Drawing the Boundary between Psychosocial and Biomedical Disorders: The Credibility Contest between Freudianism and Neo-Kraepelinianism in the DSM

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ELLEN YING

Read the Faculty Introduction here.

Introduction

Published by the American Psychiatric Association (APA), the Diagnostic and Statistical Manual of Mental Disorders (DSM) is a handbook offering a common language and diagnostic criteria for the classification of mental disorders. The fifth edition of the DSM (DSM-V), which was published in 2013, is now one of the most credible standards of diagnosis used by various social entities, including clinicians, researchers, health insurance companies, pharmaceutical companies, and even policymakers and legal systems. In contrast to the prestige of contemporary versions, the DSM did not start to gain authority or receive much attention until DSM-III, which was drastically divergent from the previous two editions, was published in 1980. In this paper, I will examine the changes from DSM-II to DSM-III as well as the historical backgrounds fueling these changes. I argue that the boundary between psychiatry and other professions in the 1960s to 1970s was blurred due to psychiatry’s adoption of Freudian psychoanalysis. In response, a new school of psychiatrists, Neo-Kraepelinianists, changed the DSM so that patient diagnosis was more based on specified symptoms and “mental disorders” were redefined as problems within individuals. In doing so, they successfully distinguished scientific Neo-Kraepelinianism from unscientific Freudianism, thus establishing their own epistemic authority and redrawing the boundary between psychiatry and other professions. 

The loss of boundary of American psychiatry

To understand the driving force behind the changes from the DSM-II to DSM-III, I will first explain the ideological trend of American psychiatry in the 1960s and how it blurred the boundary of psychiatry as a scientific profession. The 1960s American psychiatry was dominated by Freudian psychoanalytic perspectives. During the post-World War II period, practitioners and students of psychiatry witnessed how this approach was effective in treating soldiers returning from battlefields with mental disorders and were therefore overwhelmingly passionate about it (Decker 341). They believed that perceivable symptoms of mental illness are mere reflections of people’s underlying psychological dynamics. To interpret and cope with these symptoms, the most effective way is to put them in the context of a person’s personality and life experiences (Mayes and Horwitz 249-250). The widely shared interest among psychiatrists in practicing psychoanalysis made Freudianism the mainstream ideology of American psychiatry at that time. 

A direct consequence of the dominance of Freudian psychoanalysis was that psychotherapy, as opposed to medication, became the main treatment for mental illnesses among psychiatrists. Freudian psychotherapy features conversations facilitated by psychoanalysts that are aimed at figuring out and resolving patients’ unconscious mental conflicts. No medical training was required for the practice of psychotherapy. Psychiatrists, whose traditional approach was medication but started using psychotherapy, were still occupying the “professional monopoly” for treating patients as if they were still specialized in medication. In contrast, non-psychiatrists could only be eligible to provide counseling although their practice also focused on psychotherapy (Mayes and Horwitz 255). Practicing the same approach yet being entitled to different authorities, non-psychiatrists such as psychologists, social workers, and counselors began to question the psychiatric authority on treating patients with mental illness.

Meanwhile, the prevalence of Freudianism also led to a widespread engagement among the American psychiatrists in preventative actions for mental health problems. A side note of the Freudian view on the nature of symptoms as symbolic reflections of deeper dynamic processes is that everyone’s mental health condition ranges “along a continuum with health at one end and illness at the other” (Decker 342). There is no one definite boundary between being mentally healthy and unhealthy; all people are constantly facing the risk of having mental disorders. Therefore, psychiatrists started to make efforts to solve “social problems that made for unhealthy and impoverished environments for their patients” and to intentionally find people who had incipient syndromes of mental disorders and treat them before they started to get worse (Decker 342). They were no longer merely interested in the issues inside the clinics and started to strive for finding resolutions for social problems.

