Why the Fuss Over the DSM-5, When Did the DSM Start to Matter, & For How Long Will it Continue to?

Hannah S. Decker

Hannah S. Decker

June 6, 2013

Why all the fuss over DSM-5?  Why did Robert Spitzer, the editor of DSM-III, begin to protest about the “secrecy” surrounding its production as early as 2007?  Why did Allen Frances, editor of DSM-IV, begin in 2009 to challenge the American Psychiatric Association’s (APA) announced goal that when making DSM-5 “everything is on the table”? Why did he dispute the APA’s position that there had been enough progress in neuroscience to call for a “paradigm shift”? And why did Frances and others go on to protest repeatedly what they viewed as DSM-5’s “medicalization of normality?”

So, why all the fuss about DSM-5?  After all, most psychiatrists, psychologists, social workers, and counselors don’t usually pull out their copy of the current DSM to run their fingers down the diagnostic criteria when they are required to make a diagnosis.  And family doctors and internists, who prescribe over 80 percent of all psychotropic medications, almost never do.

There is a fuss for two main reasons. First, whether a health insurance company will pay mental health professionals for their recommended treatment for patients and clients hinges on the diagnosis the clinicians provide.

Second, and more vital, is that the diagnoses in the DSMs have come to affect the daily lives of millions of people in the United States, not to mention those abroad, since the DSM is translated into many languages.  For these people much hangs upon whether a particular diagnosis is in the manual or is not.  At stake is their treatment, insurance coverage, and decisions affecting such fundamental matters as where they will live, what jobs they can hold, and how their children will be educated.  Significantly, the DSM is used by public housing authorities to decide eligibility, by employers who must comply with the Americans with Disabilities Act, and by public school systems to determine whether to provide free special services for students.  In the criminal justice system, the DSM is employed by lawyers, judges, and prison officials.  To these circumstances must be added the unfortunate reality that the stigma that may accompany one particular diagnosis but not another is of considerable concern to individuals who may be identified as having a mental disorder.

A short thirty years ago, this panoply of affairs (aside from problems with stigma) did not exist.  The first two of the APA’s diagnostic manuals of 1952 and 1968 were mere blips, small spiral-bound booklets of some 130 pages, more overlooked than consulted by clinicians, and totally unknown to the general public.  The third edition, the DSM-III of 1980, a massive hardbound volume of 494 pp., changed within a decade the benign neglect that the manual had been receiving.  A revolution in American psychiatry had occurred.  DSM-IV (1994) was a reiteration of III, and greatly expanded.   By 2000 the revised IV was nearly 1,000 pages.  In spite of some reorganization of chapters and several new diagnoses, DSM-5 bears a remarkable resemblance to its famous ancestors.

DSM-III discarded the psychoanalytic emphasis of DSM-II, with its theories of unconscious conflict as the root cause of most psychopathology.  And then in a quest for diagnostic reliability—at that time mired in a state of abysmal inaccuracy—DSM-III inaugurated a new approach to mental disorders based solely on observable signs and symptoms.  Checking off these “operational (eventually diagnostic) criteria” became the goal of an increasing number of psychiatrists.  (Interestingly, the notion of operational criteria was derived from the principle of “operational analysis” as the road to knowledge, first propounded in 1927 by the Harvard physicist P. W. Bridgman.)  In DSM-III mental disorders were now neatly divided into discrete descriptive categories, and the psychoanalytic idea of disorders ranging along a spectrum from normal to severe psychopathology was dropped.  With a few exceptions—the most notable being Autism Spectrum Disorder—DSM-5 remains categorically based like III.

Yet there are notable differences between III and 5, and they speak to historical developments in psychiatry.  Much attention has recently have been given to the new diagnoses to be found in 5, but some matters have received less publicity.  One is that the multiaxial system, proudly introduced by Spitzer, has been shelved by the makers of 5.

