CHAPTER NINETEEN
Jessica N. Lee
In his 2012 “Teaching about Mental Health and Illness through the History of the DSM,” Joshua W. Clegg declares that “the ways that mental illnesses are defined have always been, and continue to be, principally by consensus rather than in terms of organic pathology.”1 The implications of Clegg’s statement imbue representations of mental illness in popular culture with particular significance, highlighting the ways in which reflections of popular culture as seen in books and movies affect and are affected by the consensus that governs how mental illnesses are determined. In what follows, I trace the evolution of diagnosing psychiatric illness in the United States. In particular, I juxtapose the development of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM) with narrative accounts, each based on the author’s experience with inpatient psychiatric hospitalization. This comparison provides a unique perspective through which to view the ways in which an ever-evolving diagnostic system necessarily affects depictions of mental healthcare.
The function of diagnostic labels in the United States’ mental health system holds significant rhetorical force and material consequences. Diagnostic labels are dangerous in their potential to stigmatize those diagnosed. Yet categorizing and labeling a person’s mental health distress, while criticized, also serve an important rhetorical function. Specifically, defenders of diagnostic labels point to the ways in which such a system allows medical professionals to learn from and utilize treatments that others have attempted for persons with similar, if not the same, diagnoses. Additionally, defenders of diagnostic labels cite the ways in which this categorization of illness can add to the body of medical knowledge and advance more effective treatments.
In the absence of a system that would allow for the effective treatment of individuals suffering from mental afflictions without the need for a diagnostic label, it becomes necessary to acknowledge the rhetorical force and material consequence of diagnostic labels by understanding the framework in which they are situated. In particular, recognizing the impossibility of a “theory-neutral” system of classification for mental illness, as well as acknowledging assumptions about mental illness reflected in different classification schemes employed in mental illness diagnostic systems such as the APA’s DSM can do much to mitigate any harmful consequences of categorizations that would unnecessarily pathologize difference.
1918: Statistical Manual for the Use of Institutions for the Insane, National Committee for Mental Hygiene
Before the advent of the classification system the United States uses to determine types of mental issues today, as represented in the Diagnostic and Statistical Manual of Mental Disorders, the Statistical Manual for the Use of Institutions for the Insane, first published in 1918, served as a tool for health practitioners to record and keep track of mental health abnormalities. The Statistical Manual was primarily concerned with the biological manifestations of mental distress and, as such, contained instructions for its users on “how to prepare uniform ‘statistical data cards for each patient, including mostly demographic information (age, ethnicity, occupations, etc.)’ along with some basic information about the presenting ‘psychosis.’”2 Although revised in 10 subsequent editions, the overall biological method identifying and organizing mental health issues persisted into the 1940s.
1946: Medical 203, Office of the Surgeon General, U.S. Army Service Forces
The widespread practice of classifying mental illness primarily by its biological effects was disrupted in 1946 by Medical 203, a medical bulletin of military nosology for the United States Army directed by psychoanalyst William Menninger, a World War II brigadier general and the head of psychiatry in the Office of the Surgeon General.3 Medical 203 was revolutionary for the ways in which it reframed thinking about mental health issues. Rather than primarily focusing on biological and behavioral deviations, Medical 203 attempted to identify and organize shared environmental and/or experiential precursors for various manifestations of mental distress. Some scholars speculate that this shift from focusing on the biological to the psychological causes of mental pathology was also, in part, motivated by World War II and the Holocaust and a subsequent desire to renounce anything German-related, including the “systematic study of psychopathology that had distinguished the German school.”4
1946: The Snake Pit (novel)
This shift in U.S. psychiatry from psychopathology to psychoanalysis is the context in which Mary Jane Ward’s The Snake Pit was received. Published in 1946 as a work of fiction, Ward nevertheless “admitted that The Snake Pit is based on personal experience” and as such was understood as an “important document in the education of the public […] call[ing] attention to the inadequacies of even [the U.S.’s] better institutions for the mentally ailing.”5
In The Snake Pit, the protagonist is Virginia Cunningham, a recently married woman who has unexpectedly found herself in an unfamiliar, frightening environment. Part of the fear Virginia experiences has to do with the gaps she has in her memory, specifically her inability to recall how or why she has come to be in such a place, or what the place itself even is. Gradually, Virginia is able to piece together where she is—a mental hospital—but returning to her “everyday” life with her husband (who himself seems, at times, unreal to Virginia) proves to be immensely difficult, as she deals with both the precipitating reasons for and the devastating effects of her hospitalization.
