Classifying Mental Disorders Research Paper

This sample Classifying Mental Disorders Research Paper is published for educational and informational purposes only. If you need help writing your assignment, please use our research paper writing service and buy a paper on any topic at affordable price. Also check our tips on how to write a research paper, see the lists of psychology research paper topics, and browse research paper examples. This sample research paper on classifying mental disorders features: 8200+ words (28 pages), an outline, and a bibliography with 12 sources.

Classifying for purposes of research or intervention is a feature of the scientific method. Traditional methods for classifying mental disorders emerged from 19th century advances in the biological sciences basic to the science and practice of medicine. Underlying such advances was the explicit adoption of the world view of mechanism, the root metaphor of which was the transmittal of forces. In this context, physicians constructed systems for classifying organic disease. These systems provided the model for traditional psychiatric diagnostic and classification systems.

Nontraditional classification systems flow from an alternate worldview—contextualism, the root metaphor of which is the historical act in all its complexities. Instead of relying on the medically inspired concept of psychopathology, nontraditional practitioners speak of ‘‘unwanted conduct.’’ This practice explicitly recognizes that a moral judgment is being made on the strategic actions that people employ to solve their problems in living. In the nontraditional method described in this research paper, classification is not of disease processes but of interactional strategies and the conditions that influence the success or failure of such strategies.

Outline

I. Introduction

II. The Purposes of Classification

III. The Traditional Approach to Classification

A. The Mechanistic Conception of Unwanted Conduct

IV. The Contextualist Construction of Deviant Conduct

A. Happenings and Doings

B. Unwanted Conduct

V. Assumptions and Alternatives

A. Internality

B. Physicality

C. Individuality

D. Value Judgments Accompanying the Concept of Disease

VI. Diagnosing within a Contextualist Framework

A. Early Efforts to Construct a Contextualist Framework

B. The Narrative Framework

C. Strategic Actions

VII. Coda

I. Introduction

As a preamble to a research paper on alternate ways of classifying mental disorders, we point to a built-in source of ambiguity. The use of the construction, ‘‘mental disorders,’’ together with the phrase ‘‘mental health’’ in the title of the encyclopedia, reflects an implicit acceptance of a particular worldview from which the traditional approaches to classification are generated. The use of the word ‘‘mental’’ implies an assured and nonproblematic ontological status for the concept of mind, notwithstanding the many critiques of the concept, and by the claim that ‘‘mind’’ is an exemplar of the human tendency to transfigure a metaphor to a literal entity. Lost in the history of lexicography is the recognition that at one time mind was a verb, useful for talking about silent and unseen actions, such as thinking, imagining, and so on.

For the most part, the traditional approach treats ‘‘mind’’ as a literal entity, often as a quasi-organ parallel to the brain, or as an epiphenomenon arising from the workings of the brain. In actual practice, mental health professionals do not deal with ‘‘minds,’’ but with persons whose actions fail to meet a particular society’s standards of propriety or fail to meet self-imposed standards. It is an illusion that therapists aid in reconstructing ‘‘minds,’’ although they may be instrumental in modifying beliefs and values, in reinforcing strategies for managing interpersonal relations, in changing habits, and in acquiring self-knowledge.

‘‘Disorders’’ is also an unsettled concept. The term implies a departure or deviation from ‘‘ordered’’ conduct. It is important to note that the supraordinate concepts ‘‘ordered’’ and ‘‘disordered’’ (staples of mental health and mental illness doctrines) are derived from a particular worldview, probably unrecognized by the vast majority of mental health workers. The worldview is that of the machine, the root metaphor of which is the transmission of forces. Being ‘‘in order’’ or ‘‘out of order’’ (disordered), although apt constructions for describing the condition of a clock, a motor, or a computer, are misleading when applied to the acts of human beings. As a descriptor for unacceptable conduct, ‘‘disorders’’ is derived from traditional practices for classifying absurd or unwanted conduct— such practices being consistent with the mechanistic worldview that the ‘‘mind’’ operates like other machines— as a vehicle for the transformation of forces.

Related to the mechanistic conception of order is another implicit meaning of ‘‘disorder.’’ The concept of ‘‘social order’’ grew out of the belief in an orderly universe. Thus, ‘‘disorder’’ is applied to violations of the normative expectations for human conduct in everyday life. Shared constructions of the social order supply the context within which conduct may be classified as mentally disordered, deviant, nonconforming, abnormal, inept, or improper. Further, the shared constructions provide the background for legitimating interventions such as hospitalization, incarceration, or other systematic effort to restore order to the social group the equilibrium of which has been disrupted by the conduct of the ‘‘disorderly’’ or ‘‘disordered’’ person.

II. The Purposes of Classification

Behind any classification system is one purpose or more that provides the basis for distinguishing and defining categories. In Western culture, classifications of ‘‘mental disorders’’ have been designed to serve the purposes of the science and practice of medicine: (1) to select and guide treatment and (2) to facilitate research. In medical science, classifications are employed as a means of identifying diseases. For historically documented reasons, the classification of unwanted conduct has followed the patterns laid down by medical science for classifying organic disease. In regard to treatment, there are marked differences in the goals of treatment of measles and treatment for unwanted conduct (such as phobias). For measles, the ministrations of the doctor are in the service of providing a cure. For the person seeking help to control unwanted conduct, ‘‘cure’’ may be a less apt term than one that describes helping an individual to achieve his or her purposes in ways that are less objectionable to relevant others or more acceptable to oneself.

