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The History and Tyranny of The DSM

In 1971, gay activist Frank Kameny stormed the American Psychiatric Association’s annual conference, held that year in a Washington ballroom.  

Pushing his way past shocked elderly psychiatrists, he seized the microphone and shouted: “Psychiatry is the enemy incarnate.  Psychiatry has waged a relentless war of extermination against us.  You may take this as a declaration of war against you.”

What inspired Kameny’s activism?  At the time, it was the psychiatric establishment’s diagnostic hostility toward gay people.  But it targeted something much larger, too, namely, the entire enterprise of psychiatric diagnosis through the APA’s rigidly judgmental classification system, the so-called “Diagnostic and Statistical Manual of Mental Disorders (DSM).”

Like Kameny, we, too, declare war on American psychiatry for its reliance on the DSM.  The DSM may no longer specifically deride gay people as “pathological personality types” as it did in years past.  But it continues its intolerant tradition against many other people in many other ways.  Today, the DSM deigns to impose a standard of “normalcy” upon us all, labeling as “abnormal” all who fall into its superficial, categorical caricatures.  Like a criminal code, it defines and demonizes deviations from “appropriate lifestyles,” medicalizing all those who fall under its gaze, without regard to specific circumstances, causes or backgrounds. 

But unlike a criminal code, the DSM does not prescribe punishments.  It prescribes “treatment” through expensive pharmaceutical products.  This, in turn, has led to a medicalized—and medicated—population.  It has led to an analyzed, branded, categorized, demonized, drugged population—even when drugs may do nothing to relieve their pain.  Worse, the DSM inflicts permanent psychological damage through the “life sentences” it imposes on its subjects, labeling them “abnormal,” “deviant,” “mentally ill” or “sick.”

Unquestionably, the DSM wields enormous power.  It is accepted as scientific authority by clinicians, researchers, drug regulation agencies, health insurance companies, the court system, legislatures and policy makers.  Its categorical definitions sway official opinion and authorize involuntary medical treatment.  It purports to speak for our society, telling its readers who does not belong, whose behavior is dangerous, and who needs “help.”  In the process, it assumes a guardian-like role, enshrining itself as the enforcer of normal living, normal behavior, normal thought.  In every sense, the DSM is a moral work as much as an allegedly “scientific” one: It vindicates the “normal” against all else—as if such a thing as normal ever existed at all.

How did the DSM assume its powerful position?  And how exactly does it function?  History always lights the way to understanding, and a walk back through the DSM’s history answers many questions. 

As the DSM’s title suggests, statistics played a primary role in compiling an authoritative handbook on mental disorders.  Western society—and especially American society—has long had an interest in knowing which of its citizens are “crazy.”  American society has not only wanted to know how they are crazy; it has also wanted to know how many of them live in the community.  In the United States, the first official drive to answer these two questions came in 1840, when the Census Bureau created a category called “Insanity/Idiocy” to count how many “insane people and idiots” lived in a particular community.  A crude method, to be sure.  But it began the whole American program of locating, counting and categorizing those who somehow “did not fit” in “normal” society.

In these early times, medicine did not really play a role.  From the statistician’s perspective, it did not matter how a person was an “idiot.”  It was up to the census counter to decide whether the person was or was not an idiot.  If he was, he got a check mark.  If he was not, he did not get a check mark.  Deciding whether a person was crazy was a layman’s decision.  There was no professional obfuscation; it was essentially just a common sense judgment, such as whether someone is drunk. 

Still, deciding whether a person is “crazy” is undeniably a judgment.  It involves observation, value assessment and conclusion based on the observer’s values.  That process of observation, assessment and conclusion requires language, and as the history reveals, language took a leading role in the DSM’s ultimate development.

By the early 20th Century, the medical community had taken a “scientific” interest in people formerly dismissed as “idiots” or the “insane.”  For these early doctors, “idiot” and “insane” did not sufficiently describe these people; they needed more specific names.  So they set about formulating a whole new language to categorize them.  For the first time, statistics and medicine mixed.  Now, it was not just a census question whether a person was an idiot or insane; it was also a technical, medical one.

