The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been met with significant controversy and debate. However, DSM critiques are not uniform, and the surrounding debate is not a fixed one, argues a research team in Canada, led by Melissa Roy from the School of Social Work at the University of Ottawa.
In their new paper, featured in the Public Understanding of Science journal, Roy and colleagues systematically explore critical reactions to the DSM to identify dynamic components of these critiques as well as points of intersection.
They write, “The DSM is not simply a scientific manual, but a social laboratory where political, sociological, ethical and psychological issues are discussed and confronted. In order to critically analyze the DSM, it is important to consider the claims that challenge the APA’s narrative of the DSM.”
Their research offers a novel typology of audiences that have critically responded to the DSM. Further, they highlight the points of divergence and convergence across these perspectives. They explain the nuance embedded within the seemingly polarized DSM debate and their research aim:
“While some of their claims present argumentative polarities, others overlap, thus challenging the idea, often presented in academic publications, of a fixed debate. In order to further discuss on the Diagnostic and Statistical Manual of Mental Disorders, we draw attention to claims that ‘travel’ across different communities of audiences.”
Ultimately, Roy and the team sought out to “deepen the understanding” of previously discussed debates. For example, social scientists have investigated already the primary critiques of the manual. However, few have taken a systematic approach to examining the reception of the DSM-5. Alternatively, Roy and colleagues understand audiences to take up a significant role in making meaning of the manual. Audiences participate in framing the debate and redefining the content.
In this way, Roy and colleagues view the DSM as a “cultural object” in that different actors utilize it in different ways. For instance, some may respond to the DSM as a set of rules, whereas others may use it as a mere tool to pragmatically cover insurance fees. Its function, therefore, is not intrinsically derived in as much as it is determined “from the bottom up” and encoded with meaning through its reception. This counters the notion that texts are simply vehicles of dominant belief systems that are uncritically transferred to their audiences.
Roy and team describe this conceptual lens:
“The DSM-5 as a material object can only have a social impact through the ways in which meaning is encoded in it. It can then be understood as a cultural object, that is, a complex structure sustained and produced through the articulation of receptions, reactions, and claims relating to it.”
Therefore, this team of researchers has drawn from a framework that focuses on the DSM’s reception, the different actors and audiences that “receive” the DSM, and a more systematic investigation of the manual’s meaning. Recognizing that different categories of people share their opinions across various mediums, Roy and colleagues examined press releases, newspaper articles, critical blog posts, and online forum posts.
First, they examined the American Psychiatric Association’s presentation of the DSM-5 to determine the degree to which this framing diverged or overlapped with its reception. Therefore, the APA’s press releases were examined separately from texts illustrating responses to the DSM-5 by external audiences. Overall, the presentation to the general public included claims that the manual exemplified scientific rigor intended to establish a common diagnostic language and facilitate response to research breakthroughs.
Next, they analyzed content from this website, Mad in America, to include perspectives critical of the psychiatric field. In addition to this, they analyzed content from primary news sources in the U.S., followed by recent content about the DSM-5 on the internet forum, Reddit. In total, 74 texts were reviewed and collected.
Using a qualitative methodology, thematic analysis, Roy and colleagues organized their findings into the central argumentative positions and frames. Eight audiences were identified and grouped within these positions. They write:
“Our analysis shows that the APA’s framing of the DSM-5 was challenged in various terms. More specifically, we were able to categorize eight types of audiences that received the association’s main narrative differently.”
First, four audience groups challenged the scientific nature of the DSM-5. These audiences were labeled in the following ways: (1) Conformist, (2) Reformist, (3) Humanist, (4) Culturalist.
Conformist Audiences. Conformist audiences refer to those responses that have corroborated the APA’s vision of the DSM-5 as a useful, reliable tool. This audience views the manual as successfully facilitating psychiatric diagnosis procedures. They not only understand the DSM-5 to be scientifically rigorous but perceive significant changes across revisions as common sense reflections of developments in modern times.
“Disease definitions change over time because of new scientific evidence. This is what has happened with addiction. We should embrace the new D.S.M. criteria and attack all the substances and behaviors that inspire addiction with effective therapies and support. (Markel, 2012).”
Reformist Audiences. Reformists, although optimistic about possible improvements to the manual, are critical of its alleged scientific nature. They argue for changes that enhance the alignment of the DSM with biomedical paradigms used in medicine and biology. The reformist critique is centered around the belief that the APA lowered the threshold for validity in clinical trials, informing the 5th edition of the manual.
“The point of the reliability tests was to demonstrate that the diagnostic criteria are reliable, but now that the results are in, it remains unclear whether the levels of reliability achieved are acceptable. This is because there are no generally accepted standards for what counts as reliable enough against which the DSM criteria can be judged (Cooper, 2014).”