For these individuals four points were at issue.  To start with, it had been Spitzer’s idea that there be a separate axis (Axis II) to call attention to underlying personality disorders that might escape notice when clinicians focused on acute syndromes that had brought the patient into treatment.  But that diagnostic neglect has mostly changed since 1980, a time when many researchers had challenged the authenticity and validity of what they considered to be the “soft” personality diagnoses.  Today personality disorders are regarded as “legitimate,” drawing a great deal of clinical (and even research) attention, and therefore are not being placed on a separate axis.  Second, Spitzer had been concerned that clinicians might not want to use Axis IV (“Severity of Psychosocial Stressors”) and V (“Highest Level of Adaptive Functioning Past Year”), and his surmises turned out to be largely correct.  Over the years, a significant group of clinicians have complained that using the multiaxial system was burdensome and time consuming, and the makers of 5 decided to respond to this.  The observer is tempted to ponder if this development in 2013 also speaks to psychiatrists’ greater attention to short “med-checks” as opposed to their psychotherapeutic focus 30 years ago.

The third point regarding the multiaxial system is that the architects of the new volume decided that they did not want to draw a sharp line between mental and medical conditions, as DSM-III’s Axis III (“Physical Disorders or Conditions”) had often dictated.  Spitzer himself wanted DSM-III to be a tool to portray psychiatry as scientific in order to combat the anti-psychiatry movement of the 1960s and early ‘70s.  However, the present builders of 5, with their goal of tying psychiatry to biology as openly as possible, have sought to reiterate that psychiatry, as a medical discipline, shares vital links with science.  Finally, Spitzer’s multiaxial innovation was the victim of unintended consequences.  It often occurred that health insurance companies reimbursed less for Axis II disorders, taking the listing of Axis I (“Clinical Syndromes”) before Axis II to mean Axis II disorders somehow ranked “below” Axis I disorders.  (It did not help, of course, that personality disorders could be more expensive to treat than some acute Axis I disorders, since personality disorders often called for lengthy psychotherapeutic intervention.)

Another historical change from DSM-III to DSM-5 is that much greater attention was paid to possible monetary conflicts of interest of the DSM-5 Task Force and Work Group members than had ever been the case for the developers of DSM-III.  For one thing, the creation of III was the first time that the making of a new manual had involved large numbers of contributors.  DSM-I and II had been written by small committees whose financial ties had never been a consideration.  Thus, the ties of the makers of III were barely scrutinized.  Furthermore, substantial payments to researchers and clinical consultants from pharmaceutical companies—the source of most conflicts of interest—were just beginning in the early 1970s when III was being constructed.  Psychiatrists then were more likely to get grant money from their institutions and the NIMH than from private companies.  But it was the very form of III, with its new and specific categories, that had beckoned the pharmaceutical industry to develop medications for recently developed diagnoses. The professional landscape altered.  To urge the prescribing of the new drugs, companies now paid psychiatrists who had done research (often with industry grants), or had other experience with their products, to disseminate information about them, often at delightful small dinners.

By the time the creators of DSM-5 were assembled c. 2007, it was widely recognized that financial support from “Big Pharma” posed serious potential conflicts of interest.  Already certain prominent psychiatrists had been exposed as taking large sums from the pharmaceutical industry that they had not disclosed to their home institutions.  There were accusations that the reports and papers of some researchers had been written for them by commercial organizations.  Eventually, during the process of making of DSM-5, the American Psychiatric Association (APA) did considerable vetting of ties with drug companies and the Task Force and Work Groups members had to publish financial disclosures.  They had to agree that their aggregate annual income derived from industry sources (excluding unrestricted research grants) would not exceed $10,000 in any calendar year.

A final historical development was barely a fleck on the screen until several weeks ago.  DSM-III had had the enthusiastic support of the NIMH.  The bulk of the field trials of DSM-III were supported by a grant from the NIMH.  Since its formal establishment in 1949, the NIMH and the APA have had a close relationship.   As the APA began to contemplate a revision of DSM-IV in 1999, a partnership was formed between it and the NIMH, “with the goal of providing direction and potential incentives for research that could improve the scientific basis of future classifications” (A Research Agenda for DSM-V, 2002.)

