Client subversions of DSM knowledge

DSM as knowledge practice

The DSM, with its ever expanding set of labels and descriptions, affords mental health practitioners considerable opportunities to map out defining stories of persons’ lives (Madigan, 2007). Furthermore, many critics argue that the number of persons vulnerable to such capture is set to increase markedly with the forthcoming publication of the DSM-5 (e.g. Frances, 2010). One of the dangers of this trend is that DSM diagnoses easily become ‘I am’ conditions (Estroff et al., 1991: 338): it is not, for example, that I experience eating related difficulties, or cut my arms; it is that ‘I am’ anorexic or borderline. The practice of labelling the person mentally disordered promotes what poststructural narrative therapists refer to as ‘problem-saturated’ identity-conclusions (e.g. White, 2000: 7). In order to know the ‘truth’ about oneself, the person is pushed to subsume his or her self-understanding within the terms of this or that particular diagnostic lens.

The force of this imposition is reflected in one person’s statement that, following her diagnosis as Borderline Personality Disordered, she felt ‘sewed…up’ into that label (Horn et al., 2007: 261). Such suturing of identity is associated with reduced access to the complex multiplicity of identity options that would otherwise be available. Countless avenues of personhood are thereby shut down as persons are corralled into pre-scripted accounts of who they are.

Klossowski (1997) suggests that such closing down is a general feature of knowledge practices, and is not unique to the DSM. Knowledge, after all, is ‘an instrument of conservation’ (Klossowski, 1997: 103), working to produce things into their knowledge-determined forms, and to generate for both knower and known a sense of stability and order. The DSM has a powerful capacity to position the person within the confines of its knowledge structures, and to hold him or her to that place. This is not necessarily experienced negatively by the person: a DSM diagnosis can promote a sense of being understood and contained, thereby reducing anxiety or confusion in the face of distress. Nevertheless, as the person comes to think of himself or herself in diagnostic terms, he or she becomes an agent of his or her own subjection, and an unwitting participant in the reproduction of this particular way of knowing (and of the social and power relations that support and are supported by it). The person is thus recruited as an agent for the conservation of DSM knowledge practices.

Consider, for instance, a person who self-identifies as schizophrenic or personality disordered. Such self-understanding in turn facilitates submission to treatment programmes, and may lead the person to interact in a correspondingly ‘appropriate’ manner with mental health professionals, medical insurance companies, and so on. Psychiatric knowledge conserves itself and its practices in part by recruiting its own subjects.

I am not suggesting that knowledge’s conservational tendencies should in principle be opposed. Without the reifications provided by knowledge, we would have little basis for any kind of self- or other-understanding: indeed, we would have ‘no… meaning at all!’ (Hall, 1985: 93). Even knowing myself as an English speaker means I have been recruited to conserve and perpetuate that language and its practices. And yet there is something that makes the DSM system especially disturbing in this regard. Consider that it receives a powerful social sanction for its practices, insofar as it is closely aligned with and supported by many societal norms and institutional activities: for instance, medical insurance companies, the courts, and education systems all utilise and contribute to the reification of its knowledges, which are also circulated in commonsense discourse. This system is thereby facilitated in its practices of monologically imposing its accounts on anyone coming into its field of view, of arresting and containing the person within its predetermined set of discursive forms, and of simultaneously foreclosing other possibilities for self-understanding. It is its hegemonic, socially validated status that gives the DSM a powerful platform to perpetrate what I consider to be its greatest violence: the nullification of precisely those aspects of the human being that make him or her a living, dynamic being.

Let us turn now to that issue.

The person as destabiliser of knowledge

I am working on the idea of identity in poststructural terms. But making sense of the person in such ways is a complex and controversial undertaking. Because of space limitations I will not discuss the relevant tensions here. Instead, I aim to articulate an orientation to the person that is more often implicitly than explicitly conveyed in the poststructural literature, but which I have nevertheless found useful in my work as a therapist; as one who often meets with DSM diagnosed people. This is the idea of the person as one who is not only capable of, but displays an inclination towards, the destabilisation of self-knowledge. I suggest that this is an idea for which the DSM, in its relentless commitment to the performance of its own knowledges, makes no allowances.

