What it produced was DSM-III, known as a “flat conceptual playing field”, comprised of lists of symptoms defining each disorder devoid of any theoretical assumptions, which was supposed to eliminate the shortcomings of the previous psychoanalytically-based, social judgement oriented manual. That observable behaviours has now become the standard with which people are being judged on their normality was presumed to be able to increase diagnostic reliability indicates that the psychiatric discipline has finally understood the problems arising from external perception of a person’s internal workings. However, when the criteria in DSM-III acquired a “descriptive rather than etiological” nature, it meant that the social context where the symptoms arose, and thus any consideration of its causation, was eliminated from the process of diagnosis. Where previously social context was essential to diagnosis, much of which was a judgement of the proportionality of reaction, behavioural or psychological, to triggering event, it is now dispensed with. This, according to Allan Horwitz in the article “The Age of Depression”, was a major drawback for DSM-III. In Horwitz’s eyes the distinction between conditions that are merely “normal sadness” and those that are genuinely cases of disorder – or as it would have been known in the early 20th century, as “without cause” and “with cause” – was the most important task of a psychiatrist. Over-diagnosis has just as much ill-effect on the patient as under-diagnosis. By taking away the social context, the possibility of misdiagnosis because psychiatrists had to judge the ‘proportionality’ of behaviours to causation was eradicated, but it also meant that people who are merely sad – a normal condition, according to Horwitz - have now been prescribed with anti-depressives meant for abnormal conditions.
To understand what Horwitz was saying it is necessary to examine the concepts of normality which distinguished DSM-III from its predecessors. In traditional psychiatry, where symptoms were produced by events or contexts that would be expected to produce them, they were seen as normal; otherwise it was a disorder. Another decisive factor was the self-healing process. Should these symptoms be able to “abate in a reasonable period of time”, then it indicated a normal condition; but reactions “of a more marked degree and of longer duration than normal sadness may be looked upon as pathological”. As mentioned above, that first decisive factor was abandoned in DSM-III, but the second survived into DSM-IV. For a person to be considered having a depressive disorder he must fulfil five out of nine items on a list of symptoms, and these symptoms must persist for a two-week period. If these reactions decrease over time as coping mechanisms appear to be dampening them, then a ‘trajectory of adaptation’ is deemed to have occurred, and the person is considered to have ‘normal sadness’; but if this did not happen then it would be possible to infer that the person was dysfunctional in the sense that the self-healing process failed to commence. Major exceptions exist; in the case of bereavement, considered a major grief reaction ‘with cause’, depressed or even suicidal feelings may still be regarded as normal. What was a marked change in DSM-III compared to previous manuals, and indeed to Jahoda’s criteria, was that the lists of symptoms no longer required external perception; one can easy judge himself, perhaps even more reliably than through others, on “fatigue”, or “insomnia”, or indeed “recurrent thoughts of death”. All this forms the backdrop of Horwitz’s article, in which it is apparent that he attempted to draw a clean line between ‘normal sadness’ and ‘abnormal depression’, and then concluded that ‘the DSM criteria used by researcher do not allow the distinction to be made’. By writing that “the DSM-III’s de-contextualised symptom-based criteria for depressive disorder had… some instances of intense normal sadness [classified] as disordered” Horwitz accused the psychiatric institution of over-inflating the latter, thus creating ‘an age of depression’ marked by a drastic rise in depression cases that was unexplainable by any social theory. The self-diagnostic nature of DSM-III and its successors allowed many to attempt to fit themselves into a diagnosis, which served to fuel the public panic about depression, and this in turn increased the social-wide depression phenomenon even further.
What are the problems with Horwitz’s argument? It would seem that Horwitz, having drawn a distinction between normal and abnormal sadness, has come to the implicit conclusion that it would be unwise for conditions capable of self-healing, and thus a ‘normal form of misery’ to be labelled as abnormal and then medicated or subject to psychotherapy. What he has not explained is why this ‘trajectory of adaptation’ in a ‘normal condition’ of sadness should not be accelerated, or assisted, with the use of professional treatment; in view of the rapid pace of life in many societies, it may in fact be beneficial for the person in question to be restored to emotional stability as soon as possible – and here an example of how social context affects methods of psychological treatment can be seen. However it is upon the presumption of the existence of such a ‘trajectory of adaptation’ that the concept of normality and abnormality were forged and applied by Horwitz and other psychologists. He admits that the balance between over-intervention and under-treatment can only be reached if a ‘conceptually valid approach to the distinction between disorder and non-disorder’ can be formulated. How valid, then, is the concept of normality based on the existence of the trajectory? The endorsement of this concept, by DSM-III, was recognition of several underlying culturally-based principles and definitions: First, Horwitz indicated that ‘two months’ was seen as an appropriate duration of time in which the coping mechanisms should be able to return the person back to a state of normality. It is unclear whether this was a culturally or scientifically based judgement, but there certainly exist cultures which expect extended mourning, and in conservative Catholic societies up ‘til the early 20th century, families who have lost their members may be required to observe mourning by specific dress codes or behaviours for years, and this would undoubtedly have an effect on the psychology of those individuals. Secondly, acknowledgement of the existence of such a trajectory, no matter how long this might take to function, necessitates the recognition of a definition of that ‘state of normality’ which lies at the end of the trajectory – and this would invariably return us to the definitions put up by Jahoda at the beginning of this essay. The exemption of behaviour caused by bereavement is, thirdly, the culmination of the first two underlying principles, for not only is this grief allowed a much longer period for its dissipation, but also that the exhibition this grave sadness is itself considered acceptable by social norms – which is certainly different in a Buddhist culture.