Medical research also explores the causes and treatments of diseases. Knowledge of treatment efficacy depends on research. However, in order to conduct research, particular instances must be located in classes in order to process data from a collection of similar cases. The literature of psychiatry and clinical psychology is replete with research reports that are indeterminate because traditional classification by ‘‘disorders,’’ which, like diseases, are categories based on ‘‘symptoms,’’ has not been sufficiently reliable nor valid.

If we add to treatment another purpose of classification, prevention, then examining the contexts that influence persons to engage in unacceptable conduct will influence the choice of categories for distinguishing among kinds of unwanted behavior. Such a move in the purpose of classification would require abrogating pretensions to being ‘‘objective’’ and value-free. The problem with the value commitments that attend the notion of ‘‘disease’’ is not that they are value commitments, for example, that the patient is not responsible for behavior ‘‘caused’’ by some internal happening. Any intervention into the life of another person engages a value commitment. The problem rather is that practices based on the notion of ‘‘disease’’ or ‘‘disorder’’ follow from the profession’s commitment to a counterproductive set of values that positions the person as without agency.

III. The Traditional Approach to Classification

To write about nontraditional ways of classifying persons whose conduct fails to meet contemporary standards of propriety requires that we first lay out the boundaries of traditional classification systems the better to show contrasting features. We take as the prime exemplar of traditional classification systems the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association, with the most recent edition (hereinafter referred to as DSM-IV) published in 1994. DSM-IV provides a detailed nosology, a critical analysis of which opens the door to an understanding of the underlying worldview that guides the practice of classifying deviant conduct. The claimed purpose of the nosology is to provide a means of establishing reliable diagnoses.

A. The Mechanistic Conception of Unwanted Conduct

The history of science makes clear that the mid-nineteenth century witnessed tremendous progress in the science of biology. This progress was directly related to the mechanization of biology. All biological phenomena were to be explained in terms of the mechanistic transmission of physical and chemical forces. Scientific explorations sought principles that were invariant. During this period medical doctors took on the task of explaining abnormal behavior by extrapolating from the findings of the rapidly developing field of neuropathology. The context for this development was the surface resemblance of symptoms of neuropathology to unwanted conduct for which no neuropathology could be found. During this period Emil Kraepelin formulated his initial classification of psychiatric diseases, a classification that assumed all abnormal behavior to be related to organic causes, even in the absence of organic signs and symptoms. ‘‘Organic’’ and ‘‘functional’’ were the terms of convenience to identify whether or not neuropathology was demonstrable. The remote influence of the ideology that influenced Kraepelin’s formulations can be deduced from the explicit claim in DSM-IV that ‘‘nonorganic’’ mental disorders have a biological basis.

The mechanistic framework inherited from Kraepelin creates serious problems for professionals engaged in the therapeutic enterprise. First, DSM-IV continues to manifest only marginal reliability, in spite of Herculean efforts by its creators. Second, the validity of the categories all too often fails traditional scientific tests and settles for negotiation and consensus among professionals. And third, the tendency to expand both the number of diagnoses, as well as the number of criteria, yields a continuing expansion of the category ‘‘mental disorder’’ into what might, from a less mechanistic point of view, be seen as the necessary travails and tragedies of everyday life. (The first Manual, published in 1952, listed 106 categories. DSM-IV lists 357 diagnostic categories.)

Beginning with the question of reliability, it has been convincingly demonstrated that the accumulation of more categories and more criteria adds only marginally to the reliability of diagnostic practice. The self-advertised theoretically neutral ‘‘descriptive’’ character of diagnostic language may minimize unproved explanatory hypotheses, but it can yield no more agreement among practitioners than the language it uses to describe persons or behavior. For example, the stipulation that something must have been present for ‘‘at least 6 months’’ offers precision in a fairly trivial way compared to the difficulties of reliably assessing whether a set of actions is ‘‘disabling’’ or ‘‘not disabling.’’ No behavior exists as simply disabling or not disabling, independent of the social and psychological context, most of which is beyond the specifiable stipulations of diagnostic manuals.

Marginal reliabilities compromise research by including in samples persons whose conduct is heterogeneous but who are lumped together into diagnostic categories. More serious is the questionable validity of diagnostic categories in the course of selecting treatment programs. Traditional classification manuals fail to deal with the question of whether a ‘‘mental disorder’’ exists apart from a culturally specific context— whether, in other words, the label for a disorder names a part of nature that is independent of the social constructions of clinicians and the authors of diagnostic manuals. The controversy of a quarter century ago, whether homosexuality is a ‘‘disorder,’’ is not an exception in its clear dependency on normative judgments and negotiations that occur in a historical and cultural context. Most unacceptable conduct, even if reliably identified, is ‘‘disordered’’ only in terms of a culturally relative standard. Cross-cultural research has shown no consistency across cultures in the use of traditional diagnostic categories, for example, ‘‘schizophrenia.’’ It is unclear whether this lack of consistency indicates different social constructions by clinicians or different causal antecedents. Professionals are not justified in construing that the meaning of a set of behaviors in one culture is the same in another culture, in the same way that diabetes in one culture is the same in other cultures.

Finally, in addition to the expansive and fluid character of the catalogue of disorder through its five editions, the Manuals’ tendency to medicalize all human discomfort inspires even more questionable logic. The latest such version is the creation of ‘‘shadow syndromes,’’ which are formulated to legitimate treatment for persons whose conduct fulfills only some of the Manual’s criteria for a disorder. Extrapolating from the proliferation of diagnostic entities over the various editions of the Manual, one might predict that through the typical negotiation process of the experts, some of these syndromes will come out of the shadows and enter the next version of the Manual as certified ‘‘disorders.’’