In 1917, the American Psychiatric Association’s committee on statistics compiled a document called the “Statistical Manual for the Use of Institutions for the Insane.”  For the first time, it listed diagnoses, 22 of them.  Around the same time, the New York Academy of Medicine created an “official” psychiatric nomenclature, just as other medical communities had created “official” nomenclatures for body pathology and anatomy.  It called its work the “Standard Classified Nomenclature of Disease.”

Now, a mere layman could no longer simply dismiss a person as “an idiot.”  Although society in 1917 still casually branded people “insane,” it now had a lexicon to describe precisely how.  And only professionals had recourse to this lexicon.  The business of observing and judging “deviance” now fell to doctors, and they expressed their conclusions in arcane, inaccessible language.  Society still had an interest in knowing who was crazy and how many crazy people there were.  The difference now was that it entrusted doctors to make the call. 

Language gave rise to the DSM.  As the 20th Century progressed, doctors further refined the language they applied to “mental disorders,” streamlining their criteria, shaping their elements.  They invented a whole new vocabulary to talk about what their forerunners simply called “insanity.”  Like botanists, they observed their subjects and noted their particularities.  They standardized, classified, subclassified, defined.  They invented Greek and Latin neologisms to encompass every form of so-called “deviant behavior.”  They treated “mental disorders” like any other bodily ailment: They listed elements, dressed them in fancy language and set about applying them as “professionals in practice.”

Despite these developments, there was still no standardized, authoritative manual for mental disorders.  Enterprising doctors had formulated their own definitions and diagnoses, but there was no lingua franca among fledgling “mental health professionals.”  There was still no centralized authority that empowered one language over another.

All that changed, however, during World War II.  The army had a substantial interest in assessing the psychological well-being of soldiers.  In order to “select, process, assess and treat” both recruits and active duty personnel, the army wanted a standardized handbook listing mental disorders.  Like the census bureau a hundred years before, the army wanted to know who was crazy, and how many of them infiltrated the ranks.  The questions hadn’t changed.  Only the language had.

To draft such a handbook, the army turned to a well-known psychiatrist, William C. Menninger.  Menninger’s claim to fame before the war had been to open a clinic called The Menninger Foundation in Kansas, specializing in the “treatment of behavioral disorders.”  Beyond his work in the clinic, Menninger had been active in the Boy Scouts, even writing a “skipper’s manual” for young sea captains.  In 1941, the army made him a Brigadier General and appointed him “Director of the Psychiatry Consultants Division.” 

As chairman of that committee, Menninger compiled the closest direct ancestor of the DSM: War Department Technical Bulletin, Medical 203 (“Medical 203”) in 1943.  That document streamlined all previous efforts to classify mental disorders, setting forth clear diagnostic categories with concise, medically-based language.  In short, Medical 203 established an authoritative language for defining, labeling, assessing and diagnosing mental disorders as “psychopathology.”  It became a universal dictionary for military psychiatrists, ending all debate as to which “disorders” actually “existed,” setting forth standardized criteria for identifying them. 

Medical 203 proceeded on the assumption that mental disorders were “diseases” with symptoms.  It assumed such things as “normal,” “moral” personalities and drew distinctions between disorders that affected “normal people” as opposed to “abnormal people.”  Additionally, Medical 203 assumed a class of “permanently flawed personalities,” including an entire section on “Pathological Personality Types.”  These “types” could not be helped; they were simply abnormal.  At best, they could be identified and avoided. Medical 203 also refused to analyze causes; it merely listed symptoms and assumed that these symptoms stemmed from underlying pathology.  

In essence, Medical 203 took no account of the individual.  It simply observed behavior from a detached, medical perspective and described how it deviated from normal expectations.  It assumed things such as “normal stress,” “unconventional behavior,” “reality” and “effective work habits.”  It also demonized “eccentricity,” “queerness,” “immaturity,” “people who are always in trouble” and “people who do not adequately relate in social situations.” 

Medical 203 also took a decidedly moral tone, despite its claims to neutral “medicine.”  Not surprisingly, it considered homosexuality “sexual deviance,” in the same category as “transvestitism,” “pedophilia,” “fetishism,” “rape,” “sexual assault” and “mutilation.”  It bears note that “sexual deviance” appears in a category right next to “Asociability,” referring to habitual criminals, “gangsters, vagabonds, racketeers and prostitutes.” 