The Snake Pit provides a personal perspective of how shifting approaches to diagnosis—in particular, how diagnosis rooted in psychoanalytic understandings of mental health—impacted mental healthcare. The book’s only direct statement of what Virginia “has” comes well into the advancement of the plot, and is even then only revealed by Robert, Virginia’s husband, as opposed to her presumed “diagnoser,” her psychiatrist, Dr. Kik. Robert informs Virginia of her diagnosis during one of his visits to the hospital. Robert and Virginia have a picnic outside, spreading a blanket out on the grass. However, when Virginia becomes weepy about being separated from Robert because of the hospitalization, Robert stands up and declares, “‘I think we had better sit on a bench now. I’ll put the rug around you. You mustn’t catch a cold.’”6 In response, Virginia laments, “‘I wouldn’t mind having a cold, double pneumonia or something I could understand. […] What’s the matter with me? Is it a brain tumor?”7 Robert and Virginia’s subsequent exchange is as follows:
“God, no,” [Robert] said. “Whatever made you think that?”
“I don’t know,” Virginia said. “I just now thought of it.”
“It’s a nervous breakdown,” he said.
“That doesn’t sound so bad, does it?”
“It takes time, that’s all.”8
Why is Virginia only told of her diagnosis now, several months into her hospitalization and after nearly a dozen shock treatments?9 And why is the announcement of her diagnosis made so casually, almost as an aside, by her husband, and not by her doctor? Whether this is even her “official” diagnosis is anyone’s guess, as Virginia’s conversations with her doctor make no mention of what she is being treated for. I argue that such a cavalier attitude towards Virginia’s diagnosis is indicative of the general societal attitude toward diagnosis at the time, when the Statistical Manual for the Use of Institutions for the Insane and its biological explanations and categorizations of mental illness were being discarded for Medical 203, with its heavy emphasis on psychoanalysis. More important than Virginia’s diagnosis seems to be determining the root cause of her mental distress. For those who would believe the diagnostic process is an example of a way to determine the root cause of a mental illness, the minimization of Virginia’s diagnosis in her treatment can be understood as a devaluing of determining specific biological causes and subsequent medicinal responses in favor of identifying the “powerful emotional charges, usually attached to certain infantile and childhood developmental practices” that Virginia is repressing and thereby causing her mental distress.
1952: DSM-I
The next stage of the U.S. mental health diagnostic system is embodied in the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I), which was published in 1952. For the most part, there was little difference between the DSM-I and Medical 203, as both shared the conceptualization of mental health issues as rooted primarily in environmental causes. It was the DSM-I’s reiteration of a focus on psychoanalysis that led, in part, to the need for a subsequent edition. Shorter explains that “the psychoanalytic period began to be rung out with the introduction of effective new pharmaceutical agents.”10 In particular, the tricyclic antidepressant imipramine was launched in the United States in 1959, shifting approaches to mental healthcare back to biology.
1964: I Never Promised You a Rose Garden (novel)
It was within this context that Joanne Greenberg’s I Never Promised You a Rose Garden was published. First printed in 1964 under Greenberg’s pen name, Hannah Green, Rose Garden, like The Snake Pit, was semiautobiographical: “In real life, [Greenberg] was ‘Deborah’ [the protagonist of Rose Garden] and Dr. Fromm-Reichmann was ‘Dr. Fried’ [Deborah’s psychiatrist].”11
In Rose Garden, 16-year-old Deborah is institutionalized by her concerned parents following Deborah’s increasingly antisocial behavior and recent episode of self-harm. Deborah divides her time between reality and a world which exists in her mind, named “Yr.” What first began as a coping mechanism for the harshness she experiences in reality, however, is rapidly overwhelming Deborah and blocking her ability to interact in the “real world,” separate from Yr. Upon being hospitalized, Deborah is treated by the famous Dr. Fried, who takes Deborah on as her sole clinical case in the midst of a life of research, teaching, and lectures. Together, Dr. Fried and Deborah determine the significance of Yr for Deborah, in particular, the corresponding traumatic events in Deborah’s life that have caused her to create Yr’s elaborate infrastructure. Though Deborah does eventually recover, choosing reality over Yr, Greenberg resists providing an immediate, tidy moment of transformation, instead depicting the shades of grey often present in one’s quest towards mental health. Deborah’s journey towards becoming a functioning member of society is gradual, as she goes from being restricted to the ward, to the hospital grounds, to having town privileges, to living outside the hospital in the neighboring town while continuing to participate in therapy at the hospital. Deborah also suffers several setbacks requiring repeated hospitalizations but, importantly, such hospitalizations do not send Deborah back to square one. Instead, Deborah continues to learn and grow from her relapses, the overall effect of which is a nuanced portrayal of living and ultimately functioning with mental illness.
