Achieving Scientific Objectivity for the DSM
Guest Post by Bennett Knox
The revision of Diagnostic and Statistical Manual of Mental Disorders (DSM) is sometimes derided as more a matter of canonizing consensus among powerful psychiatrists than an objective scientific search for truth. This type of criticism raises a series of questions. What would it take for the DSM revision to be an objective scientific process? Should patients and other non-psychiatrists have a voice in the revision process—if so, which ones? What are the obstacles to the meaningful integration of these perspectives, and how should integration be carried out? These are the questions I set out to address in my article Exclusion of the Psychopathologized and Hermeneutical Ignorance Threaten Objectivity (Knox 2022).
Taking my cue from the work of Anne-Marie Gagné-Julien, I embrace a form of “social objectivity” for the DSM revision process. Rather than thinking that psychiatry must reject the presence of all values in the process in order for it to be scientifically objective, the social objectivity approach calls on the DSM revision to include a wide range of value-laden perspectives and bring them into critical dialogue with one another. It is through this critical dialogue that a socially-embedded process such as this can achieve meaningful scientific objectivity.
If the social objectivity approach is the right one for the DSM revision process, then the question becomes how to achieve the appropriate critical dialogue. Which perspectives are the relevant ones to include, and how should this inclusion work? In my article, I argue that there are certain relevant perspectives—those of the people whom psychiatry attempts to categorize (whom I call the “psychopathologized”)—who must be given a meaningful voice in the process if the DSM is to achieve social objectivity.
I am far from the first to call for inclusion of this group of people in the DSM revision process. The lead up to the publication of the DSM-5 in 2013 saw a number of calls for inclusion of the perspectives of patients and their allies. But these calls have often been resisted on the basis that inclusion of these perspectives would undermine the objectivity of the process by allowing values to influence it. If the social objectivity account is right, however, this kind of criticism gets things exactly backwards. Inclusion of patients does not undermine the objectivity of the process, in fact it is required if the process is to be a scientifically objective one
I argue that the DSM process must find ways to meaningfully engage with the perspectives of people within the psychopathologized group who understand themselves radically differently from how mainstream psychiatry does.
But even more radically than this, I argue that the DSM process must find ways to meaningfully engage with the perspectives of people within the psychopathologized group who understand themselves radically differently from how mainstream psychiatry does. This includes people who subscribe to the Neurodiversity Paradigm, the Mad Pride Movement, and even strains of the Psychiatric Survivor Movement that call for the abolition of psychiatry. However, my argument is only that such perspectives must be given meaningful uptake of their criticisms, and not be dismissed out of hand. This does not mean that every criticism coming from these groups must be fully taken on board. And what meaningful engagement of psychiatry with these perspectives will look like in practice is an important further question.
As an obstacle to this type of inclusion, I point to a particular phenomenon that may lead psychiatrists to reject these types of perspectives without giving them the full consideration they are due. This is the phenomenon of “hermeneutical ignorance” referenced in the title of the article. Hermeneutical ignorance occurs when a dominant group (here the psychiatrists) fails to take the understandings of a less powerful group (here the psychopathologized) appropriately seriously. The dominant group may simply not understand why the marginalized group understands their experience in a certain way, because the dominant group does not have the types of experiences that call for such understandings.
As an example, I point to the way that members of the Hearing Voices Movement understand the experience of hearing voices that others do not hear. For many of these people, understanding this experience as a symptom of a pathology is not productive; instead, they understand their voices as meaningful parts of their experience, and attempt to make sense out of and live with them. A psychiatrist who has never had the experience of hearing voices may not be able to easily see why someone would understand their experience this way, and may be prone to dismiss this understanding without taking it sufficiently seriously—this dismissal would be hermeneutical ignorance.
If this type of dismissal due to hermeneutical ignorance stands in the way of psychiatrists taking the perspectives of the psychopathologized seriously in the DSM revision process, then it presents a serious obstacle to achieving the type of meaningful inclusion that would make that process socially objective. Thus, I conclude that for the DSM revision process, Exclusion of the Psychopathologized and Hermeneutical Ignorance Threaten Objectivity.
Bennett Knox is a PhD Candidate in philosophy at the University of Utah, and the winner of the 2022 Karl Jaspers Award from the Association for the Advancement of Philosophy and Psychiatry (AAPP). They work primarily in the philosophy of psychiatry, and are especially interested in pluralism, the role of values in psychiatry, and the relationship between psychiatric science and social movements.