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31 iulie 2013

DSM attacked from philosophical positions: response to an article written by Robert D. Stolorow




I have not read yet the DSM-V, but I heard about the debates that took place around its appearance, especially concerning some possible new disorders like the addiction to video games or the addiction to internet. Here is not the place for this debate to continue however but, with such intention, the DSM had upset some companies that found themselves in the position of competing with the pharmacological medication proposed by psychiatry. This finally ended with the new-antipsychiatric documentary "the marketing of madness". Made for to reach the ears and eyes of the public, this documentary uses all possible arguments, especially those relating to advertising, to demolish not only the DSM, but in the psychiatry in general. I analyzed in detail these arguments in this article:

But recently, I have read an article by the psychoanalyst Robert D. Stolorow, published here:
or here on 02 Apr 2012.

In the article quoted above, Stolorow make another kind of criticism to the DSM V, quite bizarre, respectively from a philosophical position. I’m not saying that DSM would not fit a philosophical investigation; if the epistemology seems rather a discipline in itself, detached from traditional body of philosophy, though, the philosophy of science (which has not yet announced its independence) could apply for such an approach. But the Stolorow’s article, somehow, seems written in a hurry, rather looking like a need to maintain a halfabandoned blog than a need to seriously develop a theoretical approach. I have in mind the philosophy professionals that use to write as if, over a certain period, the writing would not be permitted any more. Their need to construct an idea as complete as possible and to exhaust its implications, lead to very long texts which often bore an unprofessional reader.



The very short text provided by Stolorow in this article seemed the negative reverse to the contemporary philosophers’ texts. The philosophical shorting on from this article invites the reader to recover the theoretical discourse like a puzzle that few pieces are missing. There are some ambiguities in his position that I have to clarify them myself, taking into account as many variations as possible to interpret his ideas. Although his “World, Affectivity, Trauma: Heidegger and Post-Cartesian Psychoanalysis” (Psychoanalytic Inquiry, Vol 35) gives the impression that he has dealt with philosophy for some time, I think Robert D. Stolorow has some deficiencies in digesting the trends that he refers to. In this article he makes two large errors concerning this field. The first one is accusing the DSM (particularly, the DSM 5) that would have philosophically descended from the Cartesianism or even a pure Cartesianism (it is not very clear from his text which one of these two variants relate to, so I will analyze both in more details). The second one is confusing the Cartesian rationalism with Heidegger's phenomenology or even with the medieval scholasticism. I will start with the first issue and, relative to it, I will first analyze the variant that DSM would be a Cartesianism.

Descartes, through his rationalism, wanted to fight the solipsism (in a reaction-formation way, I would say). This trend believes that the empirical knowledge is false, and the world would be created by the shape everyone’s mind, namely that the reality is a kind of our dream and, just like a dream, it depends on the mental peculiarities of the person that dreams, but not by the (outside) nature itself. It is strange that this solipsism is rather an oriental allure spirit than a thinking trend itself. Even the solipsism’s scapegoat in the history of European philosophy, namely Berkeley, is not a typical solipsistic thinker. Anyway, I do not want to insist on this way now, I just want to say that almost all European philosophy until Kant, fervently argued against such a solipsism that seems to rather exist inside the combatants minds than inside those days philosophical or scientific community. Descartes did the same thing. In his case, the more silent and absent this idyllic solipsism was the sharper against it the arguments had become. Descartes dramatically gave up to any empirical knowledge to start the philosophy from an absolute and rational truth: “I think, therefore I am”. The Descartes’ dualism and ambivalence starts here; to postulate a mind that controls the matter as the sailor controls the ship (rather unclear from what Descartes himself describes) is closely related to his gnosiological ambivalent need to escape the empirical knowledge uncertainties and to base on the rational truths.

So the Cartesian dualism has basically two main criteria: the first one is the gnosiological primacy that gave up the empirical factor in establishing the truth, but still relate to it; the second one is mind / matter parallelism that ambivalently blend each other. Descartes contradictory described these entities. Kant showed their dialectic in detail; the mind and the matter merge each other but yet, in the same time, they would have no relation to each other, as isolated. (It should be noted that by now Descartes desperately tried to somehow connect the two entities). Well, the DSM has no connection to any of these theories. First, the treaty is not interested either in epistemological or gnosiological issues; then it is not interested in the of mind / matter issue. Its main task is to classify certain psychopathological symptoms. Therefore, the DSM could not possibly be an ad litteram Cartesianism.