IV. The Contextualist Construction of Deviant Conduct

But there are practitioners and scholars who operate from a different worldview, namely, contextualism— a worldview the root metaphor of which is the historical act in all its complexity. Novelty and change are features of this alternative worldview that provides the foundation for a nontraditional approach to the classification of intentional actions. Historical acts are engaged in by people. Further, historical acts are narrated, told as accounts, anecdotes, and stories in which men and women make choices to resolve their everyday problems of living. Because contextualists construct the world in terms of historical actions, they look for reasons for such actions, unlike the mechanistically inclined clinician who would look for causes.

The contextualist worldview directs us to see human beings not only as biological specimens, but as agents, as doers, as performers and problem solvers. In so doing, we are perforce obliged to develop understandings of how human beings employ narrative structure to shape their life histories.

A. Happenings and Doings

Completely overlooked in the constructions of traditional psychiatric classification is a simple distinction, that of happenings and doings. Examples of happenings are ruptured spinal discs, toothaches, brain tumors, and carcinoma. Such happenings are attributable to causes, empirically established or hypothesized. As exemplified in DSM-IV, abnormal actions are caused by happenings—the transmission of forces in the brain or in the metaphorical mind. Neurotransmitters, phrenological bulges, chemical anomalies have been sought as the causes of abnormal behavior. The diagnostic drama guided by traditional classification has no room for the client as agent, as doer, as capable of intentional action.

On the other hand, doings are the agential, intentional, purposeful actions of persons attempting to participate in a drama based on their self-defining narratives. Slapping a child, seeking a mystical experience, declaring that one is host to multiple personalities, avoiding a confrontation, are examples of doings, of actions.

The distinction between happenings and doings is helpful in understanding how the traditional diagnostic system and its vocabulary of symptoms has contributed to the medicalization of distress. In the absence of a strong competitor, the language of the medical model was embraced by neighboring professions to describe unwanted conduct. To refer to an action as a ‘‘symptom’’ is to adopt a special linguistic system. The use of ‘‘symptom’’ carries the implication ‘‘symptom of something.’’ The ‘‘something’’ is a happening that is the presumed cause of the symptom— in traditional medicine, a microbe, a tumor, a morphological anomaly, a toxin, a chemical imbalance, and so on.

The application of the mechanistic worldview with its emphasis on causal happenings has worked well in organic medicine. A perusal of DSM-IV makes clear that the model was adopted in its entirety by modern biological psychiatry. The Manual is explicit in proclaiming that the diagnosis and treatment of ‘‘mental disorders’’ belong to the domain of medical practice.

Classifications of any kind must follow from some articulated theory. Although the authors of DSM-IV claim to being atheoretical, it is apparent that the claim is a veiled cover for a weakly defined theoretical system that is reminiscent of Kraepelin’s mechanistic framework, that is, that all deviant conduct is caused by anomalies in organic systems. On this framework, DSM-IV fails because of the large proportion of cases for which no biochemical or other organic substrate can be found.

B. Unwanted Conduct

We employ ‘‘unwanted conduct’’ rather than ‘‘psychopathology’’ to emphasize the moral judgmental component of diagnosis. Every society creates procedures and practices for marginalizing persons whose public actions fail to meet propriety norms. Beginning in the mid-nineteenth century, the responsibility for controlling such marginalized persons was assigned to physicians practicing in institutions variously named mad houses, lunatic asylums, and mental hospitals. The criteria for detention included atypical imaginings (‘‘hallucinations’’), nonconforming beliefs (‘‘delusions’’), and incomprehensible or absurd gestural or speech behavior. Behind these criteria were implicit premises about maintaining public order. Authority figures (parents, police, magistrates, and doctors) made the initial judgment whether any particular item of conduct was to be classified as unwanted. Those whose nonconforming behavior was under scrutiny were labeled as mad, insane, lunatic, crazy, and more recently, mentally ill.

In the twentieth century, the scope of psychiatric practice included diagnosing and treating men and women who were self-referred. Not regarded as mad or insane, such self-referred patients sought help from medical doctors on the belief that they were suffering from ill-defined but nonetheless genuine ‘‘nervous’’ ailments. Hysteria was the diagnostic label employed to denote a wide variety of such ‘‘nervous’’ conditions. In due course, clinicians sorted the presenting complaints into a number of classes identified by labels derived from Greek or Latin roots, such as neurasthenia, psychasthenia, anxiety, hypochondriasis, and depression. These terms sometimes reflected unwanted ‘‘feelings.’’ Persons seeking help for dealing with unwanted ‘‘feelings’’ would verbalize their complaints with vague and ambiguous expressions, such as ‘‘I am anxious,’’ ‘‘I am depressed,’’ ‘‘I can’t concentrate,’’ ‘‘I’m sitting on a volcano.’’ Taken together, these complaints are subsumed under the general medical term ‘‘dysphoria.’’

Clinicians who subscribe to the medical model regard dysphoric complaints as symptomatic of a bodily dysfunction. It has become common practice among physicians to prescribe medications to reduce the extent of the dysphoria by altering the body chemistry. A radically different approach would be taken by contextualist clinicians who are sensitive to the notion that distress follows from the failure of strategic actions to solve problems of living. The self-reports of distress that are expressed in the language of ‘‘feelings’’ are construed as the patient’s sense-making of proprioceptive and interoceptive changes associated with failed strategies to solve existential or identity problems. Contextualist clinicians direct their attention to the reasons for the unresolved strains-in-knowing rather than to reports of ‘‘feelings’’ that are adjuncts to personal problem solving. Their focus is on understanding the antecedents of the unsatisfactory attempts at problem solving, or expanding the library of plots for interpreting distress, and on the exploration of alternative strategies for maintaining an acceptable self-narrative.