Thus, it came as a great shock to almost all when Thomas R. Insel, Director of the NIMH, announced on April 29 of this year, just three weeks before the release of DSM-5, that the NIMH would no longer be guided by the DSM.  Insel acknowledged that ever since DSM-III appeared in 1980, the manual had helped produce reliability in psychiatric diagnosis because it enabled more consistent communication among clinicians. However, its great “weakness,” he went on, was its lack of validity.  By this he meant that a descriptive diagnostic category, as found in III or IV, might in reality encompass several different disorders having different etiologies and needing diverse treatments, thus making the current diagnostic category invalid.  This was hardly news, it being widely recognized that Spitzer had sacrificed validity for reliability.

But Insel proceeded.  The DSM was, “at best, a dictionary, creating a set of labels and defining each.”  It was a collection of symptomatically-based diagnostic categories without any regard for etiology, at odds with the rest of medicine.  “Patients with mental disorders deserve better, “ he declared, and proceeded to drop a bombshell:  The NIMH would henceforth “be re-orienting its research away from DSM categories.”  In their place the NIMH would create a new classification that would be based on “genetic, imaging, physiologic, and cognitive data” and would no longer support research projects based on the DSM nosology.

Have we come to the end of the DSM-III model, just 33 years after it was created?  Is this the start of a new era that will bring to psychiatry the much-desired validity sought by Eli Robins and Samuel Guze in their famous 1970 paper, “Establishment of Diagnostic Validity in Psychiatric Illness”?  Probably not right away.  The NIMH has launched a new project, the Research Domain Criteria (RDoC), to transform diagnosis and create “precision medicine” such as has radically changed cancer diagnosis and treatment.  But for the present, clinicians and the wider society that use the DSM, will have to rely on it or the International Classification of Diseases (ICD).  After all, what else is there?  The NIMH project is still in its infancy.

Insel predicts his project will be “a decade-long.”  Even that seems overly optimistic considering the obstacles to such an etiological revolution.  There is also the troubling feature that in his far-reaching blog he declaims that “mental disorders are biological disorders” with no mention of the role of human psychology.

History provides some perspective here.  In 1845, a leading German psychiatrist, Wilhelm Griesinger, pronounced that “mental diseases are diseases of the brain,” which became the mantra of most medical students.  Almost 30 years later, Theodor Meynert, Sigmund Freud’s teacher at the Vienna medical school, wrote in his textbook: “The reader will find no other definition of ‘Psychiatry’ in this book but the one given on the title page: Clinical Treatise on the Diseases of the Fore-Brain.”  It was in reaction to such declarations, and their failure to advance knowledge, that the famous psychiatrist, Emil Kraepelin, coined the phrase “brain mythology.” Kraepelin, the father of the historic division of the psychoses into dementia praecox and manic-depressive illness, eschewed chasing after slippery etiologies and turned to describing what he observed.  Freud, born the same year as Kraepelin (1856), was affected, as Kraepelin, by the identical disappointment with the sluggish progress in dealing with mental disorders.  He went in another direction and created psychoanalysis.  The two, Kraepelinian descriptive psychiatry and Freudian psychodynamic theories, have both contributed to our knowledge and have as well their recognized limitations.  Importantly, they also stand as reminders of the arduous tasks involved in understanding human beings.

Hannah S. Decker is Professor of History at the University of Houston, Adjunct Professor of Medical History in the Menninger Department of Psychiatry, Baylor College of Medicine, and Adjunct Faculty member, Center for Psychoanalytic Studies, Houston.  She has recently published The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (Oxford University Press, 2013.)

Hannah S. Decker

Why the Fuss Over the DSM-5, When Did the DSM Start to Matter, & For How Long Will it Continue to? Comments RSS

7 thoughts on “Why the Fuss Over the DSM-5, When Did the DSM Start to Matter, & For How Long Will it Continue to?

  1. “Why did Robert Spitzer, the editor of DSM-III, begin to protest ”

    “There are no atheists in foxholes.”
    Old military axiom

    In short, Dr Spitzer has finally realized that we are all mortal, including himself, and he’s not getting any younger.

    And all the misery he and his hypothetical disease constructions have imposed on countless people, in his own ill considered quest for recognition, is beginning to dawn on him and perhaps weigh somewhat more heavily upon him than it did 30 years ago.

    Bon Chance Bobby.

    Don’t forget your sun screen lotion.

  2. Thanks for this brief history of the Dehumanizing Smear Manual. I like seeing historians around this place.

    “DSM-III inaugurated a new approach to mental disorders based solely on observable signs and symptoms.”