After the war ended, the American Psychiatric Association was so impressed with Medical 203 that it substantially accepted the text as the first incarnation of the DSM.  Having seen the advantages of authoritative, standardized diagnostic language in military application, the APA eagerly sought to apply the same language to civilian life. 

DSM-I appeared in 1952, containing 106 diagnoses for so-called “mental disorders.”  Its language largely tracked Medical 203.  It bears special mention that the seminal DSM arose from a military document intended to “select, process, assess and treat soldiers.”  It also bears note that Medical 203 arose from an early 20th Century movement in the medical community to classify “the insane” for statistical purposes. 

Viewed broadly, the DSM arose from a tradition that views human beings as curiosities to be labeled, counted, demonized and judged against an assumed standard of “normalcy.”  DSM-I in particular arose from a military perspective, regarding its subjects as soldiers in an army.  And soldiers must be organized, homogenized, disciplined, punished, corrected.  That is the nature of military order, and that is the order embodied in DSM-I.

Criticism has dogged the DSM from its first appearance.  In the 1960s, opponents chiefly challenged the entire notion of “mental illness.”  After all, the DSM’s classification system only applies to “mental disorders.”  Before the DSM even applies, one must accept that “mental disorders”—as a metaphysical matter—exist in the first place.  Critics like Erving Goffman contended that “mental illness” was a canard, a heavy-handed social weapon intended to suppress non-conformists.  Thomas Szasz argued that “mental illness” had nothing to do with health; it referred simply to individual moral conflict.  At the same time, behavioral psychologists claimed that the DSM’s methodology was fatally flawed because it relied on unobservable phenomena like “normalcy,” as well as unverifiable cultural bias.

In response to these attacks, the APA revised the DSM, publishing DSM-II in 1968.  This incarnation attempted to clarify its diagnostic language while expanding its reach.  It contained 182 “disorders” this time, retaining the DSM-I’s original classification against homosexuality as a “deviate sexuality.”  The DSM-II’s stance against homosexuality further inflamed critics, leading to an “anti-psychiatry movement.”  These critics blamed the DSM-II for providing medical justification for bigotry and intolerance, not just against homosexuals, but against anyone whose behavior did not match an assumed “norm.”  This movement led Frank Kameny to crash the APA’s annual meeting in 1971, impugning all psychiatric diagnosis as biased and illegitimate. 

At the same time, a new generation of data-oriented psychiatrists criticized the DSM-II’s nonscientific language.  Columbia University’s Robert L. Spitzer called DSM-II an “unreliable diagnostic tool” because no two practitioners could similarly diagnose a patient presenting the same symptoms.  Spitzer argued that the DSM-II needed tighter language, more objective data and greater uniformity.  Critics like Spitzer were not “anti-psychiatry;” they merely wanted to make psychiatry “more scientific.”

Once again, the APA reacted to the attacks.  In 1974, its Executive Board rewrote the DSM-II’s section on homosexuality.  For the first time, it removed homosexuality from the classification “mental disorder” and placed it in a new category: “Sexual orientation disturbance.”  And during the late 1970s, Robert Spitzer served as chairman for developing the new DSM-III, bringing mainstream expression to the new “data-oriented” trend in psychiatry.  

In 1980, Spitzer’s committee published DSM-III, containing 265 diagnoses.  Using “reliability” as a guiding principle, DSM-III substantially overhauled DSM-II’s categories in an effort to promote greater uniformity in diagnosis.  To achieve this result, Spitzer insisted on greater research and data to support particular classifications.  He also aimed to change the DSM’s language, making it even more medical and inaccessible.  

In Spitzer’s words, “mental disorders are a subset of medical disorders,” and medical disorders required their own, inscrutable language.  Now, homosexuality was no longer called “Sexual orientation disturbance.”  DSM-III completely covered it over in jargon, labeling it “ego-dystonic sexuality.”  This trend toward inscrutable medical language permeated the entire text, making the business of psychiatric diagnosis more inaccessible to laymen than it had ever been.

And there was another reason DSM-III changed its language.  Beyond the customary professional impulse to keep language confusing so as to retain power over laymen, DSM-III had to adjust its words to accommodate a new player on the psychiatric landscape: Pharmaceutical companies.