V. Assumptions and Alternatives

The difficulties with traditional methods of diagnosis can be specified in terms of four assumptions routinely built into diagnostic manuals (1) internality; (2) physicality; (3) individuality; and (4) the value judgments accompanying the concept of disease. For each of the assumptions undergirding traditional modes of classification, we propose an alternative assumption that is consistent with the contextualist perspective.

A. Internality

The current system envisions each abnormal psychological condition to be a malfunction generated from within the person. In a given situation, one person may behave in accordance with common sense expectations while another may not. The latter will be labeled abnormal, deviant, disordered, disturbed, and so on. The difference between the two cases does not come from the social context that traditional diagnosticians assume to be the same for both. What is taken to produce acceptable conduct from one and unwanted conduct from the other are processes internal to the person.
The most elemental of diagnostic decisions, for example, that of orientation to time, place, and person, depends on this diagnostic procedure borrowed from the standard neurological examination. Like that examination, what is being assessed is assumed to be inside the person. More elaborate diagnostic judgments, such as deciding between ‘‘depression’’ identified as a disease, and ‘‘mourning a death in the family,’’ which is not so identified, depend, for example, on sadness in the absence of mourning. Such a judgment influences the traditional clinician to locate the cause of the phenomenon inside the body rather than externally, in human relationships.

It is clear that most human behavior is oriented to concrete immediate situations. Human behavior is jointly produced not only by a person and a situation, but each of these factors also responds to the other over time to create a dialectical whole, such as a relationship. When a relationship contextualizes a behavior, as is always true even in diagnosis, the meanings of any behavior must take into account the dialectical determinants. The complex of avoidant actions identified by the label ‘‘agoraphobia,’’ for example, does not exist inside the person. The actions are ways of coping with situations that have developed over time. Nontraditional approaches that depart from the disease model begin with the individual’s history of trying various ways to cope with his or her environment. Traditional diagnosis underplays the agential character of human behavior because ‘‘diseases’’ are ordinarily understood to be happenings that take place inside the person.

B. Physicality

The traditional diagnostic system construes a person as a complex biological machine the controlling mechanisms of which are the neurochemical patterns of the brain. Information processing is seen as the central function of the brain, a conception that extends from neural transmissions to perceptions of the environment. This information is selected for its relevance to a given stimulus situation. Such selection is not always without error. The result of acting on mistaken perceptions is conduct that may violate social norms, leading to a psychiatric diagnosis.

Observing a person confounding imaginings, rememberings, and current perceptions, a clinician would invoke the diagnostic label ‘‘hallucinating schizophrenic.’’ Or, observing a person confounding irrelevant sad feelings with nonpresent situations, the clinician might entertain the diagnosis ‘‘depression.’’ In these instances, information appears to be scrambled, and there is a strong presumption that the brain, as the organ of information processing, is malfunctioning and the unwanted behaviors are thus believed to be caused by chemical imbalances in the brain.

Information, however, is not merely physical. To be sure, information can be reduced to a ‘‘signal’’ that can be described in the vocabulary of physics, but the signal never embodies meaning. In this sense, meaning is not physical but is constructed—the achievement of human beings who have acquired linguistic and epistemic skills. To sustain the premise that abnormal behavior is the product of exclusively physical processes would be like saying that the science of acoustics can reveal to us the meanings carried by human speech. The concepts and theory of sound waves and temporal patterns can tell us about human speech in their own terms, and that is hardly trivial. But scientists who do such work make no claims that their instruments can tell us anything about the meanings of words and sentences, the logicof theory, or the motives of actors who try to communicate with one another. To extend physical science into realms of meanings and motives is to claim too much. It is to persevere in a metaphysical belief that the only reality is the reality of the physical world, a belief that ignores the arguments and demonstrations that realities are social constructions.

C. Individuality

The current system envisions abnormal psychiatric conditions as affecting encapsulated individuals. While cultural differences in the incidence of unwanted conduct are well known, and some patterns of behavior are culturally specific, as anorexia is to modern industrially advanced cultures, the goals of treatment, as well as the interpretation of the problem, rarely extend beyond the distressed individual. Although the stresses of poverty, for example, may increase the incidence of many abnormal conditions, current practice assumes that abnormal behavior happens to individuals independent of social contexts. To take more seriously conditions such as poverty, and to make them medically relevant, one can of course add a note to the diagnostic statement, codified as the marginally salient Axis IV in DSM-IV. An impartial examination of demographic data of persons diagnosed as psychopathological would suggest that the mental health professions should advocate as therapeutically relevant such conditions as full employment, adequate welfare safety nets, and a livable minimum wage. But this practice is marginal exactly because taking it seriously would require economic, political, and governmental intervention rather than psychiatric or psychological attention. The entry of the treatment professions into politics would undermine the value-free pretenses of the diagnostic system. Such political involvement, especially since it pretends to be scientific rather than political, runs many risks already revealed to us in the awkwardness of courts of law where psychiatric (diagnostic) testimony becomes a part of society’s decision to blame wrongdoers—or to excuse them. The risks already incurred by our diagnostic pretenses to scientific accuracy could stretch wildly the current legitimacy of the treatment professions. There is, of course, no simple solution to these problems, but it is clear they are made much worse by the notion of discrete diseases, some of which traditionally supply an excuse, others of which do not.