When psychiatrists started to practice psychotherapy in a way that required no medical specialty and engaged in non-medical affairs outside of clinics, the boundary between psychiatry and other professions was blurred. Although psychiatrists still claimed themselves as medical professions on the face value by using terms such as “diagnosis,” “patients,” and “treatment,” the biomedical aspect of mental disorders in fact yielded to Freudian psychoanalysis and psychotherapies (Decker 342). Psychiatric practice became essentially the same as non-psychiatric practice, and the field of psychiatry lost its prestige as a medical specialty. Thus,  became subject to critiques on its authority on the diagnosis and treatment of mental disorders. 

The challenge to psychiatry’s neutrality and scientificity

With medical specialty no longer prominent in the psychiatric practice, medical and social science scholars started to question the epistemic authority of psychiatrists, criticizing their lack of scientificity and neutrality. Critiques finding faults with the scientificity of psychiatry mainly focused on the low reliability of psychiatric diagnosis. Thomas Scheff, a sociologist and also a major critic of psychiatry, for example, pointed out that mental illness was used as “an explanation of the last resort” (qtd. in Mayes and Horwitz 252). He noted that when psychiatrists could not normally explain deviant behaviors, they usually categorized them as mental illnesses even if those behaviors might have causes that can be fixed without any medical treatment. Consequently, the possibility of false diagnosis of mentally healthy people emerged, which was finally revealed by an experiment in a mental hospital. David Rosenhan, a Stanford psychologist and lawyer, conducted a secret experiment to provide evidence for the lack of reliability in psychiatry. He asked people to visit the clinicians in the hospital and to show fake symptoms of having hallucinations. After they were admitted into the hospital, however, they immediately started to act like “normal” people. Regardless, they remained imprisoned in the hospital, with one pseudo-patient being kept for 52 days (Decker 344). From this experiment, Rosenhan successfully gave a powerful punch to the field of psychiatry by revealing that those people who called themselves psychiatrists could not even give a legitimate diagnosis to patients. This shocking picture of psychiatry posed a huge challenge to its scientific authority.

Besides, more deadly to the legitimacy of psychiatry was the practice of Freudian psychoanalysis, which is not value-neutral, but often operated under the guise of objective science. Thomas Szasz, a famous American critic of psychiatry, directly criticized the discrepancy between psychiatrists’ claims and their practices. He commented that although psychoanalytic psychiatrists merely communicated with “patients” through psychotherapy, they still talked “as if they were physicians, physiologists, biologists, or even physicists” by using terms such as “sick patients,” “treatment,” and “hospitals” to medicalize their study (Szasz, The Myth of Mental Illness: 4). By pointing out this inconsistency between what psychoanalytic psychiatrists do and what they say, Szasz questioned whether Freudian psychiatrists were trying to use seemingly scientific approaches to cover its unscientific essence. Freudian psychoanalysis, without a solid empirical foundation, is very likely to involve therapists’ biases and values. In the attempts of Freudian psychiatrists to fix the problems their “patients” have in living, their own religious and political orientations, as well as attitudes towards related issues such as abortion and suicide, can influence their judgements (Szasz, The Myth of Mental Illness 125-126). Their ideas on the patients’ real problems and the proper means to fix them can be substantially colored by their own stances. However, all these were disguised under psychiatrists’ claim to be medical professionals who approach mental illnesses through scientific principles. According to Szasz, his behavior of “imitating medicine” served as a strategy to create a delusion that the field of psychiatry was capable of revealing the truths neutrally and objectively while it in fact could not.