Before discussing this notion of ‘inclination’, I want to acknowledge my affinity with Foucault’s (e.g. 1988a) opposition to any essentialising view of the person as containing some a priori ‘nature’. Foucault was especially concerned with the fixing of power relations that such a belief might entail. At the same time, as Foucauldian scholars have highlighted (e.g. Falzon, 1993), opposing essentialism does not mean that the person is only a social construct; only a subject within power/knowledge dynamics. So let us entertain this notion of the person as having a pre-discursive interest in destabilising the hold that psychiatric (and other) knowledges exert over him or her.

This idea first caught my attention when I read Heidegger’s lectures on Nietzsche – lectures, which Foucault (1988b: 250) described in terms of ‘a philosophical shock’. Heidegger (1987: 16; italics in original) says that for Nietzsche, ‘the essence of life is life-enhancement’; enhancement meaning ‘over-beyond-itself’. Already this gives us a sense of a living being who moves to exceed itself; to be ‘over-beyond’ what it knows, or what is known, about itself. Later, Klossowski (1997: 103) articulated the related point that, in contrast to knowledge’s tendency towards conservation, the living being embodies a ‘principle of disequilibrium’, entailing a throwing off of the constraints of knowledge. This seems to me consistent with Foucault’s (e.g. 1990) insistence on the person’s ever present capacity to resist the impositions of power and knowledge, and even more so with Deleuze’s (1988: 74) clarifying statement that ‘the final word on power is that resistance comes first’.

These expressions share the implication that the person always seeks to exceed the stories that can be told about him or her, and the practices into which he or she is recruited. This exceeding movement is not merely reliant – as Foucault may have felt obliged to argue (Hoy, 2004) – on the cultural availability of alternative discourses. When Deleuze says that ‘resistance comes first’ (i.e. before power/knowledge), and when Klossowski says that the living being embodies a ‘principle of disequilibrium’, they are alluding to the idea that we are more than these stories because we are always already restless, nomadic creatures.

It is in this sense that I understand the Foucauldian idea that resistance is not a response to power, but its condition of possibility. This insight allows us ask the question of whether the DSM’s integration with widespread societal institutions might even be necessary for its maintenance of a firm diagnostic hold on the otherwise ‘slippery’ – resisting, dis-equilibrating – persons it attempts to describe. It seems that the person’s capacity to refuse the psychiatric capture of his or her identity is such that it needs to be countered with considerable social alignments. For example, a patient cannot simply assert that her psychiatrist is wrong in his understanding; a vast edifice of backup measures function to prevent the success of this resisting move. These measures may include the omnipresent murmurings of commonsense discourse, which tend to favour professional over lay knowledges; the scientific status of the DSM and its subsequent support by a host of professionals and others in the various institutions with which the person must engage during the course of his or her life (e.g. the courts, schools, workplaces, other sites of medical practice – places in which DSM terminology may be used in unquestioning ways); and the ‘encouragement’ provided by others, which can lead to various degrees of enforced treatment (e.g. the abusive man who initiates therapy because his wife threatens to leave him if he does not), or even incarceration.

My point is not only that the DSM system enjoys widespread social support, but that this network of mutual support may be necessary precisely because of the unstated anticipation that the person will otherwise subvert the knowledge claims made about him or her. Power, in the sense of the social alignment of knowledge practices (Wartenburg, 1990), is perhaps a response to that fact.

The person is something before becoming a subject. And it is the very mobility and dynamism of that something that the DSM and its support network moves to arrest.

Implications for therapeutic practice

In my therapeutic work I experience DSM-diagnosed people in ways that seem significantly different from the complexity-reducing and knowledge-conserving ways in which the DSM and its practitioners describe them. I have been impressed with personal phenomena to which the DSM blinds its practitioners, and which it does not allow those on behalf of whom it speaks to legitimately experience: clients’ abilities to circumvent, to slip beyond, and to resist, the personal ‘forms’ (cf. Foucault, 1997: 290) assigned them by such knowledge practices. People continually – though often fleetingly and without recognising it – subvert the conclusions implied or suggested about themselves by such categories and knowledges. This is true even of labels of which people approve. Consider, for example, those empathic therapist reflections that elicit energetically affirmative statements from clients (e.g. ‘you’ve hit the nail on the head’), evoking a sense in him or her that something true and central to his or her self-experience has been recognised and named. Even these seemingly ‘core’ emotions and thoughts can quickly, for the client, begin to lose their experientially centred status. The person moves on. I am persuaded that such exceeding of self-construction (whether imposed by the DSM or not) is ubiquitous to the human being.