Empirically demonstrable is the fact that such socioeconomic variables as poverty can be relevant to diagnosis, a fact that cannot be acknowledged so long as mental illness is seen as an individualistic phenomenon. Behavior that has traditionally been labeled mental illness is hardly a private matter analogous to such patently medical conditions as diabetes or cancer where internality and physicality are demonstrable.

D. Value Judgments Accompanying the Concept of Disease

The current system envisions mental illnesses, like other illnesses, as conditions to be eliminated. Diseases, in our current understanding, rarely have value and meaning beyond that of deserving the most concerted efforts to eliminate them. The more internal, physical, and individual the diagnostic concepts and procedures, the less are abnormal actions perceived as addressing some aspect of a person’s effort to position himself or herself in the world of social norms and moral expectations. An individual’s complaints of depression and anxiety are not valued for their indexing a struggle with a personal decision or with a moral dilemma. They are merely ‘‘symptoms’’ that, when sufficiently aggregated, indicate a disease, and a disease is to be cured.

Just as the elimination of pain by analgesic drugs may mask a bodily ailment, so may the elimination of anxious or depressed behaviors mask a moral crisis. Furthermore, the individual diagnosed may, on the authority of the mechanistically oriented professional, misinterpret his or her own life narrative as internal happenings. Beyond that, the profession might address the possibilities for preventive measures. It can of course be argued that such a ‘‘public health’’ approach in psychiatry may have to pretend to know with some precision the societal and family conditions that engender contranormative behavior. The parameters of the ideal family or neighborhood or school have yet to be spelled out. The prevailing practice of dealing with instances of human distress as ‘‘diseases’’ removes from the profession any pressure to allocate research resources to filling gaps in knowledge necessary for implementing prevention programs.

VI. Diagnosing within a Contextualist Framework

A. Early Efforts to Construct a Contextualist Framework

The diagnostic procedures based on Kraepelinian doctrine have been the subject of earlier critical works. During the first four decades of the twentieth century, the Swiss-American psychiatrist, Adolf Meyer, promoted a contextualist view of unwanted conduct. He rejected the idea that the causes of deviant conduct would be discovered with advanced anatomical and histological technology. Instead, he urged his colleagues and students to attend to the whole person in his or her social and cultural milieu. His focus was not on purported biological happenings but on the person’s ineptitude in adjusting to his or her life circumstances.

The history of the first half of the twentieth century credits Meyer’s contextual approach with having a widespread impact on the direction of American psychiatry. A number of well-known texts promoted Meyer’s contextualist views. These texts made use of formulations drawn from the social sciences and the humanities, among them discourse analysis, role-taking, socialization, learning theory, pseudocommunity, overinclusion, and so on.

Meyer’s approach had a positive impact on the development of American psychiatry, but his contextualism faded into obscurity when the psychiatric profession enthusiastically adopted psychoanalysis as its quasi-official theory. The displacement of Meyer’s contextualist framework by psychoanalytic doctrine may be attributed to the fact that the hydraulic model advanced by Freud was consistent with the mechanistic perspective that was already entrenched in the medical sciences. In addition, Meyer, unlike Freud, had no self-proclaimed disciples, no professional institutes to promote his contextualist formulations, and no organized corpus of writings.

More recent challenges to the validity of the Kraepelinian- inspired DSM-IV have been made in critical works by scholars working from contextualist behaviorism and from social psychological orientations.

B. The Narrative Framework

The contextualist model sensitizes the clinician to focus on the master question: ‘‘what is the client or patient trying to do?’’ Answers to this question will inevitably be in the form of a narrative that includes the parts played by other actors in the client’s drama. The constructed narrative provides clues for a diagnosis in terms of the class of strategic actions employed. The clinician’s answer to the master question satisfies the original purpose of diagnosis—namely, to guide the therapist and the client in developing a treatment plan.

Classification for purposes of scientific research should consider the narrative context within which a distressed person is trying to do something. Also relevant to scientific classification is the issue of how the client’s narrative fits or fails to fit into the narratives of the client’s family, social group, or subculture. Sorting cases into categories to explore differences and similarities requires attention to crucial attributes, including meanings, of the behavior itself. Science cannot ignore these narrative meanings and contexts in deciding whether cases are similar or different.

Unwanted behavior, then, is performed by agents whose purposes are crucial, even if such purposes may not be clear to relevant others or to the agents themselves. The talk, actions, and expressions of feelings that are the results of failed strategies to fulfill the requirements of an ongoing self-narrative are the raw data from which the clinician formulates a diagnosis. This alternative approach assumes that the narrative context must be understood if the puzzling behavior is to be understood. The narrative that guides a particular failed effort must be specified, as well as the fit or lack of fit, between such a narrative and the larger narratives of the social context. Usually, there is a lack of fit, which appears as a violation of norms and values held by social groups and codified in cultural traditions.

The narratives that fit these traditions may be referred to as ‘‘conventional,’’ and those that do not, as ‘‘unconventional.’’ Those people whose behavior issues from a life-narrative that is incomprehensible or grossly nonconforming become candidates for psychiatric diagnosis. These are not people without self-narratives; they are people with unconventional narratives, and/or an unwillingness to disclose them. For example, it is not comprehensible to most of us how someone might seriously suspect a man’s unconventional narrative in which he identifies himself as Jesus Christ. In the case of such a client who is apparently convinced of the authenticity of his claims, diagnosticians have no way to understand this conviction and this narrative except to construct the inference: ‘‘the man is psychotic.’’ The logic of that inference is consistent with DSM-IV criteria that qualifies the client’s claim as a delusion and as sufficiently ‘‘bizarre’’ to assign the diagnosis of schizophrenia (if the belief had been held for 6 months or more).

