Book Review: The Diagnosis and Stigma of Schizophrenia

The Diagnosis and Stigma of Schizophrenia

C.E. Harman. (2003). Brookings: Old Court Press.

The Diagnosis and Stigma of Schizophrenia, by Charles E. Harman, is the third book in a trilogy which looks critically at government, law, and psychiatry. Harman offers a rather informative history of the diagnosis of severe mental illness and how the stigmas associated with it have evolved. One strength of this historical survey is its placement of the stigma of mental illness within larger contexts of multiple forms of social prejudice and oppression. It traces various forms of prejudice and stigma in the United States and Europe back through their histories of racial and ethnic oppression and argues convincingly that these histories should be understood as a context in which the pioneers of psychiatry created the diagnosis of both schizophrenia and mental illness in general.

One of the more compelling historical arguments in this book describes the relationships between the eugenics movements of the early twentieth century in both Europe and the United states, Fascism in Europe, and early theories about the nature of schizophrenia. Harman depicts the profound power and control given to psychiatrists over the status of people with severe mental illness in the early twentieth century. Included is a lengthy and rather scathing portrayal of Kraepelin as a scientist who easily set aside scientific scrutiny when empirical evidence was not in line with his personal theories. Harman argues that despite the gradual improvements throughout the twentieth century in the treatment of people with severe mental illness, the nature of DSM diagnostic theory and procedure is still today so heavily indebted to the influence of psychiatrists from the first half of the twentieth century, that it cannot help but continue to dehumanize people with severe mental illness, distort their experiences, and have negative social consequences for them. He claims that while we are no longer in a situation where a diagnosis of schizophrenia can have the power to force inhumanities such as sterilization or euthanasia and the rights of patients with severe mental illness progressively receive more intention, we are still limited to a classification system based on the work of men who had the social power to determine whether or not, or to what degree, a patient had value as a human being. Harman argues that that the influence of this history continues exert itself on how both psychiatry and society as a whole continue to perpetuate the stigmatization of people with mental illness.

Harman also surveys the history of the search to improve the lives of people with severe mental illness and their places in society. This is portrayed in a rather optimistic light, focusing on the human ability to make significant progress in this area. Included are movements which have tried to challenge how schizophrenia is understood as an illness while at the same time not recognizing the relevance of understanding it as a construct within social and cultural contexts.

In response to his challenges made to mainstream psychiatry, Harman offers possible alternatives to DSM-style diagnosis. One alternative proposed is to develop psychometric computer programs which would be able to give a person a profile showing similarities with other people who responded similarly, rather than receiving a stigmatizing label. Cluster analysis could be used to create "diagnoses" which could focus on giving consumers insight into what sorts of other people they are like, rather than giving them a word which they may not understand and which sets them at odds with society.

Clinicians influenced by existential or humanistic paradigms often express criticism toward the abstraction of human experience through statistical analysis, and with good reason. It may therefore seem odd that an author, who criticizes the history of mental illness diagnosis in a fashion similar to that of these paradigms, would posit statistical analysis as an alternative to personal diagnosis provided by an actual human being. Some humanistic and existential clinicians who do use DSM-style diagnosis may claim to address the limitations of the manuals by incorporating into their diagnoses more existentially relevant interpretations based on the theories of various paradigms. Harman presents his alternative in a such a way as to draw this practice into question by repeating his fundamental question "Who is to judge others?" The existential clinician who is skilled in bringing into the diagnosis relevant insights from the patient's lived experience may ultimately be still be coming from the same diagnostic standpoint as the clinician who relies purely on strict DSM criteria: one person granted by society the power to make a subjective decision about the social status of another human being, based on the so-called "consensus of experts." Harman does not suggest that computers replace clinicians or that statistical analysis can replace the insights and support offered by real people. Rather, his suggestion is directed specifically at the area of diagnosis, and essentially would require a dethroning of the clinician's power to produce and perpetuate stigma. If in fact the DSM itself is proposed to be founded on objective, statistically significant, empirical research, there should be no objection by its supporters to the notion of using technology to remove from the process the subjective interpretation of the clinician. Harman is not saying that the subjective opinions of clinicians are not relevant. In fact he suggests that it is the personal determination and compassion of many clinicians that has allowed them to challenge the status quo and attempt to improve lives of people with severe mental illness. What he is claiming is that clinicians should not have the power to define other people for all of society. The cluster analysis alternative could offer clinicians orienting direction and background for treatment, which is often the way in which existential and humanistic clinicians use the DSM now. The major difference would be that a diagnosis would be a computer-generated list of descriptions about "What the patient is like," rather than a label influenced by subjective human judgment that tells society "What the person is."

While clinicians may be either concerned or dismissive toward the possibility of alternative forms of diagnosis, Harman argues that any such changes are not likely to originate from the top down. Cultural trends of "consumer movements" in both the United States and in Europe may indicate that more and more people are starting to treat the mental health industry as less of a government endorsed cultural authority and more as a consumer industry, where the personally determined needs of those paying for services tend to be seen as more relevant than a consensus of experts. While these movements are still in their infancy, their popularity seems to be growing and reflects a widespread dissatisfaction with the current state of mental health services. It may be the case in the coming years that interest in such movements may reach a critical mass and demand that the stigmas associated with mental illness and the power given to clinicians be addressed in a matter relevant to those paying for treatment.

The possibility of clinicians competitively bending their practices to capitalize on changing market trends of a mental health economy will probably, and hopefully, be a frightening thought for many clinicians. Some will argue that such a situation and its negative consequences are already evident today. Nonetheless, Harman argues, it should be recognized by all clinicians that interest in these consumer groups represent the demand of a growing number of people that the mental health profession fully recognize and address the reality of the stigma and oppression that very often results from the power that a small group of individuals has over many others. If this is the case, the relevance of Harman's book is rather timely. It is highly recommended as informative for consumers and clinicians, both for those who are already deeply concerned over the stigma of severe mental illness, as well as for those who may be skeptical about its relevance and wish to learn more about it from a historical perspective.

Brian Uhlin

Brian Uhlin