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In Values and Psychiatric
Diagnosis John Sadler analyses the "values structure" of the Diagnostic
and Statistical Manual of Mental Disorders (D.S.M.), the classification of
mental disorders published by the American Psychiatric Association and now used
worldwide. Sadler examines the explicit and implicit values that have shaped
the D.S.M. classification, and considers how an adoption of different values
might improve future editions. Chapters consider how the D.S.M. has been shaped
by particular assumptions regarding sex, culture, the medical profession,
politics, science and basic metaphysics.
Sadler's project is ambitious, and Values
and Psychiatric Diagnosis is correspondingly long. Though his prose is as
simple and elegant as academic writing can be, getting through the 550 pages is
hard work. The book is written for mental health professionals with a serious
interest in classification rather than for the casual reader.
For those who can get through it, Sadler's
book repays study. Most of the issues discussed by Sadler will be familiar to
those who have followed the D.S.M. debates, but his book manages to bring
together these issues within a unifying framework for the first time. Sadler
develops an account of the different roles values can play in shaping science
and sees all the debates about the D.S.M. in these terms. His notion of "values"
is broad. Many think of ethics, aesthetics, and political philosophy when they
talk of values, but Sadler is also happy to see value commitments in
metaphysical positions. To me talking of "individualism" or "essentialism"
as a value commitment sounds odd. These positions make claims about the nature
of reality, not about what is good or bad. As such, I'd find it more natural to
talk of "assumptions behind the D.S.M." rather than so broadly of "values
commitments". This, however, is merely a terminological quibble, and doesn't
affect the substance of Sadler's claims.
Many of the issues discussed by
Sadler have been discussed elsewhere. Familiar topics include a discussion of
gender-roles, whether the categories can be applied cross-culturally, whether
relational diagnoses should be included in the D.S.M., and the criticisms of
those who adopt a hermeneutic approach to mental disorder. However much
previous discussion has been heated and shrill. A major strength of Sadler's
work is that he manages to discuss the views of those who produced the D.S.M. and
the views of their most ardent opponents with equal generosity and
good-sense. The resulting balance ensures that if one is going to read one book
on the D.S.M., this is the book to read.
Sadler makes many sensible claims
in the course of his book. I think the most novel and interesting are in
chapters nine and ten, on technology and politics respectively. In Chapter
Nine, Sadler uses work on the philosophy of technology to make sense of the
ways in which technologies tempt us to forget our ultimate ends and get wrapped
up in means instead. Rather than making use of technologies we all too easily
become slaves to them. Sadler suggests that those who make and use the D.S.M.
can fall into this error. Instead of remembering that their aim is to help
patients and seeing the D.S.M as a guide, clinicians can end up thinking of
hard-to-diagnose patients as problems who cannot be made to fit within
the D.S.M. framework. The wish to use the technology efficiently comes to
obscure the end goals of medical care.
In Chapter Ten, Sadler suggests
that the processes by which the D.S.M. was produced were implicitly modelled on
decision processes employed in democratic governance. In seeking to have
representatives of different interested groups on working groups, and in its
policies of openness and accountability, the D.S.M. sought to mimic the good
practices of good government. Similarly, the different committees of the A.P.A.
involved in producing the D.S.M. acted to check and balance the decisions of
one another, in the same kind of way as does the fragmentation of the roles of
government between different institutions. Sadler goes on to discuss the
necessary problems of democracy, and how these feed in to creates tensions in
the decision procedures of the D.S.M. revision process.
In the final chapter, Sadler
considers positive recommendations for the next DSM. These are modest and
sensible. For example, Sadler suggests the current D.S.M. has erred in trying
to satisfy too many groups -- presently it is intended to be used by clinicians,
researchers, and administrators, and is also readily available to lay people.
He suggests that the different needs of these groups can not be met by one
classification system, and that specialist systems might be developed for each.
In addition, Sadler recommends that patient groups should have a greater input
into the next D.S.M., and that a more explicit awareness of the values that
shape the D.S.M. would be beneficial.
Overall, Values and Psychiatric
Diagnosis is a valuable addition to the growing literature on the
philosophy of psychiatry. It will become a key text for mental health
professionals with an interest in classification.
Cooper, Ph.D., Lecturer in Philosophy, Institute for Environment, Philosophy
and Public Policy, Furness College, Lancaster
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