    Remember folks, psychiatry can declare any problem/facet of life a “symptom” and make it sound like the situation is “medical” in nature. Don’t be fooled. This is not only declaration of disease by fiat, its word magic where anything they say is a “symptom”, is a symptom. Until Dehumanizing Smear Manual volume 3, being gay was a “symptom”.

    dbunker is right, it is very interesting how these ex dons of the DSM have these late in life conversions. Always after the well funded retirement is in place by the way.

    The beautiful thing is how Insell just pulled the trap door on the NIMH’s own gallows. How lovely it will be to watch them squirm as they go from biomarker discovery failure to biomarker discovery failure iteration number 78,983. The extremes of human life aren’t a brain disease, and the brain didn’t impose those extremes on human life. Even human life isn’t just a brain. These modern day snake oil salesmen will continue to be an embarrassment to science. And sadly, continue to abuse the human rights of millions of people for a while longer yet.

    In their arrogant desire to be seen as real physicians, they’ve impugned the dignity of countless millions of people by spreading stigma and dehumanization, giving pseudoscientific ammunition to families and governments who love the idea of declaring problem people to be nothing more than defective brains visited upon mankind through some quirk of nature, like cancer.

    The madhouse keepers and attendants and orderlies of past history are remembered in popular imagination as cruel thugs and quacks, rightly so. If you work in a state hospital today, don’t be so sure history will judge you any better. I’ll certainly be doing my best to document psychiatry’s atrocities and folly for the rest of my life, on the internet, for future generations to see. So that one day people can read and learn that not everybody bought into this dehumanizing view of troubled and distressed human beings as broken machines. I pity not only the people who are forced to interact with this quackery, but those who in their misguided zeal actually saw the ‘biomedical mental health’ professions as a worthwhile place to spend their finite lifetimes on this earth. Reaching or approaching retirement and realizing you’ve on balance probably left the world a worse off place than you found it, must be painful. It’s such a pity and a shame that humanity decided to approach the problems humans have in their lives and minds as though such things are “just like diabetes”. So mindless, so glib, so tragic. So sad. The cost has been high.

    And stay tuned for the dead air. Insell and his taxpayer trough minions are not going to be able to prove that believing the CIA is spying on you is a brain disease or that believing the CIA drone program is justified is a state of ‘neurological health’. Only a fanatic would say he’s ten years away from ‘explaining’ human life as merely the actions of an organ inside the body.

    We fund fanatics, who are indoctrinated into a brain blaming pseudoscience cult, to the tune of billions of dollars. We allow them the power to forcibly enter the bodies of distressed citizens and call it help. We allow them to tinker with and drug the growing brains of school children on the basis of slapping a DSM label on them. We allow them to electroshock old ladies in nursing homes. We allow them to decide who to free, and who to blame.

    We allow this creation story, that brains no physician has ever examined have somehow been proven diseased, to run a significant part of modern life. When a modern religion was found hiding inside secular, shiny, prestigious “science”, no one really wanted to look and acknowledge how terrifying it was that dogma was driving a fake science into our lives. 20 years after Communism fell, humankind awakes to find itself in the grip of another ideology, psychiatry.

  3. Hannah,

    You mentioned “secret meetings” behind the new DSM.

    At the risk of appearing to be a “conspiracy theorist,” there were also plenty of secret meetings in getting the new health care act passed (aka, ObamaCare). There was also lots of help from PhRMA (Pharmaceutical Research and Marketing Association), which spear-headed a barrage of television ads in a propaganda campaign.

    The DSM-5 comes along in that same time period (beginning roughly 2007 – present, although next year is the big on with the health care act).

    Could it be that those in positions of leadership within the APA and DSM task force are (were) privy to what will and won’t be paid for under the Affordable Health Care Act – not the law itself, as much as HHS administration guidelines, laws, regs?

    What illnesses, drugs, etc will be covered under federal law – not by private insurance (which will soon be a thing of the past), but by the complex system of exchanges in the act, and HHS rules and regulations.

    Maybe that’s all the DSM-5 is really all about.