While this diagnostic term ought scientifically be seen as a description of the patient’s conviction, it is usually taken as an explanation. This elision of description to explanation is one of the outcomes of employing the disease model. It renders unnecessary any understanding of the narrative as a context for unwanted conduct, or understanding the social or moral circumstances that provided the context for the particular narrative. The illicit shift from description to explanation is in great measure responsible for the standard professional practice of ignoring the patient’s life story.

However, it is important to note that not all behavior that is subject to professional diagnosis is merely an unconventional narrative. In a case of homicide, a truck driver strangled his wife in the heat of an argument in which she declared she had been unfaithful and was about to leave him for her lover. This threat not only confirmed his prior suspicions, it enraged the client. ‘‘I couldn’t control myself, I was so mad. The anger inside me had to come out. I exploded.’’ While this case is not one of clinical diagnosis for purposes of treatment, it is one of legal diagnosis for purposes of adjudication. To call him ‘‘insane’’ at the time of the murder would be to say that his behavior was caused by stimuli the provocative power of which controlled his behavior. He himself was helpless, the argument would go (and has gone); his being an agent of his actions would not be considered a factor.

At the same time, we recognize that the man was following a well-known and not unpopular narrative plot of ‘‘punishing an unfaithful wife.’’ The narrative does not excuse his behavior, but it makes it intelligible. It collects those circumstantial factors together in a way that, in fact, is how we understand his behavior. It bears on why he did it, when we understand the ‘‘why’’ as searching for reasons, rather than causes.

This kind of contextual understanding does not resolve the question of whether or to what degree the man should be excused for his actions. It certainly avoids the possibility that the extreme behavior was caused by a diagnosable disease. And yet such contextual understanding is absolutely essential in order to understand the action, which, given the circumstances and the stock of cultural narratives about unfaithful wives and angry husbands, is quite easy to understand. This understanding addresses the question of what this man was trying to do. It opens up a psychological investigation of his strategic actions, given a particularly vivid set of circumstances.

This case, like most behaviors that come to professional attention, deals with a struggle in which both social and moral questions abound—questions about what one is to do, who one is to be. Except for behavior that is casual or genuinely accidental, human beings behave in such a way as to work toward achieving their goals, one of which is to be a certain kind of person. Was the truck driver to perceive himself as a cuckold? Was he to perceive himself as a failure in not controlling his wife? He not only wanted to punish her, but also likely wanted to persuade her, and he certainly did not want his manhood challenged.

These themes are congruent with common narratives in certain pockets of society, and they are not without influence. Grasping such meanings is what clinicians must do in order to have any intelligent grasp of clients’ conduct. Such interpretive psychological work certainly does not suggest that a disease was the proximate cause of a death, as traditional diagnostic thought could imply. Finding a basis for such interpretive work is the point of the alternative model to which we now turn.

C. Strategic Actions

As an alternative construction to the implicit theory underlying DSM-IV—that unwanted conduct is caused by anomalous happenings in the biological machinery— the contextual construction takes its point of departure from the premise that people are agents. They are performers, actors, doers, discourse partners. This premise turns attention to a person’s actions, not to postulated happenings in the brain or in the metaphorical mind. The actions of interest are in the service of resolving strain-in-knowing, particularly those actions that give rise to self-judgments or to other-declarations that such actions are unwanted. Strain-in-knowing is a response to conditions that interfere with the continuity of the person’s self narrative. These are the conditions that are ordinarily subsumed under the heading of emotional life.

Strain-in-knowing occurs when there is a discrepancy between the demands of emotional life and the actor’s current constructions (beliefs and values). An alternate way of formulating strain-in-knowing is the expenditure of effort to locate or position oneself in relation to the world of occurrences. Sometimes identified as anxiety, disequilibrium, threat, or unassimilated input, the center of the concept is ‘‘I have a problem.’’

The implicit and explicit behaviors intended to resolve strain-in-knowing may be called ‘‘strategic action.’’ Often intelligible to the actor, strategic actions are not necessarily intelligible to others, for only the actor is the potential beneficiary. In cases we call abnormal, such strategic actions may become habitual and automatic, a condition that makes it difficult for actors to explain their conduct in ways that are intelligible to others. Strategic actions to resolve strain-in-knowing may appear to others as obscure or meaningless, or as potentially dangerous or embarrassing.

It is important to add a disclaimer that strain-in-knowing is not a passive phenomenon taking place in the metaphorical mind. The multifarious behaviors that are traditionally regarded as abnormal or incomprehensible may be parsimoniously classified as phases in the construction of a self-narrative. Whether successful or not, strategic actions in the service of resolving strain-in-knowing become a part of the lived narrative.

We present herewith a brief sketch of a model that derives from various contextualist frameworks. The model returns personal agency to the matrix of constructions that are employed to understand human action. The central feature of the model is a list of ‘‘strategic actions’’ that can serve as the scaffolding for a contextualist classification system. Strategic actions may be classified as follows:

instrumental acts (including rituals);
tranquilizing and tension-releasing acts;
attention deployment acts;
acts to change beliefs and values;
nonaction.