It must therefore be recognised that the criteria for depression in the supposedly context-removed, theory-neutral DSM-III is in fact as much a cultural product as was previous generations of the DSM, or Jahoda’s work in the 1950s. The roots of the three principles described above indicate roots in the middle class, white urban cultures of America or other western countries, from which in the late 70s the drafters of the DSM-III and the patients they used as a reference originated. Horwitz admitted that the theory-neutrality of the DSM-III allowed it to be used by rival ideologies as standard definitions upon which their arguments can be made interchangeable, an indication of the benefits brought by the direction towards ‘universality’ that the DSM-III was moving. What would later emerge to be very dangerous, was when this universality, in reality applicable only within the western cultural context where these competing theories were devised, was taken onto an international level by unsuspecting psychiatric professionals. This has led to accusations of ethnocentrism when the DSM, as in fact an etic standard, was used to evaluate and treat depression in ethnic minorities living within Western cultures, such as the Pakistani population in Britain, as researched by Rashda Tabassum et al. (2000) who found that “the meaning of the word depression is different for ethnic Pakistanis living in the UK than it is for Western psychiatrists”, and that “western symptoms did not always directly translate [in the Pakistani language] and the Pakistani culture had some different ways of conceptualising mental disorder”. Whilst some symptoms such as aggression were more important in Pakistani culture than others, Tabassum focused on the differences between ‘emic definitions’ or depressive symptoms with existing predominant etic ones used by western psychiatrists, and expressed concern over how they dictated Pakistanis as being mentally healthy or unhealthy.
What must then be questioned is the validity of this emic approach, as well as how it might reduce the reliability of diagnosis. This latter question would require another essay, but the former does raise the concern as to whether in Tabassum’s eyes it is more important to provide treatment for a ‘category’ of disorder (depression), or to the symptoms that constitute a disorder. It is clear that, if patients are being treated for their observable symptoms, then it would hardly matter whether the meaning of the word ‘depression’ which merely serves to categorise such symptoms are different between cultures for the person handling out the medication necessary. What does follow to be a real problem, is that the definitions of such symptoms were either still ambiguous, or were involving value judgements that prevented direct translation, and this appears to be a technical problem where the emic approach plays little part, but where it does is on the issue of how a mental disorder is conceptualised by Pakistani culture. Such disorders, according to Marsella & Yamada (2007) should not be separated “from the very psyche in which it is construed and the very social context in which people respond to it”, and it is necessary to understand the emics, or cultural-specifics of depression in Pakistani culture, which requires the acceptance of the role of inner-cultural norms when conducting analysis or treatment.
This is essentially a cultural relativist view of psychology. The anthropological origins of the distinction between etic/emic approaches, lie in the quest to find universal moral standards which ended with the discovery of the fact that there is practically none. The ideology of cultural relativism eventually arrived at a conclusion that acknowledged realities and rejected the notion of judging the ‘morality’ of the norms of another social group or even changing them. This is because no universal standard of morality can exist. It also meant, however, that the morality of another social group should not be transplanted to that where one belongs because of a difference of habits between the two, and here it diverges from moral relativism which held the belief that morality is interchangeable among members of different groups. The words of Clyde Kluckhohn were that “anthropology does not as a matter of theory deny the existence of moral absolutes. Rather… discovering such absolutes… if all surviving societies have found it necessary to impose some of the same restrictions upon the behaviour of their members, this makes a strong argument that these aspects of the moral code are indispensable.” Applied in psychiatry to the diagnosis of disorders in ethnic minorities, the argument would be that the social morality of such communities should be observed and the patients judged accordingly. It has been proven above that both context-based and context-removed criteria are ethnocentric products of cultural norms. Hence in any case the deviance from accepted social norms would qualify as abnormal behaviour in that community; the psychological ‘state of normality’ would be where the behaviours of the patient falls in line with those norms. This is an inherently dangerous theory, as here psychiatric treatment has worked to enforce social norms in these communities. For the individual the treatment would have been aimed at restoring to him attitudes, behaviours and values for a social identity deemed appropriate for the role assigned to him in that society – in effect it had become a tool of social control assisting in the reinforcement of hierarchies that may be unjustifiably brutal. The rebellious slave would have to be tamed; whilst the master sympathetic to the subjugated, for example Nazis like Oskar Schindler who disapproved of anti-Semitism, would need to be mentally reformed. It serves to justify the classification of political dissidents in Nazi Germany or Soviet Russia as mentally insane, particularly when what they disagreed with was an ideology deemed to represent rationality itself. This is whilst the use of emic diagnosis on people who belong to sub-cultures would imply the recognition of the norms of the sub-culture as a state of normality, rather than regarding that sub-culture as an abnormal phenomenon to be rectified, and its members restored to the state of normality accepted by the larger socio-cultural group.