Humanist Audiences. The humanist audience brings forth a broader discussion regarding the purpose of psychiatry. Roy and colleagues describe that this type of audience argues for a more compassionate approach to psychiatry that prioritizes “human qualities” over “scientific rigor” held up in behavioral neuroscience. Humanists discuss the limitations of a biological perspective of mental disorders.
“More than 50 years ago, I chose to become a psychiatrist precisely because it was not scientific. [. . .] It is long past time for us to stop pretending we know more than we really do (Altshul, 2013).”
Culturalist Audiences. The fourth type of audience criticizes the medical nature of the DSM-5, which naturalizes Western frameworks of distress and suffering. Rather than representing a therapeutic tool, culturalists argue that the manual more accurately represents an analytical tool that illustrates what is “socially sanctioned and praised,” Roy and team write.
“What makes the DSM so pernicious is that it is a cultural document whose influence transcends not only psychiatric practice but also the Western civilization from which it originates (Datta, 2013).”
The next four types of audiences are identified based upon their reaction to the DSM-5 and its “normalizing power.” These audiences include the: (1) Naturalist, (2) Conflictual, (3) Constructivist, (4) Utilitarian.
Naturalist Audiences. The naturalist audiences tended to criticize the medicalization of suffering viewed as natural and occurring in response to “ordinary” life events. Naturalist audiences expressed concerns about overdiagnosis and overprescription.
“And there is a commercial on the radio telling parents that their teens need psychological counseling just because they are exhibiting the normal teen ‘I HATE YOU!!!!!!’ melodrama. WTF? Apparently, being a normal teenager is a disorder now. (Anonymous Reddit user, published in the thread ‘The new standard for psychiatric criteria in the U.S.A (DSM-5) is released in 4 days time, and it’s set to make some big and unpopular changes’).”
Conflictual Audiences. Conflictual audiences discuss the capitalist inclinations and cultural forces driving the DSM-5. They criticize the involvement of pharmaceutical companies and other institutions.
“Diagnoses on the basis of vague and broad ‘symptoms’ are now good enough to prescribe a drug, to the profit of the docs and drug makers. They invent a medication, then invent a ‘disorder’ to use it on. (Anonymous Reddit User, published in the thread ‘The new standard for psychiatric diagnostic criteria in the U.S.A. (DSM-5) is released in 3 days time, and it’s about to make some big and unpopular changes’).”
Constructivist Audiences. To constructivist audiences, the DSM-5 is perceived as secondary to clinical judgment. They call into question the practical importance of the manual, viewing the debate that surrounds it as “sensationalized.” Because the DSM-5 is seen by constructivists as rarely used by clinicians in their work with clients, they understand its significance to arise out of how it is appropriated and used.
“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 (Decker, 2013).”
Utilitarian Audiences. Utilitarian audiences are those that emphasize the pragmatic utility of the DSM-5 as a tool for accessing specialized services and insurance reimbursements. Therefore, the utilitarian audiences are less concerned with critiquing the essence of the DSM-5 than they are focused upon limiting its potential adverse effects, describe Roy and colleagues. They write:
“For utilitarian audiences, the DSM is a fait accompli or, at its worst, a necessary evil: clinicians must then use it only when absolutely necessary, for the benefit of clients or patients.”
The findings from this review indicated the following:
“The main debates surrounding the critical reception of the DSM-5 relate to two major themes: (1) the pseudo-scientific nature of the manual and (2) its normalizing power. More specifically, our conceptual framework allows us to depict the DSM-5 as being appropriated by different ‘audiences’, occupying various argumentative positions and uttering claims which correspond to the meaning they decode from (and encode in) the manual.”
Furthermore, the researchers interpret these different perspectives as complementary, featuring claims that can “travel” and allow for “argumentative intersections.” Roy and colleagues further discuss and interpret the strong voice of professionals throughout the different audiences, who weigh in, especially in debates that challenge the scientific nature of the manual. More diverse audiences are featured in the discussion around the normalizing power of the DSM and its social effects.
Roy and colleagues believe that their results have demonstrated how arguments can interact in dynamic ways, highlighting both overlap and opposition. These findings not only challenge a belief that counterarguments to the DSM-5 are uniform and fixed but underscore the need for future research to analyze these arguments further to “deepen and advance the debate on the DSM, creating new alliances outside and within social sciences.”
Roy, M., Rivest, M. P., Namian, D., & Moreau, N. (2019). The critical reception of the DSM-5: Towards a typology of audiences. Public Understanding of Science, 28(8), 932-948 (Link)