Given the waning popularity of psychoanalysis, the aftermath, in part, of a renewed interest in biological understandings of the workings of the mind, it is perhaps not surprising that, unlike The Snake Pit, the reader learns Deborah’s diagnosis fairly early on in the novel. Depicting Dr. Fried’s deliberation of whether to take on Deborah’s case, Greenberg introduces readers to Deborah’s formal diagnosis through the eyes of Deborah’s future psychiatrist, a point of view automatically imbued with authority by virtue of her credentials. That readers learn of Deborah’s diagnosis through Dr. Fried’s point of view also stands in stark contrast to how The Snake Pit’s protagonist’s diagnosis is declared, almost an aside by her husband as a “nervous breakdown.” In Rose Garden, readers learn of Deborah’s diagnosis when Dr. Fried “[sat] down with the [Deborah’s case] folder, opened it, and read it through.”12 Deborah’s initial diagnosis is schizophrenia, a conclusion that is partially explained by subsequent notes on the results of testing: “Tests show high (140–150) intelligence, but patterns disturbed by illness. Many questions interpreted and overpersonalized. Entire subjective reaction to interview and testing. Personality tests show typically schizophrenic pattern with compulsive and masochistic component.”13 This greater emphasis on testing and diagnosis in comparison to The Snake Pit thus reflects the evolution of the U.S. diagnostic system, as diagnosis moves to take center stage.
1968: DSM-II
In the late 1960s, despite the waning popularity of using psychoanalysis to understand and treat mental distress, the framework of DSM-II, published in 1968, varied little from DSM-I. The impetus for the second edition of the DSM, managed by Ernest Gruenberg, was the forthcoming eighth edition of the World Health Organization’s International Classification of Diseases (ICD), thus prompting a desire to coordinate the U.S. diagnostic system accordingly.14 Clegg notes, however, that “the account of this process, as well as DSM-II itself, makes it clear […] that the ICD was changed much more than was the DSM.”15
1980: DSM-III
The advent of the DSM-III in 1980 marked a “profound break” from the previous classification systems of DSM-I and DSM-II. Shorter comments that “the success of the new psychopharmacology had demonstrated that the brain was involved in illness after all and that biological perspectives were the field’s future.”16 In 1973, the APA commissioned a new edition of the DSM and asked Robert Spitzer, a biometrician at Columbia University, to direct the task force. The displacement of psychoanalysis with diagnoses entailed “explicit attempt[s] to remove all evidence of early psychodynamic explanations for disorders.”17 Of particular significance was the concept of diagnostic criteria, “the list of symptoms a patient would require in order to ‘get into’ the diagnosis.”18 With these diagnostic criteria came “the removal of explicitly theoretical descriptions,”19 which Clegg argues “left DSM-III without any clear basis for the diagnostic categories provided, other than the consensus of clinical judgment.”20 This “consensus of clinical judgment” was considered valid when compared with empirical evidence, reflecting “the growing belief that the diagnosis and treatment of mental disorders would have to be based on ‘data.’”21 With the DSM-III’s “medicalization” of psychiatric diagnoses came a reframing of the understanding of the very concept of mental illness itself. No longer necessarily caused by traumatic events of the past, mental illness was now presumed primarily the product of biological, anatomical issues.
1987: DSM-III-R
With this renewed focus on the biological causes of mental illness, the accuracy of diagnostic criteria came under scrutiny. In response to data from new studies that were inconsistent with the DSM-III’s diagnostic criteria, revisions on the third edition began in 1983, a short three years after the first publication of the third edition. Clegg observes that revisions in the DSM-III-R “included renaming and reorganizing some categories (perhaps the most significant of these changes being the addition of the new category ‘developmental disorders’), removing and adding a small number of categories, and changing some of the diagnostic criteria for various disorders.”22 The basic etiological perceptions of mental illness that saw such problems as stemming from biological matters, however, remained the same.