And so this is the starting point for my therapeutic work: a commitment to the idea that while formalised knowledge practices exert a constraining and conservative (holding-in-place) force, they are inevitably subverted by the human being they are designed to capture. This view finds some expression in White’s (e.g. 2004) narrative therapy, which orients to the facilitation of persons’ resistances against, for example, imposed diagnostic labels, unwanted reputations, or other problem-saturated narratives of identity.

We can borrow from Bakhtin (1984: 59) to add to this therapeutic starting point, viewing the client as possessing an ‘inner unfinalizability’, entailing a ‘capacity to outgrow, as it were, from within and to render untrue any… finalising definition of them’. Bakhtin elaborates further: ‘As long as the person is alive he (or she) lives by the fact that he (or she) is not yet finalised, that he (or she) has not yet uttered his (or her) final word’ (p. 59).

The argument being made here is not that the person inherently desires a particular form(s) of subjectivity, and that the DSM displaces this ‘true self’ – such a belief would revert our thinking to a kind of individual essentialism and naturalism - but simply that he or she will move to outgrow or trouble any finalising personal form. We refuse to be eternally trapped within some or other story or subject position. As Foucault put it: ‘One’s way of no longer remaining the same is, by definition, the most singular part of who I am’ (cited in Rabinow: xix). This proposed inherent dynamism means that we are always ‘poised on the threshold’ (Bakhtin, 1984: 63; italics in original). We are always on the verge of change.

I have found it useful to think of therapeutic practices (with persons who would otherwise be subject to DSM diagnoses) in line with these arguments. In particular, I find it useful (1) to notice the small, temporary, fleeting, and often barely visible ways in which people trouble or unbalance the identity conclusions that have been reached about them, (2) to lend support to these subversions by promoting their storying, and (3) to facilitate a pathway for these often barely recognised exceptions to be filled out in the realm of meaning – of knowledge. After all, as noted above, the solution is not to be found in the dissolution of all knowledge. The knowledge de-stabilising tendencies of the human being must eventually yield to the conservative tendencies of knowledge if these inclinations are to mean anything at all; if they are to become socially real, and have their own effects. But of course, in time these new knowledges must too be subverted.

The DSM functions, as I see it, as a powerful counter-force in relation to the person’s living force of disequilibrium. Validated by its promotion of erudite, scientific discourse, and its associated far reaching coordination into existing social and institutional practices, it serves to pull the person back from the threshold of ongoing change and self-overcoming, to centre him or her squarely within its knowledge claims. It is located in the conservative world of knowledge and knowledge practices, rendering invisible and/or disqualifying the person’s tendency to decentre and unbalance knowledge’s hold on him or her. And so if the person is always ‘poised on the threshold’, then in the case of DSM based knowledges it is treatment – and not the person – that serves as the agent of that threshold-crossing from one position (e.g. as mentally ill) to another (e.g. as mentally healthy). It is true, as one ‘patient’ stated, that a DSM diagnosis can make one feel understood, and make visible a ‘light at the end of the tunnel’; but, significantly, this light tends to be associated with the promises of ‘treatment’ (Horn et al., 2007: 262); not with the person’s unfinalisability. Threshold-crossing, from one discourse or position to another, becomes dependent on obedient subjection. This is to privilege stultified, imposed knowledge as life- and meaning-generating trajectory, instead of the dynamic, living, human being.

Conclusion

DSM labelling practices limit people’s access to alternative stories about themselves. Such a narrowing down of identity options should surely be questioned and problematized, but this restriction is not particular to DSM knowledge practices. This is what knowledge – not just the DSM – does: it lends order to social practice by holding in place that which it describes.

What makes the DSM system especially problematic, from my perspective, is its arresting, and its ‘degrading and deadening’ (Bakhtin, 1984: 59), of the very aspects of the person that make possible dynamic, meaningful living. For some, being diagnosed is experienced as ‘the killing of hope’ (Horn et al., 2007: 262). As it subjects us and holds us to its own truths, the DSM demobilises what I have proposed is our inclination to go ‘over-beyond’ who we are at any given moment. It constructs the person as a dead thing; nothing more than an object of its own discourse.