    Duane

    • Big industry and big government working in tandem, again?
      This time with a *huge piece* of secret federal legislation and the drug makers, their pill pushers… in this case, a task force of secretive shrinks?

      I wouldn’t be surprised…
      Gotta love *crony* capitalism.

      Duane

  4. What an incredibly insightful and poignant article! I don’t know who this Hannah Decker person is, but it is clear that we are dealing with a true genius. An intellectual giant of the highest order. I commend you Dr. Decker for your insight, wisdom, and perspicacity.

  5. Are there “unconscious” motivations, for the fuss over DSM-5?

    In terms of individual survival, do we see an obvious competition for the resource of objects, (financial means of self-preservation) yet collude with a taken for granted scientific method, which adopts a subject to object orientation?
    Like the taken for granted, “objective” worldview presented here;

    “There is a fuss for two main reasons. First, whether a health insurance company will pay mental health professionals for their recommended treatment for patients and clients hinges on the diagnosis the clinicians provide.”

    Presented here, is an accepted mode of survival, based on an economy of objects (monetary or other material objects), while in the field of mental health, we are confronted with the hidden economy of human survival, in the core motivating affects of health and mental motivation? Core motivating affect’s like, fear, anger, rage, joy and interest-excitement, which are modulated by our higher cortex function of rationalization (cognition).

    IMO confusion reigns, in our need to deny the arousal of such core vitalizing affects, like the “outrage” projected onto the DSM-5. IMO we all seem to collude in denying the uncivil conflicts of interest, inherent in our civilization process. Historically, civilization has been organized on a hierarchical thriving of groups, at the expense of other groups. IMO we collude with “the system,” we think we see, by not pausing to feel the arousal of core e-motive affects, and their projection.

    Hence, Hannah writes of the apparently obvious, in perceiving;

    “Second, and more vital, is that the diagnoses in the DSMs have come to affect the daily lives of millions of people in the United States, not to mention those abroad, since the DSM is translated into many languages. For these people much hangs upon whether a particular diagnosis is in the manual or is not. At stake is their treatment, insurance coverage, and decisions affecting such fundamental matters as where they will live, what jobs they can hold, and how their children will be educated. Significantly, the DSM is used by public housing authorities to decide eligibility, by employers who must comply with the Americans with Disabilities Act, and by public school systems to determine whether to provide free special services for students. In the criminal justice system, the DSM is employed by lawyers, judges, and prison officials. To these circumstances must be added the unfortunate reality that the stigma that may accompany one particular diagnosis but not another is of considerable concern to individuals who may be identified as having a mental disorder.”

    Yet is this an “objective” view of the world “out there” which does not pause to feel its own emotional projection process, as articulated by the genius of Murray Bowen, back in the 1950′s? Please consider;

    “Societal problems from an emotional systems view:

    All of the people who were, or are members of families replicate the same emotional patterns in society. Family and societal emotional forces function in a reciprocal equilibrium to each other, each influencing the other and being influenced by the other. These observations are based on the same criteria used to estimate family functioning, which is the amount of principle determined “self” in comparison to the “feeling-orientation” which strives for an immediate short term feeling solution to the anxiety of the moment.

    The triangling process in a large family will help illustrate the process in society. It may begin with conflict between a parent and child. When another takes sides emotionally, he is potentially triangled. When he talks (to influence others) or he takes action based on feelings, he is actively triangled. Each person who becomes involved can involve others until a fair percentage of the group is actively taking sides. The controversy is defined on “right” and “wrong” issues, and often as victimizer and victim. In societal conflict, those who side with the “victim” are more likely to demonstrate and take activist postures. Those who “feel more responsible” for the total group will side with the parental side. They are more likely to stay silent or take action in letters to the editor, or to actively counteract the activists.

    One interesting group of activists is made up of members of professional and scientific organizations who attempt to use knowledge and social status to further entangle the triangular emotional system. To summarize the process, it begins with emotional tension in a bipolar situation, it spreads by involving emotionally vulnerable others, it is fed by emotional reactiveness and response to denial and accusation and it becomes quiescent when emotional energy is exhausted.

