this volume can perpetuate as we
consider the future of mental disorder classification. A key element in the
success of the conference was the contribution of the numerous other au-
thors and commentators, people who had substantial pieces but for space
considerations had to be left out of this book. To recognize their unpub-
lished contributions in modest measure, let me name them: Lee Anna
Clark, Irving I. Gottesman, Patricia S. Greenspan, Robert John Hamm,
Loretta Kopelman, Jerome Kroll, James Phillips, Robert L. Spitzer, George
Agich, K. W. M. Fulford, Harold Pincus, Louis A. Sass, Kenneth F. Schaffner,
Jerome C. Wakefield, Thomas Widiger, and J. Melvin Woody. Kenneth Z.
Altshuler, Elena Bezzubova, Pat Greenspan, Jerry Kroll, Bill May, James
Phillips, and Mel Woody chaired sessions and introduced speakers with
grace and aplomb.
On the publishing end, Wendy Harris has stewarded this publication
with the kindness and patience she exhibited the last time around. You’d
think she would learn! I’m grateful to the Journals staff at the Johns Hop-
kins University Press and to K. W. M. Fulford for the publicity and support
generated through our journal, Philosophy, Psychiatry, and Psychology.
Abbie, Evan, and Cole deserve special thanks for putting up with an of-
ten frazzled husband and occasionally grumpy daddy. They all are the well-
spring of love, satisfaction, and contentment that generates creative and
productive work.
 Part One
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Introduction and Background

 1
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Introduction
 . , ..

W  is wary of values. Such wariness can be recognized

through considering our ordinary talk. For instance, when we are in the
position of meeting new people, we often introduce ourselves by describ-
ing what we do. In my case, I introduce myself through various descriptive
functions: psychiatrist, husband, father, gardener, taxpayer, photographer,
and so on. Were I to introduce myself instead with the language of evalu-
ation rather than description, I would be seen as pretentious, idiosyncratic,
or downright weird: “Hi, I’m John Sadler, and I’m loyal, stubborn, and
bright.” But the wariness of values is not limited to social intercourse. If I
were to look for “values” in my local newspaper, it would be in the “Reli-
gion and Values” section, not on the front page. Newspapers are where (we
hope) the facts are, not the values. Indeed, Western society seems stratified
according to places where one can consider or discuss values with comfort.
As far as days of the week go, Sundays (and other holy days) seem reserved
for reflection about the good, the right, and the sacred. This Balkanization
of the evaluative, however, is not limited to the calendar. In particular,
those with scientific or technical backgrounds (e.g., people likely to read
this book) find themselves amazed by the rich vocabulary of values in com-
mon parlance in other settings: for instance, listening to the talk of art deal-
ers, artists, and connoisseurs at an opening for a gallery show. From where
do these people come up with these wellsprings of evaluation?
Values in matters scientific have been suspect for at least the past two
hundred years. Enlightenment rationalism permitted reason little of any-
4 Introduction and Background