Let’s go further on and consider the possibility that the methodology or its discourse could have descended from a Cartesian mindset. And still, here one has to interpret the other two possible descendences out from the Cartesianism, unspecified by Stolorow. The first is the theoretical lineage and the other is the psychological lineage. In the first case, the Cartesian dualism (relative to the mind / matter issue) had only philosophical but not scientific influences. In fact, the science itself gave up pure theoretical analysis of metaphysical problems. The above reasons can be repeated in this case too. It is worth adding that the DSM psychopathology area is incomparably smaller than that of Descartes’ concept of “mind” that far exceeds the human brain itself.

The possible psychological descendences could be a possible past Cartesian way of thinking from adolescence or DSM authors another period of life. Such criticism is also unjustified because a theorist can change its position to 180 degrees during its life, giving up for ever the older model. And it is very unlikely that all over100 authors would have had Cartesian experiences to erupt exactly at the DSM conception. So the Cartesianist or descended from – Cartesianist charge against the DSM is also unbased.

It is time now to move on to the second error that Stolorow makes in his article. Paying a closer attention at the following quote, I realize that he misrepresented the Cartesianism itself:

"This dualism concretized the idea of a complete separation between mind and world, between subject and object. Descartes’s vision can be characterized as a decontextualization of both mind and world. Mind is isolated from the world in which it dwells, just as the world is purged of all human meaning. In this vision, the mind is pictured as an objective entity that takes its place among other objects, a “thinking thing” that, precisely because it is a thing, is ontologically decontextualized, fundamentally separated from its world." 

From this quote we can see that Stolorow misinterpreted this dualism, mistaking it with the medieval scholastics or, more, even with the Heidegger’s phenomenology. The Cartesian dualism is an extreme rationalism, a rationalism coupled with an idealistic vision of the world, especially with the religious tradition that still used to dominate the Renaissance spirit. Neither the rationalism nor the idealism does not totally break apart from the empirical matter as dramatically as Stolorow describes the Cartesian dualism, namely as “fundamentally separated from its world”. The Descartes’s reasons exhibited after the introduction of the sailor and ship paradigm is due precisely to the inner rejection of such isolation perspective. Even Hegel did not afford such a radical isolation, but only Heidegger in the twentieth century.

Heidegger starts from the Descartes’ rationalist premises, but it is pretty different, as being closer to solipsism that the French philosopher actually fought with in his dualism. Heidegger never claimed that his phenomenological discourse could have any scientific value and, therefore, it is not empirically verifiable. On the contrary, all the rationalists cared a lot for the scientific validity of their position. In fact, the entire rationalism has a weakness in its... materialism; its need for the empirical factor confirmation is indispensable for Descartes, Spinoza and Leibniz. Contradictions in their discourses are, in fact, due to religious remains that their mentality could not yet give up. In the same way, based on formal logic, medieval scholasticism has created a set of deductive sentences that are not based on the concrete, on the experimental verifiable facts. On the contrary, just like the Platonic dualism which continued, Descartes relied on the fact that the mind is still interwoven with the matter, as shown above. His long and contradictory explanation exposed just after the introduction of the sailor / ship paradigm, actually brings back to another level the concept of "mind" immanent contradiction which he theorized.



Somehow, the Cartesianism charges against the DSM would not be so bad if Stolorow would correctly interpret it. The Rationalism is the next step towards positivism that human thinking has made in the Renaissance and afterwards away from religious dogmas. The general Rationalism and especially Descartes' Rationalism had total openness to the experimental factual evidence, which involved groundbreaking scientific discoveries. Although Nicolas Copernicus lived before rationalists, its scientific revolution is a rationalist one, par excellence. Descartes himself was a respected scientist. So, the problem is not the Cartesianism itself, but its metaphysical extension which makes it dualistic, as invariably happens with any metaphysical approach, as I. Kant pointed out later. So, even if the DSM would be reminiscent of a "Cartesian" way of thinking, still it can be very much science in its own right as long as this "Cartesianism" focus on a small field of reality and do not jump beyond a possible verifiable experience. This is the very case of psychopathology that does study the metaphysics infinity but a experimentally verifiable limited field, the psychopathological symptoms. This is what the DSM actually does, as I have already said.