1993: Girl, Interrupted (novel)
Seven years after the publication of DSM-III-R and one year before the publication of DSM-IV, Girl, Interrupted, a memoir by Susanna Kaysen, was published in 1993. Although Girl, Interrupted recounts Kaysen’s experiences as a psychiatric inpatient in the late 1960s, specifically 1967–1969, the biological understandings of mental illness that were already under way during this period but not formally reflected in the DSM until the third edition are evident in Kaysen’s narrative of her hospitalization.
Unlike The Snake Pit or Rose Garden, Girl, Interrupted makes no claim to be fiction, instead categorized fully as a memoir and an unapologetic exposé of Kaysen’s reality as a psychiatric inpatient. Perhaps the most striking thing about Girl is the narrator’s (Kaysen’s) somewhat contentious relationship with the reader. Rather than treat the reader as a trusted confidant to whom she is disclosing a stigmatizing experience, Kaysen instead seems intent on demonstrating the reader’s complicity with the system that hospitalized her. Kaysen juxtaposes the actual reports by various mental health professionals obtained from her case file with her own recollections detailing how the reported events occurred, challenging readers to “pick a side” when her accounts and the case reports do not match up. Overshadowing Kaysen’s credibility is her official psychiatric diagnosis, which readers are confronted with on the very first page of Kaysen’s memoir, in “Image 1” from her “Case Record Folder”:
Diagnostic Impression at Admission
1.Psychoneurotic depressive reaction.
2.Personality pattern disturbance, mixed type. R/O Undifferentiated Schizophrenia […]
32A. Established Diagnosis, Mental Disorder
Borderline Personality.23
Kaysen’s diagnosis, as well as the diagnoses of her fellow patients, are conspicuously highlighted in her overall narration, mirroring the DSM’s conversion back to a biological comprehension of mental illness. Kaysen taints her narrative by making her diagnosis her readers’ first impression of her, then forces readers to acknowledge their biases towards her because of her diagnosis. Strategically, Kaysen does not challenge her diagnosis right away, but instead waits until the very end of her recollection, after she has been discharged from her nearly two-year psychiatric hospitalization. By this point in digesting her story, readers have become acquainted with Kaysen-as-mental-patient through several vignettes Kaysen provides of key moments during her stay. Readers may even feel a kind of connection with Kaysen and as a result experience similar feelings of confusion as to why Kaysen has been hospitalized. The moment of revelation comes when Kaysen finally reads her diagnosis, what she describes as the “charges” against her, 25 years after her hospitalization. And then, upon obtaining her diagnosis, Kaysen “had to locate a copy of the Diagnostic and Statistical Manual of Mental Disorders and look up Borderline Personality Disorder” to determine what the medical staff “really thought about [her].”24 After presenting the DSM-III-R’s word-for-word explanation of the diagnostic criteria for borderline personality disorder, Kaysen systematically annotates the diagnosis, comparing and contrasting the diagnostic criteria descriptors with her own state of mind during the period she was diagnosed. This endeavor ultimately produces an unsettling indictment against the validity of the diagnostic criteria for borderline personality disorder. Overall, the major role comprehending her diagnosis plays in Kaysen’s interpretation of her psychiatric inpatient hospitalization stands in stark contrast to both The Snake Pit and Rose Garden’s portrayals of their mental health care experiences. Kaysen’s emphasis on her diagnosis might thus be construed as a representation of the influence of the DSM’s transformed epistemology of mental illness.
