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Notes -
Scott has posted a short article: You Don’t Want a Purely Biological, Apolitical Taxonomy of Mental Disorders.
Takeaway:
Some of Scott’s best work comes from the tension between categories-as-descriptive and categories-as-prescriptive, so I’m pleased to see him tackling this subject.
He has a couple potentially spicy sentences which have been interspersed with extra letters to ward off journalists. Legends say they aren’t able to remove text without an invitation, preventing context-removal. A handful of commenters immediately proceed to demonstrate why this will do nothing to keep some people from thinking Scott is literally Hitler, but perhaps it will keep them from publishing that? I’m not optimistic this will keep an opportunistic editor from stripping out letters with no direct relevance unless they’re legally required to put “…” in their place.
This post continues Scotts tradition of having jarringly different Ideas about what relationship categories have to truth than me. Scott is of the opinion that categories are just word games and that technocrats should be able to shift their borders are any time to maximize public utility. Being rhetorically gifted as he is he describes this position well. There is no natural force that decides whether whales are fish or some other category so we ought to define fish however this best serves us. It's a difficult position to assail. And yet...
I think firstly that there is such a thing as a natural category. These are things people can intuit about the territory, like canyons etched by the simple combined implications of gravity causing water to flow down hill and precipitation taking that water back uphill. This forms natural borders between things. Creatures capable of flight are an intuitively useful category, people use it for things like determining if a wall is going to keep that creature out. This kind of category cannot and will not bend to our word games. We may call it something different or create new categories that mostly but don't exactly match this category(maybe you'd like to include or exclude insects based on some further need) but the natural category remains.
What people want out of things like the DSM is for it to have as its first goal to reflect a natural category. And there are a few options here, I think whether we pick a natural category that includes or excludes homosexuality is an important debate that could go either way. But it should be about which category to pick, not whether we should shift between different categorical systems from line to line. Because if you're switching up the justifying for inclusion from one definition to the next the actually underlying category is just "Whatever I find expedient" which is a maximally bad fit for a document meant to describe reality. It makes a farse of the whole project and in the end it turns the DSM into just another locus of power in the culture war with no more legitimacy than a piece of paper that says "I do what I want".
I don't think that's true. The very premise is informing/influencing public policy. No matter how well a natural category cleaves reality at the joints, if it doesn't enshrine how we should react to the category, it's no good.
The actual underlying category should be akin to "phenomena that are mental AND have bad consequences to society." This isn't a natural, Platonic category because other people are involved. But it's also not line-to-line word games. "Pedophiles want to have sex with kids" fits both criteria. "Birds can fly over walls" only fits the second. "Homosexuals want to have gay sex" used to be viewed as fitting both. DSM authors say that it only fits the first, now, so it doesn't belong. It's a claim that the categorization was wrong, not that the category must be fluid.
Scott observes that a purely-biological-apolitical category does not fulfill the goals of the DSM authors, or really of the policymakers that would use the DSM. That's because it really only handles the first category. Leaving out the second one for being political/judgmental/whatever removes most of its utility.
I think you're confusing the use of the DSM with it's purpose. The DSM is supposed to reflect reality as its primary goal, it's written by unelected technocrats. To the degree that those technocrats are using the DSM to control industry they are usurping the role of the people. As a sanity check imagine if the APA was run by a right wing extremists group and they included leftist beliefs as a mental condition requiring involuntary hospitalization. It would certainly "fulfill the goals of the DSM authors" to include things like this, but I'd argue it is not the intended role of the DSM or its creators to be making politically salient points. They're doing a run around social consensus making and the political process itself and this would be very obvious to its defenders if it were their own ox being gored.
Sure, in a perfect scenario, the Best DSM (BDSM) measures the public impact of each response to each phenomenon. Then Congress enforces using the BDSM's best-impact response whenever insurance asks if something is covered. Popular opinion is preserved.
How should such a document be updated?
If social consensus changes, and people on aggregate believe that gay sex is okay, or that tiktok is a mental illness, or that the appropriate treatment for anxiety is mockery, that should be reflected in the BDSM. Scott might suggest a prediction market solution, or Congress could vote on each line item like a spending bill. In the interest of avoiding stalemates and weird corner cases of our full economy or democracy, we'd be incentivized to import a lot of those systems, too. For the BDSM to fully respect "the role of the people" it has to include a lot of overhead.
The solution we've used instead is delegation. As citizens are bound by judges with tenuous connections to any actual voters, insurance companies are bound by recognized experts. Yes, this leaves room for said experts to abuse their authority. So does every other practically implementable system! The fundamental principle of popular will remains even when diluted.
I understand believing the experts have exceeded their mandate on a specific issue. There is enough friction in the process that they really aren't held very accountable, and the cost to spin up an alternative is eye-wateringly high. Call it a market failure. The fact remains, though, that an effective DSM must include some level of value judgment. Without it, an apolitical/biological document cannot fulfill the delegated purpose.
Does the BDSM include a category for people who like to be tied up and called mean names?
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The apa isn't elected, they just produce a document that is currently being fed into the legitimate system. It's like there being an exposed config file for some important system that has been found and captured by a special interest, in time the hole will be patched. But we shouldn't pretend this is a legitimate purpose of the design, it was never intended for the DSM to be used as a political lever. To the extent it is being used as one it should be objected to.
This impulse people have, to recognize that there is a legitimate process for achieving some goal but instead using some hacked work around to subvert the process because it is easier than arguing your case convincingly to the public is just tyranny. That's all it is. Of course tyranny is expediant. I do not trust people who defend this impulse.
No, I think choosing whether or not homosexuality is a disorder is exactly the legitimate purpose, as intended, of the DSM.
The government wants a way to tell what insurance should and shouldn't pay for. That means it absolutely has to include judgment about what requires treatment. There can be no alternative that just describes symptoms.
Consensus, at some point, settled on this document produced by some technocrats. Now you're convinced that they've altered the deal, that the earlier version was privileged in some way that DSM-5 is not.
How do you propose such a document gets updated, if not by the authors coming together and saying "hmm yeah, that's a good pull request"?
You could have, you know, two different lists? You understand that what insurance has to pay for mean the rest of us are required to pay into it right? This is a tax benefits system with extra steps.
Yes, unelected authors. Not the people. Unelected beaurocrats vetted by the industry that brought us frontal lobe lobotomies and repressed memories. I am not impressed by this process.
So what process would impress your cynical self?
I get that you're unhappy about unelected bureaucrats raising your taxes. What's your solution?
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