But if somebody accuses the DSM for being phenomenology taking it as Cartesianism, this is a rough error in understanding these philosophical ideologies. Unfortunately, by metaphorical usage or mistaking the philosophical concepts, Stolorow does not help us to understand what he meant with his critics, actually forcing the reader for extra interpretation exercises of his lapidary text from this article. From what can I figure up at this point, I think that the parallelism between the Cartesian dualism and the DSM has another meaning. In fact, I see two ways to interpret his criticism, different from each other. The first one I think would be that the DSM does not analyze the specific individual human being but the general, the abstract person that, of course, does not exist. Skipping over bad packaging of these philosophical ideas, on direct analysis, this Stolorow’ charge on DSM could partly be right. This DSM procustesian reducing the particularity of the individual human being to a general abstract pattern is something amendable. But this is not just the DSM’s problem or general psychopathology’s problem, but the entire Medicine’s problem: “there are no diseases, but sick people” said Samuel Hahnemann, thus inviting the physician to more complete and more individualistic understand the sick person. So should do also the psychiatrist, the practitioner and - why not? - the psychoanalyst also.

But we must have in mind the goal and the limitations of DSM and the today psychiatry. If one wants to make a less psychopathology social environment and if one wants the psychiatrist to be more human with the patients, then there is absolutely no point in fighting the DSM, but to look beyond the treaty. It is better to fight for a mental institution that recognizes the non-pharmacological therapies as at least as important as the drug therapies are (especially in non-psychotic disorders cases). One could further on push for a little more honest social system, that would not entice people into different traps in order to make they give up their rights and freedoms, which involved their psychopathological predispositions worsening, that led to the very psychiatric disorders explosion in the twentieth century. The appearance of the DSM, which somehow summarizes and classifies huge number of clinical cases seen by different clinicians, is not so disastrous.
The second possible meaning of Stolorow's criticism seems to me to be the DSM’s lack of concordance between the symptoms and their cultural, emotional and even instinctual base. In this case, the Cartesian paradigm (of what Stolorow believes to be an isolation between) mind and matter could be interpreted as a breaking between the symptom and its base whatever it might be. Among the Cartesian dualism misinterpretation error pointed above, in this case it can be seen another discrepancy: Descartes certainly would place the psychopathological symptoms in the yard matter, as a “human imperfection” sign but not in the mind. Therefore, the DSM has no way to have a Cartesian dualist philosophical basis in this case; those two psychological concepts that Stolorow described as having a dual containment relationship are part of one and the same ontological entity as concerning to Descartes vision, namely the matter.

Beyond the improper Cartesian dualism criticism, the main accusation concerning the DSM’ lack of interest for the psychopathological symptom structural pillars is not really rightful. Such criticism seems somehow too demanding. It seems even stranger to me since it comes from the very blurred area of psychology. But beyond that, we know that negotiations between DSM authors during all these decades, in establishing its details, are actually negotiations his sympathies are with between behavioral and dynamicist sympathies psychiatrists. Moreover, the DSM does not limit itself to the simple exposure criteria for a specific disorder or the other; it has different prevalence statistics, incidence or certain prognostic factors. Obviously, the DSM authors decided to keep inside this manual covers only the undoubted data but not those under debates, as is the organic, cultural and psychodynamic psychopathological symptom base. Anyway, as far as could be noticed, the DSM authors barely agree on the classification of these symptoms inside of more or less coherent groups, so paying attention for their cultural and psychodynamic basis is already asking too much. If DSM would place inside all the mottled and contradictory with each other theories, concerning a symptom or another, then the DSM would become a psychological-psychiatric encyclopedia in dozens of books and not a simple “The Diagnostic and Statistical Manual for Mental Disorders” treaty as it is now.
Here it should be pointed out that the breaking symptom out of its causal factors problem is not due to the psychiatrists themselves. They are rarely theorists, as a hobby. They are physicians and have a medical training. And the medicine, as general science, knows about the brain as much as the middle ages knew about the heart. This is nobody’s fault. This is the current mankind scientific level and the psychiatrists can not be blamed for. The problem is the theorists themselves that do not provide enough scientific theories for psychiatrists to use. Psychologists / psychotherapists can not agree each other on a certain symptom causes. Even within a psychological current itself, as psychoanalysis, for example, there are discrepancies between the theories concerning the genesis of a particular symptom.