By 1980, psychiatrists increasingly prescribed more and more complicated medications to those they deemed “mentally ill.”  To respond to the demand, pharmaceutical companies had an incentive to formulate newer drugs for various conditions.  In order to get Federal regulatory approval for new drugs, however, pharmaceutical companies needed specific language to appease the Food and Drug Administration.  The FDA did not like DSM-II’s imprecise language; it wanted regulatory language supported by at least some scientific research.  This requirement played a significant role in the DSM-III’s linguistic transformation.  Now, the DSM not only had to express itself in less understandable terms.  It also had to support its categories with some research, spawning a whole new industry in self-serving “data collection” intended to appease FDA regulators.

DSM-III set the pattern for modern psychiatric practice in the United States.  For the first time, the DSM allied itself closely with the pharmaceutical industry, adjusting its language to guarantee regulatory approval for new drugs, while at the same time providing an authoritative, quasi-scientific manual by which practitioners could medicate more and more people.  As the 1980s progressed, even Dr. Spitzer lamented this trend, noting that DSM-III led to the “medicalization of 20-30% of the population who may not have had any serious mental problems.”

By the 1990s, the trend toward medicalization had accelerated.  As it did, the DSM adjusted itself accordingly, introducing more and more “science” to support its diagnostic categories.  To keep pace with ever-increasing FDA applications from the pharmaceutical industry for new psychiatric medications, the APA commissioned DSM-IV.  It appeared in 1994 under the supervision of Allen Frances.

Like its predecessor, DSM-IV cloaked itself in inscrutable scientific language.  This time, however, it took active steps to reveal its processes, ostensibly to allay criticisms against hidden bias.  To formulate new diagnoses and to overhaul old ones, it created a so-called “Steering Committee” composed of 27 members divided into 13 work groups of 5-6 members each.  These “work groups” then conducted a three-step process to hash out new diagnoses: First, they carried out an “extensive literature review” on the matter; second, they solicited “new data” from practitioners and researchers to buttress their conclusions; and third, they conducted “field trials” to test the revised language.  Following this apparently “transparent” process, DSM-IV promulgated 297 diagnoses in 884 pages.

Despite its efforts at transparency, however, DSM-IV never cited its sources.  Instead, it merely released four “sourcebooks” relating to its “guideline development process.”  These “sourcebooks” shed some light on the evidence each work group used to make its conclusions, without expressly stating sources.

DSM-IV’s authoritative language provided the ideal vehicle for the FDA to approve new drugs.  Its language, coding system and classification methods tracked exactly what the FDA needed to hear from an applicant, as well as what insurance companies wanted to hear in requests for reimbursement from patients seeking medications and psychiatric treatment.  DSM-IV created a symbiotic relationship between the psychiatric community (which received payments from the health insurance industry), the pharmaceutical industry (which received regulatory validation from the DSM-IV’s carefully crafted language and “research”) and the health insurance industry (which received more and more premiums from people seeking “mental health treatment.”).

This is the background against which the APA approved the DSM’s latest incarnation, DSM-V.  Now, the alliance between the APA, the pharmaceutical industry and the health insurance industry is set in stone.  And just as the DSM-IV did before it, the DSM-V provides the linguistic grease that keeps the economic wheels turning for them all.

But all this begs essential questions.  Is the DSM-V any more valid today than DSM-I was valid in 1952?  Is there anything about the DSM’s methodology that invites criticism?  And perhaps most importantly, does the DSM actually cause more psychological harm than good?

As we have seen from reviewing the history, there is nothing intrinsically “correct” about the DSM.  We have seen that it is merely an experimental, judgmental dictionary that enshrines dubious “normalcy” as a standard for evaluating—and now medicalizing—all kinds of human behavior.  It is merely an arbitrary nomenclature that has grown organically over time with no real authority beyond what it has awarded itself. It assumes that pathology defines all individuals’ mental health, something that has never been proven.  It now works as a rubber  stamp for FDA drug approvals and health insurance coding.  And beyond all the conceptual criticisms, the DSM now has an entrenched economic raison d’etre. 

How exactly does the modern DSM work?  And how does it judge us?  Put simply, the DSM is—and always has been—a “categorical classification system.”  Like a criminal code, it establishes arbitrary definitions based upon symptoms, which a practitioner uses to “diagnose” an individual under his observation, placing him “in” a category.  Also like a criminal code, the DSM involves a gateway procedure.  Criminal codes only apply to behavior defined as “criminal.” Similarly, the DSM only applies to behavior defined as a “mental disorder.”