    The societal projection process: The family projection process is as vigorous in society as it is in the family. The essential ingredients are anxiety and three people. Two people get together and enhance their functioning at the expense of a third, the “scapegoated” one. Social scientists use the word scapegoat , I prefer the term “projection process,” to indicate a reciprocal process in which the twosome can force the third into submission, or the process is more mutual, or the third can force the other two to treat him as inferior.

    The biggest group of societal scapegoats are the hundreds of thousands of mental patients in institutions. People can be held there against their wishes, or stay voluntarily, or they can force society to keep them there as objects of pity. All society gains something from the benevolent posture to this segment of people. A fair percentage of people are too impaired to ever exist outside the institution where they will remain for life as permanently impaired objects of the projection process.

    The conventional steps in the examination, diagnosis, hospitalization, and treatment of “mental patients” are so fixed as a part of medicine, psychiatry, and all interlocking medical, legal, and social systems that change is difficult. There are other projection processes. Society is creating more ‘patients” of people with dysfunctions whose dysfunctions are a product of the projection process. Alcoholism is a good example. At the very time alcoholism was being understood as the product of family relationships, the concept of ‘alcoholism as a disease” finally came into general acceptance.

    There might be some advantage to treating it as a disease rather than a social offense, but labeling with a diagnosis invokes the ills of the societal projection process, it helps fix the problem in the patient, and it absolves the family and society of their contribution. Other categories of functional dysfunctions are in the process of being called sickness. The total trend is seen as the product of a lower level of self in society. If, and when, society pulls up to a higher level of functioning such issues will be automatically modified to fit the new level of differentation. To debate such a specific issue in society, with the amount of intense emotion in the issue, would result in non-productive polarization and further fixation of current policy and procedures.

    The most vulnerable new groups for objects of the projection process are probably welfare recipients and the poor. These groups fit the best criteria for long term, anxiety relieving projection. They are vulnerable to become the pitiful objects of the benevolent, over sympathetic segment of society that improves its functioning at the expense of the pitiful. Just as the least adequate child in a family can become more impaired when he becomes an object of pity and over sympathetic help from the family, so can the lowest segment of society be chronically impaired by the very attention designed to help. No matter how good the principle behind such programs, it is essentially impossible to implement them without the built-in complications of the projection process.” _Murray Bowen.

    I suggest that we all contribute to this “projection process,” in a taken for granted “need” to deny the arousal of core motivating energies. A process which begins in childhood, as we are encouraged to suppress our spontaneous affect/emotions, and compete for social recognition, with apparently clever, rationalizations?

    Rationalizations, like “informed consent” which denies how human beings actually function in the anxiety relieving needs of the lived moment. If we are truly rational, well informed human beings, why do we still take up smoking, by the millions? Can the “subject to object” stance of blaming the power of commercial interest and advertising, really explain what drives our self-defeating behaviors?

    Perhaps the cognitively oriented Professor’s, of the “knowledge economy” (a mode of self-preservation), might consider an exploration of our universally denied motivations, and the emerging science of “self-regulation?” Just how do we self-regulate in the anxiety of the lived moment?

    Can a discernment of our internal world, help us to further realize the hidden nature of our projected needs, and how an “illusion” of objective rationality is created within? Can we learn how to sense our collective denial, and our deep seated fear, of the transmission of affect/emotion? Please consider;

    “Education of The Senses:

    By examining the “affects” experienced in judging another, one learns a great deal about how the illusion of self-containment is purchased at the price of dumping negative affects on that other. The level of “affective transmission” is marked in terms of how one party carries the others negative affects; his aggression is experienced as her anxiety and so forth. By means of this projection, one believes oneself to be detached from him or her, when one is, in fact, propelling forward an affect the other will experience as rejection or hurt, unless the other shield’s themselves by a similar negative propulsion, in a passionate judgment of their own. (p, 119.)

    Discernment, in the affective world, functions best when one is able to be alert to the moment of sensation, which allows the negative affect to gain a hold within. Any faculty of discernment must involve a process whereby affects pass from a state of sensory registration to a state of cognitive awareness, this does not mean that the process of cognitive reflection is without an affect itself, just that this affect is other than the affect which is being reflected upon.

