The Dream About Evidence

  1. The Dream About Evidence
  2. The DSM in Five Versions
  3. Critique of the DSM
  4. Humans Are Split Specimens
  5. Soldiers with PTSD
  6. What Now?

This is blog entry one of a series of six. You can access the other blog entries by clicking their titles above.

The review of the Association of Danish Psychologists, Psykolog Nyt, recently published an article by yours truly entitled “Drømmen om evidens.” Although the title literally means “The Dream About Evidence,” in English one would more readily write “Dreaming of Evidence.” Yet the two translations are not equivalent. “Dreaming of Evidence” is racier, it evokes action driven by manifest meaning, a WYSIWYG approach. In comparison “The Dream About Evidence” seems a bit awkward, though not in Danish where “Drømmen om evidens” is altogether fluent. Yet the very awkwardness of “The Dream About Evidence” encourages the reader to pause, to wonder whether there might be a latent meaning. Though we may wish for all meaning to be manifest, it is not always so. Hence, which to choose?

For those who read Danish, the article published in Psykolog Nyt is available on the site of the Association of Danish Psychologists at artikelarkiv and on the site Tutti-Nove, tracing the unconscious at Drømmen om evidens.

The challenge—here, one of translation—dovetails well with the subject of the article, centered as its title indicates on evidence, evidence as it relates to psychiatry. The expression evidence-based practices is a mantra these days and it is not always easy to discern what evidence, is evidence for. “Drømmen om evidens” tries to sort it out. The present series of blog entries integrate an English translation of the article as well as passages left out of the printed version.

The article begins by stating that psychiatry dreams of being able to make diagnoses that are as precise, scientific, and effective in the treatments they lead to as the most effective practices in somatic medicine. About sixty years ago, American psychiatrists introduced a diagnostic system to help make that dream come true. Ever since, it has been known under its acronym DSM (for Diagnostic and Statistical Manual of Mental Disorders). The DSM is deemed a catastrophe both from a scientific and from a human point of view: “The DSM contributes to the dehumanization of psychiatry while sacrificing science on the altar of pragmatism.”

One could stop here and repeat what a Russian psychiatrist said after a lecture in Saint Petersburg: “Who cares about the DSM, we never use it. I don’t, anyway.” Nonetheless, the DSM is now a major reference around the world. It influences the way both professionals and the lay handle mental illness. Reason enough to give the manual at least a modicum of critical thought.

To make its point, the Danish article enlists PTSD (Post Traumatic Stress Disorder), a diagnosis well-suited to illustrate difficulties with both the DSM and evidence.

Denmark has broadened the criteria used to diagnose and treat soldiers with PTSD. Until 2013, soldiers had to report their PTSD-symptoms no later than six months after their latest rotation in a combat zone to qualify for help. The problem was that a significant number of soldiers first reported their initial symptoms much later.

Asked about the problem on the radio in December 2012, the Danish health minister emphasized that the law had been penned with due regard for scientific evidence. Pressed to say more by the reporter, the minister remarked: “I’m not a physician and therefore not in a position to offer a solution.” The reporter kept pushing until the minister admitted that as a layperson she felt that we owed it to our soldiers to help them even when their initial symptoms started long after the legal 6-months limit. She declared that she would inquire whether science had another take on the matter.

If what precedes does not constitute scientific evidence, it is evidence that in real life science, politics, and subjectivity perpetually interact. Here, the minister’s views are at variance with current scientific opinion. Will she now be able to shop around for a scientific solution that better fits her needs, political and personal? Lo and behold, a few months later the wished-for evidence was available.

After yet another few months, a new version of the law passed. The new minister, like her predecessor, again emphasized on television that the revision of the law was based on the most recent scientific evidence. In striking contrast, the next news clip showed activists rejoicing over their success in having convinced politicians to change the law. Most got what they wanted, the minister got the appropriate scientific evidence and activists (as well as many others) were heard and the law changed.

References to science are everywhere. The Third Reich considered itself the most scientific social system that had ever existed and Abu Bakr al-Baghdadi is readily referred to by his followers as doctor of Islamic science. In our present perspective, science mostly refers to the natural sciences. They play the role of a beacon in a troubled sea of multitudinous spiritual movements and uncertain ideologies. During the past few centuries science has wrought extensive changes in our lives. Many have been improvements, enough in any case to motivate humans from time to time to subordinate their impressions, wishes, and fantasies the scientific discipline necessary to produce reliable and operant knowledge of the world. In recent decades, the concept of scientific evidence has experienced a vigorous revival. The movement first gained traction within the health professions as evidence-based medicine. The idea was to make it possible to better distinguish practices of unproven scientific validity from what really works in a treatment.

Yet even this has its drawbacks when references to science are used to paper over or avoid dealing with non-scientific agenda. The example above from Denmark is telling, though comparatively impeccant, at least to the extent that in the wielding of power it is not a common human instinct to submit political decision-making to the rationality of science. Even so, the present craze for evidence-based practices sheds fresh light on how the difficulties humans have managing the perpetual interplay between wishes, fantasies, and reality tend to give scientific endeavor a perverse twist. The problem is at the heart of psychiatry’s DSM, the famed and feared diagnostic manual. Even though PTSD is often considered unique among psychiatric diagnoses, in particular because of the important role etiology plays therein, it is nevertheless paradigmatic for the DSM, not only where the uses and misuses of diagnoses are concerned, but also with reference to science.

Next: The DSM in Five Versions. You can access the next blog entry by clicking here.

2014-11-07

2015 Jean-Christian Delay