Confining the classification of “mental disorders” in DSM-III

When the reliability and objectivity of Freudian psychiatry faced severe challenges, a group of neo-Kraepelinian psychiatrists initiated the changes in the DSM, thus not only leading an ideological reform of the field, but also establishing their epistemic authority. Modelled on the scientific and empirical approach of Kraepelin, a renowned German psychiatrist at late 19th century, neo-Kraepelinian psychiatrists asserted that psychiatry should utilize modern scientific methodologies and base itself on empirical scientific research as a branch of medicine (qtd. in Decker 348). They claimed that “the domination of American psychiatry by psychoanalytic and psychodynamic thinking…was responsible for its unscientific character” (Decker 345). Thus, they inserted an evidence-based Kraepelinian tradition in the changes of the diagnostic standards, which was supposed to be more scientific, reliable, and neutral than Freudianism, so that the focus of American psychiatry could be shifted back to a biomedical approach. 

The first neo-Kraepelinian change in DSM-III was a structural change emphasizing specific symptoms of mental illnesses as opposed to their etiologies. This is best illustrated by a comparative close reading of one of the diagnoses in DSM-II and DSM-III, “schizophrenia.” In DSM-II, the diagnostic criteria of schizophrenia were as follows:

This large category includes a group of disorders manifested by characteristic disturbances of thinking, mood, and behavior. Disturbances in thinking are marked by alterations of concept formation which may lead to misinterpretation of reality and sometimes to delusions and hallucinations, which frequently appear psychologically self-protective. Corollary mood changes include ambivalent, constricted and inappropriate emotional responsiveness and loss of empathy with others. Behavior may be withdrawn, regressive and bizarre. (33)

In this entry, the psychoanalytic authors emphasize the cause of the “disturbances in thinking,’’ namely “alterations of concept formation” that serves the purpose of psychological self-protection, which is an important concept in Freudian tradition. Although it also describes the symptoms of disturbances, hallucinations, corollary mood changes, etc., the manual does not clearly specify what counts as these symptoms and leaves plenty of space for psychiatrists’ own subjective interpretations on patients’ behaviors.

In comparison, the criteria in DSM-III clearly specifies necessary symptoms, conditions, and duration of the symptoms for the diagnosis of schizophrenia. For example, one of the six symptoms is described as “somatic, grandiose, religious, nihilistic, or other delusions without persecutory or jealous content” and the duration has to be “at least six months” (DSM-III 188). Different from DSM-II, which merely mentions delusions, DSM-III specifically points out what kind of delusions a patient has and how long they should exist to be counted as an illness. Also, the language is solely focused on the symptoms without judgements on etiologies. This makes the diagnosis less dependent on psychiatrists’ own subjective perceptions of the symptoms and their interpretations of the causes of these symptoms, but more on a specific set of standards given by the DSM. The new standardized diagnostic criteria was regarded by neo-Kraepelinian psychiatrists as a useful way to improve the accountability of diagnosis, and the treatment effect could be reliably tested by empirical research. 

Neo-Kraepelinianists’ second important change is the addition of the definition of “mental disorder.” The DSM-III was the first version throughout the history of the DSM that gave a written definition of mental disorder. The term “mental disorder” is defined as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that typically is associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability)” (DSM-III 363). Also, “when the disturbance [of an individual] is limited to a conflict between an individual and society, this may represent social deviance, …but is not by itself a mental disorder” (DSM-III 363). The significance of this definition lies in the confined scope of the term “mental disorder.” It is only defined as a syndrome associated with distress or disability within an individual, but not a problem of an individual which he/she encounters in daily life with people around, i.e. with society. The distinction between “dysfunction in” and “dysfunction of” an individual, as Kinghorn points out, “distinguishes the mental health disciplines (particularly psychiatry) from nonmedical disciplines which also attend to personal distress and social deviance” (54). In other words, this definition totally confines the object of the expertise of the new psychiatry within an area that necessarily required medication. The settled definition of mental disorders was completely different from the Freudian psychiatry’s blurred realm of psychosocial interest, a part of which would be easily influenced, or be seen as influenced by other non-medical factors. It thus created “a clinical safe space” (Kinghorn 54) for Neo-Kraepelinian psychiatry, where the practice of diagnosis and treatment could not be affected by factors like politics and could be more neutral than the Freudian approach. 