    In our illusion of self-containment, reason and passion or affect-emotion and cognition keep appearing in binaries, despite arguments for their separation. Such binaries attempt a distinction between the ego and a faculty of discernment, between the affect-passion and the “other I” which reflects on them, as in the palpable experience of being pulled in two directions. One direction feels more passionate, the other, more reasonable.

    The point of affective discernment though is in the work of the senses, (touching, hearing, smelling, listening, seeing) and the expression of the senses, affectively, accurately, in words, often defined and limited by traditional vocabulary. The naming of feelings is one thing, but the ability to discern the affective world within and without, requires more. Such an investigation requires a conceptual vocabulary and some means of circumventing the “affects” combined distractions. (p, 120.)

    The Limits of Language:

    At present we only have a rudimentary language for connecting sensations, affects, and words, for connecting bodily processes and a conceptual understanding of them. The further development of such language requires an attention to the pathways of sensation in the body. We need to formulate bodily knowledge more accurately and increase the rapidity of human understanding. Extending knowledge in this way is the reverse of gathering it by “objectification,” or studying bodily processes disconnected from living sensory attention. (p, 153.)

    Extending knowledge of sensation, following it further along its pathways, means extending consciousness into the body, infusing it with the conscious understanding from which it has been split, by a subject/object orientation. That split has hardened with the sealing of the heart as an organ of sensory reception and transmission, yet it has also come under examination in all the practices and knowledge’s that, taken together, presage the resurrection of the body.

    Some of these systems of knowledge already nestle in the arms of objective science, especially those focused on the complex systems of both body and brain, while others are found in more ancient, holistic health systems. What these systems of healing have in common with the study of the body and its complexity, is the notion of systems–of language and communication, insofar as a biochemical chain or a DNA sequence can be structured like a language in another medium. (p, 154.)

    The more conscious we become of what we repress in our subject/object orientation (remembering that primary repression is the repression of unprocessed sensory information) or ignore, the less we think in projected and judgmental terms. But such conscious consciousness is only possible when we invent or reinvent the words to say it with. The transliteration into language from the minutia of sensory knowledge and its sifting, may be processes entirely unknown to present day consciousness.

    Extending consciousness sensation, finding the words or images, means grasping the nuances of fleshy grammar and alphabets. It means describing and accounting for sensations, which entails translating them into the everyday currencies of speech and so extending the range of their visualization. What our subject/object ego orientation represses is not available to consciousness. This ego and its repressions, present themselves as disordered flesh, when in fact the ego and its repressions are the cause of such disorder. Disorder is not inherent in the body or the flesh, which loves natural regulation. The body thrives in health when its real needs are respected, as distinct from the ego’s imaginary anxieties. (p, 155.)”

    Excerpts from “The Transmission of Affect” by Teresa Brennan, PhD.

    In writing your well crafted essay Hannah, how aware are you, of your own internal functioning, your energy arousal, and can such internal functioning ever be captured by our tendency to be objectively rational, in our linguistic chains of meaning?

    Please consider the late Teresa Brennan’s understanding of the “illusionary” nature of our taken for granted, yet rather objectifying thoughts;

    “Vertical and Horizontal Chains of Meaning:

    The linguistic chain is split from other chains of life meaning and logic–hormones, genetic codes, solar systems–by the insertion of the subjective “I” where it does not belong. It does not belong in an order whose logic is at right angles to that of the human perspective, as if the codes of living logic, together with the chemical senses, communicate on a horizontal axis, while the human historical viewpoint functions on a vertical one. Without the insertion of the subjective “I” position into the original codes of the flesh, the structure of the linguistic chain is homologous with that of other living chains within. With this insertion, the structures of living meaning are more or less at right angles.

    Life meaning is the result of interweaving–yet diverse–chains, capable of transformation from one order of symbolization to another. Symbolization dependent on understanding the proportionate and rhythmic intersection of numbers of vast and small internally consistent chains that are all communicative and in this respect like languages. If sensory energy is composed of fleshy codes that parallel those of language, this explains why the body seems to do its own thinking, so to speak. (p, 145.)

    It behooves us, as a species, to reconnect conscious language and understanding with the fleshy and environmental codes, from which our consciousness has been split by subjective fantasy and illusion. Those natural codes do their best work in the dark, although bodily physiological and chemical processes do push for admission to consciousness, past the blocks of a self-obsessed linguistic gateway. For us speaking beings, consciousness has been changed into parallel systems of signification; the linguistic, the sensitive, and the affective.