These classes of strategic actions are connected to antecedent events and subsequent effects, the latter having a feedback function. Strategic actions are employed to neutralize strain-in-knowing. Any particular strategic act has two potential effects: the first, if successful in satisfying the intentions of the actor, would eliminate or modify the perceived source of strain, the second would provide a relevant audience with opportunities to give warrants of social validation or invalidation for the particular strategic action. In this model, the persons and institutions that enforce values are part of the external world of occurrences. The moral judgments of others are inputs that must be instantiated, matched against the beliefs and values that make up the person’s self-narrative.

The antecedent events to strain-in-knowing require no detailed analysis—the cognitive psychology of the 1960s and 1970s has given us a template. The world of occurrences may be sorted into discrete domains or ecologies: the self-maintenance domain, the time– space domain, the social domain, the moral domain, and the transcendental domain. Sensory inputs are also generated within the body, the proximal world of occurrences. Human beings (and other sentient organisms) try to match sensory inputs with their systems of knowledge. In problematic situations, the actor directs his or her efforts to the world of occurrences to gain confirming or disconfirming inputs. During the interval when no match is made, the condition of strain-in-knowing prevails. In short, the actor strives to match the inputs against a construction— a self-narrative—derived from his or her prior experience. Of special interest is the observation that efforts to find a match are not always successful.

The prototype for sense-making is the ethological concept of vigilance. When an animal, human or other, registers inputs through vision, hearing, olfaction, and so on, it tries to match the sensory inputs against its available constructions. In the primeval world, the construction might be represented by the question: Is the stimulus event to be instantiated as benign or hostile? The choice of subsequent actions follows from the type of instantiation.

The problems in living that are the starting places for both traditional and nontraditional professionals are in the social, moral, and transcendental domains. Positioning oneself in these domains or ecologies involves mapping input against existing constructions, that is, against the beliefs and values that have become part of the actors’ ongoing self-narratives. Any particular self-narrative is built up from answers to the social identity question: Who am I? to the moral identity question: What am I in relation to moral standards? and to the transcendental identity question: What am I in relation to such abstractions as God, the universe, departed ancestors, and so on. When inputs from the social, moral, or transcendental domains produce incompatible or conflicting answers to the identity question, the person experiences strain-in-knowing, a condition that involves effort to match inputs with existing constructions and/or to seek confirming or disconfirming inputs for putative matches. This is a proactive process. Effort involves physiological participation that produces interoceptive and proprioceptive inputs. These inputs feed back into the proximal world of occurrences, thus, the actor’s task includes attending to the additional sensory inputs generated in efforts at sense-making.

The use of strategic actions is not exclusive to people in distress who are the clients and patients of mental health professionals. We are all strategists in order to deal with our everyday strains-in-knowing, in our need to make sense of the welter of inputs from the various domains. It is only when the strategies fail to resolve the strain and/or are not given warrants of validation by significant figures—parents, spouses, teachers, employers, doctors—that the person becomes a candidate for diagnosis and treatment.

Each class of actions has a target: instrumental acts are directed to the external world, to change the relations between the person and some aspect of the world of occurrences. Inputs from the social domain, for example, that cannot be matched to one’s self-narrative lead to an unvoiced interpretation: my identity is at risk. The person may choose between the traditional fight-or-flight instrumentalities in their many attenuated forms. A particular instrumental act may reduce strain-in-knowing and simultaneously be validated (or invalidated) by persons who have the power to pass moral judgment. The alleged Oklahoma City bombers are said to have constructed a belief that ‘‘the government’’ was evil. They equated a federal building with ‘‘the government’’ and destroyed it. Other citizens engage in less extreme forms of instrumental action: they write letters to their senators or change the relation to the distal domains by withdrawing from social relations, or becoming a hermit. Ritual behavior is included in the strategy of instrumental acts because it is mediated by the belief that, like direct action, rituals and ceremonials can influence the world of occurrences.

The tranquilizing and releasing strategy is directed toward changing bodily sensations that may be indirect effects of sense making efforts. Alcohol, drugs, sex, hot baths, cold showers, vigorous exercise, and the excitement of gambling are examples of the choices of actions that modify inputs from the internal ecology. The use of the strategy by itself does not certify that one is a candidate for a clinic or a sanitarium. The moral judgment of relevant others on the particular tranquilizing or releasing strategy is the act that identifies the strategy as acceptable or as not acceptable.

Examples of the strategy of attention deployment are the acts that are subsumed under such traditional labels as hypochondriasis, conversion reactions, and participation in imaginary worlds. The person’s attentional resources focus on inputs other than those from the social and moral domains that are the usual antecedents to strain-in-knowing among humans. A common deployment is to attend to bodily sensations, thus avoiding critical inputs from the social world. A variant of the strategy of attention deployment is involved participation in an invented set of self-narratives, as in classic multiple personality.

Changing one’s beliefs and values is a strategy directed to influencing the structure of knowledge. It is the strategy of choice for clinicians who work in the tradition of cognitive psychology. For example, a suicidal client holds the belief that suicide (an instrumental act) will solve his or her problems. The clinician takes on the task of modifying that belief. For example, a sample of women who held suicidal beliefs repudiated such belief following individual and group therapy, skills training, and other interventions. As with other strategies, change in beliefs may neutralize strain. When the person acts on the beliefs, or makes them public, the possibility exists for others to declare the beliefs good or bad. Persons who claim to have been abducted by extraterrestrial aliens, for example, are likely not to receive warrants of validation from most professionals.

