On the futility of psychiatric diagnostic manuals (DSMs) and the return of personal agency

This article critiques the most recent version of the American Psychiatric Association's (1994) Diagnostic and Statistical Manual (DSM-IV). After pointing to the procedures employed in constructing the Manual, I note that unreliability of diagnosis is still a major problem and, more important, little attention has been paid to validity. Based on the mechanistic Kraepelinian model, the Manual contributes to the increasing medicalization of distress and directs clinicians to search for causes of unwanted behavior in biochemical anomalies. The person as agent is not part of the DSM diagnostic program. As an alternative to the DSM-IV, I propose a contextualist approach to understanding unwanted conduct. The person is treated as an agent who employs strategic actions to maintain a self-narrative. Strategic actions that fail to influence relevant others to supply warrants of social validation become the targets of clinical interventions.