This is the reason why anthropologist Julian Steward remarked that “either we tolerate everything, and keep hands off, or we fight”, unless the discipline is willing to give approval to “the social caste system of India, the racial caste system of the United States, or many other varieties of social discrimination in the world”. The work of Marie Jahoda, closely related to her social context and her personal socialist convictions, revealed that much of what accounts for mental ill-health under her criteria were caused in fact by unemployment; Allan Horwitz concluded that “changing or accepting the situations that led to the sadness might be as effective, or more effective, than medication or psychotherapy”. Whilst psychotherapy can do little other than helping the individual accepting his fate and adapting himself to the requirements of his social context, this can be fundamentally changed through government social policy. It was with this in mind that Allan Horwitz voiced his concern over whether “relabeling normal forms of misery as depressive disorder is beneficial or yields wise public policy”. At a time when “skyrocketing rates of treatment for depression” indicate that some 10% of adults in the United States are afflicted by depression every year, the disorder can no longer be considered an abnormality. As a statistical measure for government social policy-making, an inflation of the depression crisis causing a steep rise in the number of people in the population requiring psychiatric attention, certainly does not help in the allocation of resources to those who are most in need. This appears to be Allan Horwitz’s genuine concern. Here what must be examined is the statistical criteria for normality, which infer that those who fall out of a certain typical range when measured on traits and characteristics are abnormalities. Clearly concept validity is seriously lacking in the sense that what is considered statistically abnormal, one example being very high intelligence quotients, does not immediately qualify treatment as a disorder; nor is there any direct indication possible of the relationships between the statistical distribution of two or more traits. The threshold for what is considered infrequent – the 2.5% mark on either side of the bell curve – is also questionable in the sense that a percentage minority taken to a larger perspective would yield a statistically significant number, certainly in the millions if it is the worldwide population that is being examined. Thus statistics are only useful as an assisting tool to assess the dispersion of results in a population for nomothetic studies. A statistical abnormality is not the equivalent of an abnormality in the psychiatric sense.
The evolution of the concepts of normality and abnormality signify a few things. First was the realisation of the fact that social context exert an influence over such concepts, and it was the element of subjective, social, value judgement which inhibited the reliability of socially-based diagnostic criteria ranging from Jahoda, to Rosenhan & Seligman, to psychoanalytic-based DSM-II. Secondly was the acknowledgement of the problems arising from external perception of a person’s inner workings. These two factors produced a reaction culminating in the creation of a context-removed, theory-neutral DSM-III which was praised for its reliability and universality, but accused of being severely compromised in terms of concept validity. Thus the concepts of normality and abnormality was until the discrediting of the DSM-III being revised in the hope of improving its reliability in practice and universal applicability for different theories, at the cost of considerations of social context and proportionality between triggering event and reaction, which were of paramount importance to previous generations of psychiatrists. This was the basis of Horwitz’s condemnation of DSM-III regarding concept validity. However the line of distinction draw between what is considered ‘normal sadness’ and ‘depressive disorder’ and which Horwitz adopted for his argument, was based on cultural assumptions manifesting themselves in the theory of the ‘trajectory of adaptation’. Thus it was a cultural concept instead of an objectively scientific one which Horwitz took up to accuse the DSM-III of its deficient concept validity. The adoption of the theory of the trajectory of adaptation in the DSM-III, exemptions and other references found in the criteria for depression proves that the DSM-III is in reality an ethnocentric product. Its misapplication in ethnic minorities has caused a number of psychiatrists to advocate the use of an emic approach to the understanding of social norms within these communities and the diagnosis of their members. The cultural relativist undercurrent has produced a contradictory situation where psychiatric diagnosis can no longer distinguish and reform the abnormal, because the behaviours and norms of the perceived abnormal would have to be appreciated in an emic way. In any case psychiatry has been used to reinforce cultural norms and social roles by assisting individuals to adapt to their social environments, or by preaching acceptance of realities whilst contributing little to promoting any change to the situations that are the root causes of the normal or abnormal forms of misery suffered by the individuals. The struggle between validity and reliability in the design of the concepts of normality and abnormality can be understood as being one between emic and etic approaches. For a diagnostic tool, the greater ability it has to evaluate the social-context of the condition, the greater its concept validity; whilst that would have to be given up if reliable explanations that can be universally applied is to be creating. Whereby the emic approach focuses on producing standards derived from the norms of the culture[s] concerned, thus producing conceptually-valid criteria that rely on value judgements such as Jahoda’s or Rosenhan & Seligman’s, the etic approach has produced works like the DSM-III and its predecessors, which were intended to be reliable, universal standards – only to be later easily proven to be ethnocentric. The recent response of the psychiatric discipline to these questions has been to formulate an approach known as the ‘biopsychosocial’, an eclectic mix of considerations to be taken aboard when conducting diagnosis and treatment. Whether this will create more paradoxes on top of those aforementioned, or provide a solution for them, has yet to be seen.
