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Child in the BalanceZombies and Consciousness
In biology, the generic topic of classification is subdivided into three processes: classification, identification and taxonomy. "Classification" per se is the activity of creating groups. This process is primarily the work of researchers in the field who attempt to organize and understand the evolution of living organisms in order to sort those organisms into naturally occurring categories. Identification is the process by which a new organism is assigned to an existing category in a classification. Identification is what we do, for example, when we see a new bird at our feeder, and we try to decide what the unusual bird is. We search through books about birds until we find a description of what we just saw. In medicine, the process of identification is called "diagnosis." Diagnosis is what clinicians do when they see a new patient. They learn the patient's symptoms and assign the patient to a category (-ies) in a medical classification in order to describe the patient's conditions. But a diagnosis serves other purposes including aiding in treatment decisions as well as to determining the probable cause of the patient's problems. The final activity related to classification is what biologists describe with the term "taxonomy." As a process, taxonomy is a highly specialized endeavor in which theoreticians interested in biology attempt to understand how the processes of classification and identification function. From understanding those processes, theoretical models of the field develop (e.g., from the classification of Linneaus, Darwin developed his theory of evolution to explain the hierarchical arrangement of categories).
Annemarie Jutel, the author of Putting a Name to It, is a professor of nursing in New Zealand. Her interesting book was a combination of taxonomy, classification and diagnosis. Consistent with the use of the term "diagnosis" in her title, Putting a Name to It was a practical, clinically oriented work that attempts to carry out an inquiry into the sociology of diagnosis. In trying to accomplish this goal, Jutel devoted attention to exploring various changes in medical classification. Jutel was interested in how sociological and political issues have influenced changes in these systems. Particular disorders that were given emphasis in her book were homosexuality, post-traumatic stress disorder, obesity, female hypoactive sexual desire disorder, and fetal death (abortion, miscarriage and stillbirth). Jutel's thesis was that "diagnosis provides a cultural expression of what a given society is prepared to accept as normal and what it feels should be treated." (p. 3)
In writing about medical diagnosis, Jutel's focus was taxonomic. She was attempting to understand how the processes of diagnosis and classification within medicine actually occur from her sociological perspective. Jutel was persuasive in arguing that sociological/political forces have shaped medical decision making. However, Jutel was less successful in presenting a sociological theory of how those processes have influenced both classificatory and diagnostic decisions in the past, as well as providing hypotheses about how future changes in classification and diagnosis are likely to occur.
Jutel ended her book with a brief discussion of a proposed new medical disorder called "compassion fatigue." This disorder supposedly affects many caregivers who work with family and friends having chronic diseases. Jutel, while being compassionate about the stresses that these care-givers endure, wondered whether the medicalization of the symptoms resulting from these stresses warranted a new diagnostic category. "Classifying compassion fatigue as a disorder powerfully demonstrates how disease categories reflect society's anxieties and frame social reality." (p. 137) She went on to say, "An economic or political framing of this problem would not deny its existence but would situate its cause and remedy outside of the individual, in structural and political action. Had a labor rather than a psychiatric researcher decided to take on [a study of this phenomena], she or he might have more intuitively chosen to look at workload and resourcing to understand in what circumstances one is more like to feel distressed by helping traumatized or suffering individuals. Looking at compassion fatigue as the dysfunction of the individual rather than as a failure of the system close off a number of other avenues for succor." (p. 138)
Many of the examples that Jutel used in her book drew upon issues in the classification of mental disorders. Jutel was quite deliberate in doing this because she asserted that psychiatry is a gatekeeper among the medical specialities. Psychiatry has been given the role of separating what is truly medical from what can appear as if it is medical, but may be more appropriately conceptualized as either deviance (legal or illegal), socially unacceptable behaviors, or psychological (mentalistic) issues.
Concurrently, while reading Jutel's book, I also was reading a book by Emma Forrest titled Your Voice in My Head. Forrest's book was an autobiographical account, by a woman who has succeeded both as a novelist and as a screenwriter, of her therapy with a psychiatrist who suddenly died of cancer. In reading Forrest while also reading Jutel, I found myself looking at Forrest's book through Jutel's approach to diagnosis.
Jutel argued that the diagnosis of a disorder is what gives physicians their power in the medical field. They are the experts who know how differentiate conditions. She also viewed diagnosis as a central activity in the interaction between the physician and the patient. The diagnosis can provide great relief to the patient once she or he knows what is causing the distress (dis - ease). From Jutel's perspective, diagnosis is a crucial and central activity in patient/doctor interactions.
In Forrest's book, the diagnosis of her condition was not a central issue. Her first mention of a diagnosis was on page 45 of her 214 page book. Forrest talked about being admitted to a psychiatric inpatient unit and that she was diagnosed in that setting as manic-depressive. Occasionally she remarked about being "manic." Later, she commented that she was not borderline. But overall, her diagnosis did not seem to interest her. Nor, from her discussion, did her diagnosis play a central role in how the relationship between she and her therapist unfolded. What did generate a great deal of attention on her part was when her therapist was diagnosed with cancer, why he did not share that diagnosis with her, and what his death meant both to her and to other patients with whom he had worked.
Forrest's book is about the interpersonal nature of work in the mental health field. Jutel talked about the medicalization of non-biological issues and focused on diagnosis as part of the objectifying way by which physicians, like expert car mechanics, use their extensive knowledge of the systems in order to keep the body's somatic machine functioning.
The writing style of the two authors was quite different. Jutel, as a professor, wrote a well-documented, carefully argued manuscript. Her prose was easy to understand, and Jutel's book would be quite accessible to the interested lay reader. Forrest is a screenwriter. Her style was fluid and designed to portray emotionally laced images. I have presented examples of Jutel's writing earlier so I shall end with an example of Forrest's prose.
I decide that if Dr. R were in a boy band, he would be the cheeky one.
'If you were in a boy band, you'd be the cheeky one.'
"Yeah, they all have a different personality type. Like: the cheeky one, the innocent one, the tough one.!'
'They could do a boy band of psychiatric disorders .... The bipolar one, the body dysmorphic one ...'
'Right, the obsessive-compulsive one.'
'Wow. There's a name for everybody.'
I sniff, as if I'm not sure what to ask next, though I'm exactly sure.
'So ...... what am I?'
'It's not always helpful to classify.'
He writes something down.
'Seriously. What am I?'
'You are Emma.' (pp. 57-58)
Forrest, E. (2011). Your voice in my head: A memoir. New York: Other Press.
© 2011 Roger K. Blashfield
Roger K. Blashfield, PhD, is Professor Emeritus at Auburn University in Alabama. He is currently working a manuscript titled An essay about diagnosis: A memoir of a 20th century academic clinical psychologist.