This is an essential inquiry, for it determines whether the DSM applies in the first place.  So what exactly is a “mental disorder” according to the modern DSM?  DSM-IV defines it: "A clinically significant behavioral or psychological syndrome or pattern that occurs in an individual which is associated with present distress or disability [or] with an increased risk of suffering."

Parsing through this language, we encounter many intractable presumptions.  First, what does “clinical significance” mean?  In DSM-IV, over half the diagnostic categories require so-called “clinical significance” to invoke the disorder.  DSM-IV defines it: "Distress or impairment in social, occupational or other important areas of functioning." 

Here, we see the DSM’s judgmental spirit at work.  It bears note that only the professional decides whether a patient has “distress or impairment.”  That is a “technical” question left to the professional’s observation; it does not really matter what the ostensibly afflicted layman has to say about his suffering. And the technical question whether the patient has “clinically significant distress or impairment” is pegged to whether the patient fails in “social, occupational or other important areas of functioning.”  It is up to the professional to say whether the patient relates in social situations “normally,” whether he does his job “normally” and whether he “functions normally” in “other important areas.”  The text does not define these “important areas,” leaving them instead to the professional’s judgment.

"Clinical significance" allows mental health practitioners to foist their own values on their subjects.  In the process, the DSM invites psychiatrists to narrowly view their subjects in "social and occupational terms," reducing their individual essence to the judgmental question whether they "talk normally" and "do their jobs" normally. 

In a very real way, the DSM’s insistence on “clinical significance” conscripts mental health care into the service of the free market economy:  It induces psychiatrists into finding “disorder” in those who do not function “normally” in an “occupational” way.  For the DSM, “normalcy” means not feeling distress about social situations or jobs.  “Normal” people feel just fine about working for their economic betters and having “normal” conversations. 

Second, “clinically significant” mental disorders must involve a “pattern or syndrome.”  This language, too, is deeply problematic.  After all, what is a “syndrome?”  According to the dictionary, a syndrome (from the Greek word referring to “a running together”), means “a group of symptoms that collectively indicate or characterize a disease, psychological disorder, or other abnormal condition.” (Dictionary.com).  The DSM, then, focuses its gaze on symptoms, presuming that they stem from disease and pathology.  Viewed structurally, the DSM only applies to “mental disorders,” which only exist when there is a “syndrome,” namely, an “abnormal condition” or “illness.”  The DSM, then, conceptually links abnormality with disease; and its diagnostic categories only come into play when “disease” is present.  And by its very definition, “disease” and “abnormality” go hand in hand.

Third, the DSM requires that this “clinically significant syndrome” must be associated with “present distress, disability or an increased risk of suffering.”  As we saw in the definition for “clinical significance,” it is the professional’s decision whether these factors are present.  In the usual case, “distress, disability and suffering” are subjective complaints.  Usually, people tell us they are distressed or suffering and we choose whether to believe them.  We do not literally feel their pain; we can only choose to believe it is true.  People who are suffering want to be understood; they want compassion and empathy.

But the DSM takes a very different view on suffering.  It makes it a technical inquiry.  It removes compassion from the process in an attempt to make suffering “an objective standard.”  From the DSM’s technical standpoint, “distress, disability and suffering” are questions for the professional to answer, the way a doctor might determine whether there is a particular pathogen in the bloodstream.  To be sure, the professional must listen to the subject to make this conclusion, but just as a doctor observes a patient like an academic specimen, so too does the DSM psychiatrist observe his subject’s claimed suffering—with scientific detachment.  It is ultimately the psychiatrist’s professional decision to say whether the patient is “really suffering,” no matter what the patient says. 

Once the DSM psychiatrist answers all these technical questions, he may then decide whether the subject has “a mental disorder.”  If he answers yes, he may then apply the DSM’s manifold categorical standards.  And quite possibly prescribe personality-altering medications.

This is how the DSM operates.  It treats all people like specimens to be evaluated under an objective standard, the same way surgeons view people as specimens to be dissected.  But unlike surgeons, who view people in roughly verifiable, anatomical terms, DSM psychiatrists view people under the dubious standard of “normalcy.”  By its very diagnostic protocol, the DSM links abnormality with pathology, assuming both that “normalcy” exists and that it is a “disease” to deviate from that standard. Then, like a dictionary, it defines hundreds of ways in which people can be “abnormal.”