    They belong in a certain natural configuration, and a correct alignment appears necessary for an unimpeded or less impeded flow of nature’s energy. Correct alignment might be described as a symbolic transformation, meaning that the different alphabets of the flesh could be aligned in such a way that life is released from one order into another, yielding more freedom, intelligence, and energy. Symbolization is the means for transformation as the process whereby energy locked up in an alphabet in which it cannot speak (such as traumatic grief) is released back into the flow of life by words, or by the strange chemistry of tears. (p, 149.)

    The notion of aligned codes, like that of the transmission of affect, is at odds with subject/object thought and the “visualization” basic to “objectification.” The gateway between linguistic consciousness and codes of bodily sensation is manned by visual images. Which is to say, to make itself conscious, a bodily process has to be imagined–given an image. Our unconscious ego acts as a visual censor blocking bodily information surfacing to conscious awareness. It is a visual censor because it identifies objects from the standpoint of the subjective “I.” Images are stored from the three dimensional standpoint of a subject arrayed against an object. It is only when we depend on visual perception that we are led astray, into the subjective thought that takes the human standpoint as central. Such thought requires that one stand apart to observe the other and reduce it to predictable motion, the better to study it as an object. It also requires the intention of the body’s life energies, be prevented from fully connecting, in an embodied process. (p, 150.)

    “Hallucinations tend to make the abstract concrete and visa versa. This reflects the ambiguous position of image in Western epistemology, generally. Image has been assigned an inferior function, somewhere between sensation and thinking. On one hand, images are the “dregs of sensation,” carriers of information about sensations, on the way to the summation of sensations into concepts. If, on the other hand, it is realized that sensations cannot account for the formation of concepts, imagery may be granted the function of illustrating autonomous and immaterial concepts in sensuous terms. In ancient times, images were gods or messengers of gods versus sensuous misrepresentations of the unrepresentable.

    The status of image was much higher before we discovered the intellect. The idea of man as slave to his senses was a later transformation of the subjective enslavement to the power of the image. Perhaps this was necessary as a long transitional defense against the image. Distance was gained from the image by seeing it as immediate and concrete. Indeed, it is likely that the very birth of intellect was associated with the cognition of image as image (rather than, say, an idol).”

    Excerpts from “The Transmission of Affect” by Teresa Brennan, PhD.

    Please forgive this long comment. In my defense, I don’t believe that the nature of a Societal Delusion over so-called mental illnesses and the triumph of medications, can be understood from the objective viewpoint of the “world out there,” alone.

    The image of rationality is vital to our collective sense of self, and as Brennan points out above “The status of image was much higher before we discovered the intellect. The idea of man as slave to his senses was a later transformation of the subjective enslavement to the power of the image. Perhaps this was necessary as a long transitional defense against the image. Distance was gained from the image by seeing it as immediate and concrete. Indeed, it is likely that the very birth of intellect was associated with the cognition of image as image (rather than, say, an idol).”

    In his essay “The Triumph of Bad Science” Robert Whitaker points out the need to protect the image of the drugs;

    “As such, this story can help us understand why we, as a society, may end up deluded about the merits of psychiatric medications. The evidence base is massaged in a way that protects the image of the drugs. Dishonest science gets published in the Archives of General Psychiatry and is archived in PubMed, while in-depth criticisms of that bad science are relegated to the “readers’ reply” corner of the journal’s online website, and thus excluded from the PubMed archives. Meanwhile, the media tells of Gibbons’ “findings,” but omits the part about the scientific dishonesty at the heart of those reports.

    And voila, you have a process for creating a societal delusion.”

    http://www.madinamerica.com/2012/07/the-triumph-of-bad-science/

    Yet following on from Brennan’s conclusion, “the idea of man as slave to his senses was a later transformation of the subjective enslavement to the power of the image,” I suggest that the real culprit of our societal delusion, is a core need to protect the image of an idealized and rational, self?

    Thank you for your eloquent contribution to the debate here on MIA.

    Best wishes,

    David Bates.

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