So, as the psychologists accuse the DSM clinicians of being theoretical obtuse regarding the symptoms structural base, actually the charge could be turned back to themselves. Their lack of comprehension regarding the contemporary clinical diversity turns them isolated from the clinical reality and traps them into the fantasies of the customers’ that they have in therapy. The contemporary psychoanalysts have focused more on the therapeutic aspect, giving up the general theoretical issues so that the psychological fervor from the early history of psychoanalysis almost became abandoned now. Whatever psychological sympathy we might have, the clinical diversity there exists and it should be known. Both behaviorism and psychoanalysis, as other smaller psychology currents, must adapt to this new clinical reality and review their theories accordingly just like, almost a century ago, Freud revised his theories after the latest discoveries from the anthropology, the sociology or the psychopathology of those days. The psychoanalysis must give up to explain the huge spectrum of mental disorders through the 3 stages of psychosexual development in addition to other few concepts; the DSM hundreds mental disorders can not be explained anymore by these classical concepts. On the other hand, the behaviorism has to take more into account the particular predisposition, the personal response to the stimulus. This is, firstly, the convergence way between these two main psychology currents and, secondly, between them and the DSM, in particular, and the psychiatry, in general.

So, before accusing the psychiatrists of obtuseness, the psychology field must propose itself a serious discourse to be taken into account, but not a motley variety of assumptions as proposed until now. And, even less, the psychiatrists do not need classical philosophy. So instead accusing the psychiatrists as Cartesian dualists, (which many of them have not even heard) we could ourselves give up to our own classic nostalgia and give them viable theories so that they can use in benefit of both sides. Until the theorists don not show this kind of materials the psychiatrists can only deal with what they have. They need to record and then classify the symptoms that enter their cabinet. There has to be made some order in this huge number of recorded clinical cases. The classification must be made. If the groups could be too broad or too narrow, if the criteria for meeting one group or another are unclear and if the psychopathology are unable to see the disorder inner structure beyond the outside symptom shape, that’s another matter. But the order should be made.

The quick diagnosis used by DSM is absolutely necessary and it helps the therapist himself. Otherwise, we might face a psychotic explosion just in psychotherapist’s cabinet instead of being dimmed by the psychiatrist. No need to fool ourselves with childhood miracles anymore: the psychoanalysis and other psychotherapies do not have good results or have only poor results as applied to psychosis. That is the fact. But the DSM is made especially for an as prompt as possible intervention to stop such psychotic onset. If an analyst persists in keeping a potential psychotic patient in a psychotherapeutic treatment instead of sending it to a psychiatrist, then this position resembles much with that of the priest who wants to take the “demons” out of a patient that should actually be sent to hospital. It is also true that the psychiatrist itself should do the same with no psychotic risk patients, they should be sent in psychotherapy rather than to a pharmacological medication cure. This is an institutional stalemate that probably only am outside referee can resolve.

I know that the psychoanalysts had always terminological problems and therapeutic approach differences with the psychiatrists. I can think now about the term “narcissistic neurosis” that Freud proposed for schizophrenia and other psychosis in general; blinded by searching for the internal structure of mental disorder, Freud overlooked the huge difference between neurotic and psychotic symptoms, putting them the same category. It was a big error. I also know that a psychoanalyst attack against the psychiatry is viewed with indulgence in the psychoanalysis’ yard. However, solving such a deadlock between psychotherapy in general and drug therapies preferred by psychiatrists can not be done if psychotherapists / psychoanalysts do not make efforts to familiarize themselves with the clinical material diversity and to adjustment as possible as it can with the terminology used by psychiatry since the DSM latest editions. I think that this is the main point that this attack comes from, namely from the competition with pharmacology (preferred by psychiatrists) and from psychoanalysts’ not enough or even lack of familiarity to the clinical diversity. Although I am a convinced supporter of psychoanalysis and non-drug therapies, I still think that we can not convince psychiatrists to see beyond the symptoms and make a more general classification of this clinical diversity (as such classification reflects a structural-dynamic understanding mental disorder) if psychoanalysts themselves do not make a more substantial effort to see outside of their patients’ sphere and realize the other types of patients symptoms features. It is like speaking the same language as the negotiating partner. But with such a false-cultural position critics there is not do much to be done.









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