thing smacking of emotivism or the passions, and from Francis Bacon to

Max Weber (and indeed, the present day), the wish of science has been to
eliminate values in true science (Proctor, ). Value considerations in sci-
ence, in sum, are often considered pollutants. But this aversion to values is
changing, and such change is evident from diverse social strands.
Perhaps most obvious has been the bioethics “movement.” Emerging
from well-publicized legal cases of medical battery, horrific exploitations of
biomedical research subjects, and struggles over the “good death,” bioethics
established the value ladenness of medical practices. But what about med-
ical and scientific concepts? Are they value laden too? The historical culmi-
nations of the Enlightenment ethos of rationality, logical positivism and log-
ical empiricism, ran into insoluble problems in the s and s when the
strict rules governing the relations between theory and observation failed to
appear or to be found. Hanson (), Feyerabend (), and especially
Kuhn (, ) sealed the fate of just-so rationalistic science through their
studies of discovery, irrationalism, and values in science. Kuhn (), in
particular, argued that the only way reasonable scientists could disagree,
given the same facts and different theories, was through different evalua-
tions of theory: some theories were simpler, others more comprehensive,
some had more predictive power, and so on. Indeed, he led the way to the
recognition that scientific concepts (including values), framed by theory
and background knowledge, contributed to the recognition, interpretation,
and even the “shape” of the facts. After all, to establish knowledge required
an evaluation of the knowledge claim: some theories or explanations were
better than others, which meant that judgments of good and bad were in-
dispensable to knowledge. Value theory had grabbed science by the genitals.
Psychiatry, as always, marched in step with the culture that generated
such rethinking of the role of values in science, knowledge, and human ac-
tion. In , about the time the reviews of the second edition of Kuhn’s
The Structure of Scientific Revolutions were emerging in the history, phi-
losophy, science, and medical journals, the American Psychiatric Associa-
tion had decided by member vote to declassify homosexuality as a mental
disorder (Bayer, , ). Robert Spitzer, an acknowledged leader of the
move to depathologize the gay, articulated the issue around homosexual-
ity to be more of an issue of value judgments than science (Spitzer, ).
The whole controversial mess around this change brought to popular
awareness the notion that psychopathology involved value judgments, an
idea that, up to that time, was a trope for academics and intellectuals only.
Spitzer went on to spearhead the third revision of the Diagnostic and Sta-
tistical Manual of Mental Disorders (DSM), which sought a scientific rigor
 Introduction 5

to mental disorder diagnosis which had theretofore not been attempted.

Spitzer and his colleagues on the DSM-III committee wished to make di-
agnosis more reliable, and ultimately more valid, by augmenting the de-
scriptive rigor of psychiatry’s diagnostic manual. Such efforts bring us to
this volume, which, as K. W. M. Fulford has noted in his summative fan-
tasy at the end of the book, reflects an intent to augment the evaluative
rigor of classification efforts in psychiatry. The parallel between descrip-
tive and evaluative rigor warrants some further discussion.
Through operationalizing diagnostic concepts into specific criteria,
the DSM-III group attempted to diminish ambiguities in psychiatric di-
agnostic concepts in DSM-I and -II. Instead of the cryptic and general de-
scriptions of the earlier manuals, the DSM-III specified, as much as prac-
ticable, the operations required for a patient to qualify for a particular
diagnosis. Numerous advantages were expected with such a move; clini-
cians could discuss similarly diagnosed patients with a greater confidence
that their patients were truly similar in salient ways; researchers could have
more homogeneous populations of subjects in which to develop general
explanations and treatments; psychiatry in general could be more “med-
ical” through a more explicit modeling of mental disorder after disease
concepts and disease language. With a “postvalues” awareness, we might
say that the DSM-III made mental disorder diagnosis more accountable;
one could not label a patient with a diagnosis in just any way or without
reference to a method, a system, and indeed, a professional organization,
the American Psychiatric Association. What was initially intended as a
purely “scientific” enterprise nevertheless brought in a set of relatively novel
moral elements to psychiatric practice, with “accountability” only one of
the many values involved.
This book might be construed as an effort to extend this “accountabil-
ity thesis” of the post–DSM-III era. What the DSM-III did was add an ex-
plicit emphasis and method to approximately half of the experiential uni-
verse of mental disorder, that is, the descriptive/factual elements of clinical
experience. This book, building on earlier groundwork (Sadler, Schwartz,
and Wiggins, b), attempts to raise explicit awareness of the other half
of the experiential universe, that of value and evaluation in mental disor-
ders. For every delusion there is a complementary jealousy, fear, or family
member’s tears; for every addiction there is tragedy; for every depression
there is at least one lament. Psychiatry has always had its evaluations; in-
deed, without them, it would be an impoverished field. This book moves
values from the background of psychiatric diagnosis to the foreground,
where, I believe, they belong.
6 Introduction and Background

The awareness of values in diagnostic classification is not limited to

just the negative values of suffering from symptoms and their conse-
quences. As we shall see in the chapters to follow, values shape what is clin-
ically relevant (what the clinician sees or doesn’t see); what clinical evi-
dence is salient, useful, or otherwise important; the criteria of pathology;
the credibility of the diagnostic process, even the priorities in designing a
classification.

■ ■ Why Psychiatric Classification?