In reviewing the DSM’s history, we have seen that there has been little agreement on the question whether “mental disorders” exist in the first place.  In this sense, the DSM’s entire foundation lies on uneven ground.  Some critics—including Thomas Insel of the National Institute of Mental Health—contest the DSM’s “validity” because they question whether the DSM’s “mental disorder” definitions really even exist.  Moving further, however, it is debatable whether it is proper to even think in terms of “disorders” at all.  It is possible to see human problems as merely individual expressions demanding individual creativity to solve.  It is possible to treat psychological suffering without viewing it like a specimen in a cage to be labeled, observed, medicated and categorized.

Yet this is what the DSM does.  The DSM causes immense human harm because its rigidly categorical approach demeans individuality.  It refuses to take account of unique individual circumstances, preferring instead to view all human beings as potential diagnoses to be judged against an objective standard.  It does not inquire into backgrounds or causes; it is concerned solely with “symptoms” and “disease.” And because the DSM has assumed such authority in American society, its “sentences” carry tremendous social weight.  Like a criminal code, the DSM attaches stigma to those it labels “abnormal.”  But unlike a criminal code, there is no “due process” or “fair trial” required before the DSM’s sanctions come into effect.  All it takes is a single “professional” to “observe” a subject, make a conclusion whether he is “suffering” from a “syndrome,” and write out a coded diagnosis.  Once that happens, an individual’s life may change forever.  He becomes “schizophrenic,” “autistic,” “bipolar” or “hyposexual.”

It is time to reveal the DSM for the sham that it is.  A categorical, dictionary-like approach to human mental suffering that assumes pathology is simply the wrong way to tackle the problem.  History reveals that the DSM arose from a statistical tradition that viewed human beings as curiosities to be judged against an assumed “normalcy.”  We also saw that the DSM is little more than a “nomenclature book” that assigns confusing names to problems to which we can all intuitively relate.  We saw that there has never been consensus among experts with regard to the DSM’s definitions or methodology.  To the contrary, for over 60 years, thoughtful critics have attacked the DSM for everything: From its dubious assumption that mental disorders even exist in the first place, to its cultural bias, to its “bad science,” to its poor reliability and deepening economic alliance with health insurance companies and the pharmaceutical industry.

We must add our voices to the attack.  We must speak as individuals who matter.  It is time reject the DSM’s purported authority over our individual habits, characteristics and traits.  It is time to wage war on the very concept of “normal.”  The next battle in the war against the DSM is our refusal to be labeled and demonized.  It is not a disease to be a free-thinker, or an eccentric, or to be a poor conversationalist or to not like one’s job.  These are individual traits that define us all; they do not make us “mentally ill” or give us “clinically significant syndromes.”  They make us who we are; and that does not require a pill.

We must expose the DSM for what it is: A culturally biased, judgmental handbook that springs from an intolerant tradition; a presumed medical lexicon with no intrinsic authority; a text coopted by power to enforce a version of “normalcy” that serves the existing economic order.  What more proof do we need than the DSM’s own checkered history, its lack of acceptance abroad, the constant debates surrounding its legitimacy and its deepening commercial ties to drug companies?

In short, human beings are far too complicated to be categorized.  The DSM’s categorical methodology proceeds on the wrong assumptions about people.  Its ascendancy has less to do with intrinsic worth than with power’s relentless urge to maintain stable—and unequal—economic hegemony within society.  Power enthroned the DSM, and power keeps it there.  Power married psychology with science, science with medicine, and medicine with medication.  

Yet a close look reveals that the emperor has no clothes.  We need only look at the DSM’s history, methodology and effect to see that it is no talisman.  It is just another attempt by power to judge us, simplify us and keep us in line.  Like a religious dogma, it shames, judges and demonizes.  But rather than scold with “sin,” it scolds with “diagnosis” and “syndrome.”  And rather than offer “absolution,” it offers “medication.”

We are so much more than the superficial specimens outlined in the DSM.  We deserve better.  We deserve to be free from the tyranny of “normal.” 

That is why we must agitate against the DSM.  Our very individuality—and humanity—depends on it.