1994: DSM-IV
In 1994, one year after Girl, Interrupted was published and seven years after the publication of its predecessor, the DSM-IV was published. Started the same year the DSM-III-R was published, “work on DSM-IV began in 1987 so that ‘development could be coordinated with the ongoing development of the 10th revision of the International Classification of Diseases’,”25 paralleling a similar motivation to create DSM-II. The creation of the DSM-IV was also reminiscent of the formation of DSM-II in that both, for the most part, “focused primarily on the reorganization of categories and criteria, rather than on any major theoretical shifts.”26 Appreciable changes that did occur were “a greater emphasis on culture-specific aspects of diagnosis—including new discussion of ‘cultural variation,’ ‘culture-bound syndromes,’ and ways of reporting ‘cultural context.’”27 Clegg points out that such inclusion of multicultural awareness assumed “the DSM-IV must not be culture specific but instead be applicable cross-culturally.”28 Furthermore, in addition to the inclusion of culture-specific aspects of diagnosis, the DSM-IV contains “an explicit endorsement of a bio-psycho-social model of disease—that is, a model in which the very notion of ‘mental’ disorder is ‘a reductionist anachronism of mind/body dualism’,” and the clarification that “most, if not all, mental disorders result from a complex and varying interplay of biological, psychological, and environmental risk factors.”29 However, changes to the revision process itself, intended to make the process “more systematic than in previous revisions”30 through “obtaining and reviewing empirical input through three distinct, but interactive, stages, namely, literature reviews, data reanalyses, and field trials”31 conducted by “those persons likely to be critical of the conclusions of the review,”32 cast doubt on the sincerity of the DSM-IV’s problematization of the concept of mental illness. Denying understandings of mental illness based on beliefs in mind-body dualism accomplishes little when evidence of a mind-body dualism train of thought is present in actions that equate reviewing empirical input with “more systematic” methods for understanding mental illness.
2015: DSM-5
Perhaps in an effort to temper any questions related to the validity of the DSM given the comparatively rapid rate of editions between DSM-III, DSM-III-R, and DSM-IV (seven years between each edition versus 12 years between the DSM-I, DSM-II, and DSM-III), the DSM-5 was published 21 years after its predecessor. Never one to beat around the bush, Shorter characterizes the DSM’s fifth edition as giving the impression of “an identical description of ‘depression’ […] crop[ping] up on every other page.”33 In doing so, Shorter seems to imply that the next, necessary evolution for psychiatric diagnosis will concern the concept of “depression.” Only time will tell.
Concluding Thoughts
I began this chapter speculating on the implications of understanding definitions of mental illness as primarily influenced by consensus rather than presumed knowledge about biological characteristics. In particular, I raised questions as to how comprehending mental illness as primarily defined by consensus might emphasize the influence of representations of mental illness in popular culture on overall concepts of what constitutes mental illness. I traced the evolution of the APA’s DSM as a way to evaluate changing conceptions of mental illness, comparing these conceptions with popular narrative accounts of those characterized as mentally ill. In general, correlating the DSM’s implications of what it means to be “mentally ill” with the specific labels given to authors of popular narratives on mental illness demonstrated the reciprocal relationship between scientific methodology and popular portrayals. Given the interdependency of psychiatric diagnosis with popular representations of mental illness, we would be wise to not dismiss popular representations out of hand, instead recognizing the valuable insight such narratives can provide on conceptualizations of mental illness.
Notes
1. Joshua W. Clegg, “Teaching about Mental Health and Illness through the History of the DSM,” History of Psychology 15, no. 4 (2012): 369.
2. Edward Shorter, “The History of Nosology and the Rise of the Diagnostic and Statistical Manual of Mental Disorders,” Dialogues in Clinical Neuroscience 17, no. 1 (2015): 61.
3. Shorter, 62.
4. Shorter, 62.
5. Granville Hicks, “P-N Fiction,” The English Journal 35, no. 10 (1946): 529.
6. Mary Jane Ward, The Snake Pit (New York: Random House, 1946), 102.
7. Ward, 102–103.
8. Ward, 103.
9. Ward, 103.
10. Shorter, 62.
11. David Dempsey, “Shrinks and the Shrunken in Modern Fiction: The Psychotherapist as Villain,” The Antioch Review 46, no. 4 (1988): 515.
12. Hannah Green, I Never Promised You a Rose Garden (New York: Holt, Rinehart and Winston, 1964), 18.
13. Green, 18–19.
14. Clegg, 365.
15. Clegg, 365–366.
16. Shorter, 63.
17. Clegg, 366.
18. Shorter, 65.
19. Clegg, 366.
20. Clegg, 366.
21. Clegg, 367.
22. Clegg, 367.
23. Susanna Kaysen, Girl, Interrupted (New York: Vintage Books, 1993), 1.
24. Kaysen, 150.
25. Clegg, 367.
26. Clegg, 367.
27. Clegg, 367.
28. Clegg, 367.
29. Clegg, 367.
30. Clegg, 367.
31. Clegg, 367.
32. Clegg, 367.
33. Shorter, 66.