Taking together the structural changes of classifications and confined definition of mental disorder, the rationale behind DSM-III was to claim that the mission of psychiatry was to identify symptoms of mental disorders inside patients and to use medicine to alleviate these symptoms. Unlike Freudianism, this new approach made psychiatric diagnosis seem easier to be tested by empirical studies, more reliable, and more etiologically theory-neutral (Kinghorn 49). Although psychiatrists later argue that the ways of classifying and defining mental disorders initiated by DSM-III still do not fully create a value-vacuum “clinical safe space” for psychiatry (Kinghorn 56), nor does psychiatry have an absolutely solid empirical ground (e.g. there is still no empirical evidence supporting a distinctive line of six-month duration for the diagnosis of mental disorders), the goal of DSM-III was not to become absolutely neutral and scientific in the first place. What Neo-Kraepelinian psychiatrists tried to accomplish in the changes of the DSM was to appear to, in a relative sense, be more neutral, more reliable, and thus more scientific than Freudian psychiatry. In doing so, Neo-Kraepelinian psychiatrists were doing what Gieryn calls “boundary work” of “expansion” (Gieryn 16). By claiming themselves to be more scientific than Freudianism, they tried to establish their own authority on psychiatric diagnosis and treatment. During a time when Freudianism was disparaged to its lowest point, it is not surprising that Neo-Kraepelinian psychiatrists successfully managed to claim their epistemic authority. The basic principles they laid out in the third version have still been used by the latest version of the DSM, even though they were still not as perfect as the Neo-Kraepelinian psychiatrists imagined them to be. 

Conclusion

The changes from DSM-II to DSM-III highlight a history of ideological dynamics within the field of psychiatry. By looking at the specific historical contexts and the ways in which these changes were made, it is not hard to see how the social and professional critiques on the de-professionalization of Freudianism created a convenient environment for Neo-Kraepelinianism to lead the change in the DSM in order to establish their epistemic authority. Like Freudianism, the new diagnostic manual based on Neo-Kraepelinian tradition could not stand a close scrutiny on its scientificity. The ideological framework retains its authority even until now in DSM-V with only minor changes being made. By analyzing how Neo-Kraepelianism established its authority over Freudianism historically, we can see that the field of psychiatry as a branch of science is not only driven by scientific, empirical, and neutral knowledge or methodologies, but is also vulnerable to the influences of ideological conflicts and attempts to gain authority. Psychiatrists should therefore always view their profession critically to fully grasp the hidden dynamics beyond the simple classifications and diagnosis written in an authoritative manual. Only by doing so can the field of psychiatry keep evolving and benefitting society.

Works Cited

Decker, Hannah S. “How Kraepelinian was Kraepelin? How Kraepelinian are the neo-Kraepelinians? — from Emil Kraepelin to DSM-III.” History of Psychiatry, vol. 18, no. 3, pp. 337-360.

Diagnostic and Statistical Manual of Mental Disorders. 2nd ed., American Psychiatric Association, 1968.

Diagnostic and Statistical Manual of Mental Disorders. 3rd ed., American Psychiatric Association, 1980.

Gieryn, Thomas. Cultural Boundaries of Science: Credibility of the Line. Chicago, 1999.

Kinghorn, Warren. “The Biopolitics of Defining ‘Mental Disorders’.” Making the DSM-5: Concepts and Controversies, edited by Joel Paris and James Philips, Springer, 2013, pp. 54-61.

Mayes, Rick, and Allan V. Horwitz. “DSM-III and the Revolution in the Classification of Mental Illness.” Journal of the History of Behavioral Science, vol. 41, no. 3, 2005, pp. 249-267.

Szasz, Thomas. “The Myth of Mental Illness.” Biomedical Ethics and the Law, edited by James M. Humber and  Robert F. Almeder, Springer, 1979, pp. 121-130.

—. The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York Hoeber-Harper, 1961.