A prospective reader might wonder why the focus on psychiatric clas-

sification, nosology, and diagnosis in a book that might well have focused
on the “values of psychiatry” instead. Perhaps the most obvious, and least
interesting, reason is simply one of focus. As can be seen from the rest of
this book, a project that aims to make substantive comments about the val-
ues in psychiatric classification is already a large enterprise. An enterprise
that aspires to address values in psychiatry in general (e.g., diagnosis, ther-
apies, social-professional roles) will be a truly colossal project.
Psychiatric classification, however, has good reasons to be nominated
for careful attention to value commitments. First, the DSMs and ICDs (the
World Health Organization’s International Classification of Diseases) are
commonly used, nearly universal anchor points for clinical practice, re-
search, education, and administration of mental health care. The cate-
gories of these diagnostic manuals are the common language, for better or
for worse, of mental health practitioners around the world. As Michael
Schwartz and Osborne Wiggins note in their chapter, the DSMs, at least in
the United States, dominate the field of clinical research, in essence serv-
ing as a checkpoint, even a “pass” requirement for research funding and
publication. Administratively, the DSM/ICD code is found in epidemio-
logical records, insurance billing, hospital statistics—essentially, at every
level of mental health administration. Educationally, the DSM and ICD
categories frame the structure of curricula in mental health care: textbooks
are organized around groups of DSM/ICD disorders, diagnostic criteria
are the core reference for recognizing and diagnosing psychopathology,
and educational media are built around DSM/ICD categories. Such uni-
versality of the DSM/ICD influence means that these manuals broker the
thinking that is turned into public policy concerning mental health.
Perhaps most important from the public perspective, the DSM/ICD
classifications are the reference points for public understanding of mental
disorders—the manuals shape lay, not to omit professional, notions of
 Introduction 7

mental illness. In the context of psychiatric classification and public un-

derstanding, W. V. O. Quine’s witty motto “Ontology recapitulates Philol-
ogy” is particularly apt. For Quine, what something is is reflected in the his-
torical unfolding of the language that speaks of it. In the case of the DSMs
and ICDs, the immeasurably complex phenomenon of mental life is en-
capsulated and compartmentalized in particular ways; other ways of fram-
ing mental life are possible, but such alternative framings will require their
own terms and linguistic conventions, as can been seen in the chapter by
Berkenkotter and Ravotas in this book. Psychiatric classification warrants
a “values analysis” even for those who reject such manuals—the DSM in-
fluence is nonetheless powerful, a social phenomenon to be contended
with even if one disagrees with the DSM “approach” to the manifold pre-
sentations of psychopathology.

■ ■ Why Values?

This book takes values in a broad and general sense. As used here, the
term reflects a range of preferences, predilections, esteems, and predis-
positions to act. When I think about values, I define them as concepts that
(a) tend to direct action, and (b) are subject to praise or blame in reference
to such actions (Sadler, ). Values in this sense may be in the foreground
of what we wish to do and frame as goals (e.g., psychiatric classification
should be “user-friendly”) or may occupy a Quinian ontological back-
ground where values and “morality” shape how we think about things and
choose to live our lives—as clinicians, as citizens, as spiritual beings, as sci-
entists, as parents, as spouses, and so on. Such latter manifestations of value
reflect what the layperson calls a “philosophy of life,” whether carefully
thought out and articulated (conscious in the Freudian sense) or simply
assumed and enacted in everyday life (preconscious or unconscious in the
Freudian sense). As we shall see, the values that saturate the DSM enter-
prise represent all levels of intention and awareness on the part of the clas-
sification’s creators—some values are quite explicit, but many more are
implicit. Implicit values raise the question about whether they are inten-
tionally selected or merely a happenstance, accidental selection.
Hence a book such as this one is useful in that the evaluations (values)
involved in the DSMs and ICDs become more explicit and therefore more
amenable to critical thought and reconsideration. As I suggested earlier in
this introduction, the role of values in classification may be Balkanized in
the DSMs just like values are Balkanized in real life. But their influences,
nonetheless, are powerful. The values of the DSMs are answers to the
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