The fifth category is labeled nonaction. The person may have tried the available strategies and they have not worked, either in the direct reduction of strain or in gaining social validation. Under these conditions, strain-in-knowing increases. Not succeeding in neutralizing strain, the person may strive to reduce involvement in the world, lest any actions may lead to inputs that would increase the strain. Traditional diagnosticians would scan the DSM categories for one of the 10 mood disorders, a procedure that would locate the individual’s suffering as a happening.

In this connection, an alternative approach to ‘‘depressive disorders’’ should be mentioned. The nonaction of the so-called depressed person is interpretable as a subtle form of strategic action, the goal of which is to convince others that one is a helpless, hopeless, or worthless figure in a self-narrative. Specific kinds of ‘‘depressed’’ actions influence others to respond in specific ways. The ‘‘helpless’’ person, for example, calls out responses from others that are qualitatively different from the responses called out by persons who claim to be ‘‘hopeless.’’

This briefly sketched model is radically different from the medical model in that moral judgment is an acknowledged component. The appellation ‘‘unwanted conduct’’ and similar terms are moral judgments rendered either by relevant others or by self. This component is ordinarily omitted from psychiatric discourses that focus on hypothesized internal mechanisms only after the initial moral judgment has been rendered by relevant others or by self.

VII. Coda

The dominance of DSM-IV has clouded the fact that a variety of alternative approaches have been, from time to time, put forth for diagnosing psychological problems. These approaches have been eclipsed by the attempt to standardize procedures—an effort driven more by bureaucratic and insurance pressures than by scientific goals. In a historical and critical analysis of DSM some of these motivations have been laid bare. At century’s end, the economic goals of the therapeutic professions continue to favor quick categorization of patients. A convincing argument has been made that the DSMs have evolved into instruments that serve bureaucratic and financial functions more fully than they do scientific ones. When critically examined the DSM’s claim to theoretical neutrality cannot be sustained. In fact, the DSM authors take pains not to conceal a strong biological bias. Critics have argued that the current dominance of DSM prematurely closes off scientific analysis. More specifically, the authors of DSM have failed to examine their underlying assumptions, particularly those embedded in their unarticulated theoretical structure and in their choice of root metaphors. Given the state of knowledge, it is premature to posit a theoretical structure that would support the notion of clearly delineated disease-like entities. The root metaphor of mechanistic causal forces defines not only the clinical reality but human behavior in general, and it does so in a way that transforms historical actions of persons in identifiable sociocultural contexts into physicalistic happenings like infections and mechanical breakdowns that occur independent of human intentionality.

The narrowness of this perspective is obvious. It not only neglects most of the considerable advances made in social psychology and social anthropology in recent decades, it negates common sense views like those of Adolf Meyer half a century ago to be examined to construct systems for organizing the actions of people.

‘‘Problems in living’’ are neither ‘‘mental’’ in any simple distinction from somatic, nor are they ‘‘disorders’’ in any obvious contrast to an order we can identify as natural. The intellectual resources available to the task of classifying people’s problems in living are rich, varied, and often very much more precise and elaborate than the DSMs, but they have been neglected for reasons other than their scientific relevance to the task.

DSMs of the traditional kind are bound to become increasingly unworkable as the number of diagnoses approaches 500 and as the number of criteria approaches 2000. This development, together with the promulgation of critical inquiries that continue to illuminate the flaws in DSM systems, will direct professionals to entertain nontraditional theoretical premises. It is our belief that DSM systems will be replaced with systems based on the premise that human beings are agents that engage in intentional strategic actions to maintain their self-narratives. It is likely that scientists of the next century will look back at traditional DSMs with somewhat the same puzzlement that is now expressed about the claims of phrenology in the nineteenth century and the claims of lobotomists in the twentieth century.

Bibliography:

Berger, P. L., & Luckman, T. (1967). The social construction of reality: A treatise on the sociology of knowledge. Garden City, NY: Doubleday.
Borges, E. (1995). A social critique of biological psychiatry. In C. Ross & A. Pam, Psychology, 64, 1117–1119.
Follette, W. C., & Houts, A. C. (1996). Models of scientific progress and the role of theory in taxonomy development: A case study of the DSM. Journal of Consulting and Clinical Psychology, 64, 1120–1132.
Goffman, E. (1959). The presentation of self in everyday life. Garden City, NY: Doubleday.
Kirk, S. A., & Kutchins, H. (1992). The selling of DSM: The rhetoric of science in psychiatry. Hawthorne, NY: Walter de Gruyter.
Kleinman, A. (1988). Rethinking psychiatry: From cultural categories to personal experience. New York: Free Press.
Lief, A. (Ed.). (1948). The commonsense psychiatry of Adolf Meyer. New York: McGraw-Hill.
Mirowski, J., & Ross, C. E. (1989). The social causes of psychological distress. New York: Aldine de Gruyter.
Sarbin, T. R. (1997). On the futility of psychiatric diagnostic manuals (DSMs) and the return of personal agency. Applied and Preventive Psychology, 6, 568–570.
Sarbin, T. R. (1977). Contextualism: A world view for modern psychology. In Landfield, A. (Ed.), 1976 Nebraska symposium on motivation. Lincoln, NE: University of Nebraska Press.
Sarbin, T. R., & Keen, E. (1997). Sanity and Madness: Conventional and Unconventional Narratives of Emotional Life. In W. Flack & J. Laird (Eds.), Emotions and psychopathology: Theory and research, pp. 130–142. New York: Oxford University Press.
Wiener, M. (1989). Psychosocial transactional analysis of psychopathology: Depression as an exemplar. Clinical Psychology Review, 9, 295–321.