The Ontological Error

The sound of a magnetic lock engaging on a psychiatric unit is final. It is the sharp, mechanical punctuation mark that separates a citizen with rights from a patient under the state’s control. In my 792 hours on the acute floor, I have heard that sound hundreds of times. Standing on the inside, observing the intake process, you realize that this click does not just represent a change in location; it represents a metaphysical shift where the person behind the door has been deemed to have lost their agency. California Senate Bill 331 proposes to change the rules for that lock by defining a "mental health disorder" in the Lanterman-Petris-Short Act as any condition listed in the current Diagnostic and Statistical Manual of Mental Disorders. To a politician, this looks like a housekeeping measure, but to a philosopher, it is a category error. It confuses the map for the territory, and in doing so, it threatens to turn the definition of human liberty over to a private committee that never intended to write a constitution.

The DSM is a masterpiece of descriptive utility that allows a doctor in Tokyo to communicate with a doctor in Toronto about "Schizophrenia," but strictly speaking, the DSM is nominalist rather than realist. It does not describe "natural kinds" that exist in nature like gold or tuberculosis, but rather "practical kinds," or clusters of symptoms that we have grouped together because they tend to appear together. The DSM is theory-neutral and does not care why you are depressed or look for the biological mechanism; it simply asks if you have five of these nine symptoms. SB 331 creates a terrifying equivalency by suggesting that if a person fits a descriptive cluster in a book, they have met the threshold for state intervention. Yet the DSM lists 265 conditions, including "Caffeine Withdrawal," "Restless Leg Syndrome," and "Adjustment Disorder." This expansion is a symptom of what critics call "Nosologomania," an obsession with classifying every variety of human distress as a distinct medical disorder. By tethering the legal definition of disorder to this ever-expanding catalog, the State is arguing that descriptions of distress are legally equivalent to states of incapacity. This is wrong because a checklist of behaviors is not the same thing as the loss of the self.

This is where my time on the floor collides with the philosophy of Thomas Fuchs. Fuchs argues that true mental illness is not just a software glitch or a wrong thought, but a fundamental disruption of "Being-in-the-world," a breakdown of the lived structure of time, space, and the body. I have seen this breakdown when a patient stands in the middle of the hallway, weeping not because they are "sad" but because they have lost the ability to synthesize time. For them, the future has collapsed into the present. They are not acting irrationally; they are inhabiting a different phenomenological reality where their agency is structurally impossible. That is the threshold for a loss of liberty. However, I also see patients who are poor, addicted, or eccentric. They might meet the DSM criteria for Substance Use Disorder or Antisocial Personality Disorder, but they have not lost their "Being-in-the-world." They are making rational, autonomous choices within a harsh environment. SB 331 ignores this distinction. By focusing on the Checklist rather than the Phenomenology, it creates a dragnet that allows the state to detain the "struggling subject" with the same force it uses for the "dissolved subject."

We rely on the DSM because psychiatry is currently a science of observation, not calculation. We are stuck in the era of tinkering rather than limit thinking. In other fields of medicine, we have objective limits. We do not detain someone for looking diabetic; we detain them because their blood glucose is 40 mg/dL and they are in a coma. We have a biomarker that proves the biological mechanism has failed. In psychiatry, we lack these biomarkers. We do not yet have the computational tools to measure the prediction error in a schizophrenic brain or the reward function in an addicted brain, so we cannot mathematically prove that a person’s internal control system is broken. Because we lack these objective answers, we must rely on subjective observation, and because subjective observation is flawed, our legal standard for removing freedom must remain incredibly high.

This philosophical vagueness has concrete consequences. When the legal definition of disorder is loose, it becomes a playground for profit. If we cannot objectively prove that a patient is sick via a biomarker, then the diagnosis relies entirely on the narrative provided by the facility. As we have seen recently, that narrative can be engineered for revenue. In September 2024, the New York Times published an investigation into one of the nation's largest psychiatric hospital chains, detailing a systematic business model where patients were lured in with free assessments and then trapped to maximize insurance payouts. The investigation found that staff were pressured to exaggerate symptoms to justify holding patients against their will, documenting quiet patients as "withdrawn" and polite patients as "combative" if they asked to leave. The goal was not clinical stabilization but to extend the stay until the insurance authorization ran out. One executive put it bluntly. "If there were insurance days left, that patient was going to be held." This is the danger of SB 331. By defining mental disorder as anything in the DSM, we are handing these corporations a massive expansion of their catchment area. If the law allows a facility to detain a citizen for Adjustment Disorder or Caffeine Withdrawal, we are effectively removing the legal guardrails that prevent false imprisonment, allowing the hospital to define the patient as inventory rather than as a human being. When the legal standard is subjective, the tie always goes to the house, and the house always wins.

Proponents of SB 331, including the California State Association of Psychiatrists, argue that we should trust clinicians and that excluding diagnoses from the law "freezes medical practice." They posit that a doctor would never detain someone for Caffeine Withdrawal unless they were truly gravely disabled, and they argue that the DSM represents the current gold standard of medical knowledge. But this view is over a decade out of date. In 2013, Dr. Thomas Insel, then-Director of the National Institute of Mental Health, famously declared that the NIMH would pivot away from using the DSM for research. His reasoning was a system engineer’s critique: the DSM has reliability, meaning doctors agree on the label, but lacks validity, meaning the label does not map to a biological reality. Dr. Insel wrote simply that "biology never read that book." Science writer John Horgan calls this phenomenon "Neurocentrism," the mistaken belief that we can explain all human behavior by looking at neurons. In his critique of the field, Horgan notes that despite decades of hype, neuroscience has failed to produce a single unifying theory of the mind or a single biomarker for mental illness. Yet SB 331 asks us to codify this uncertainty into law, treating the soft descriptions of the DSM with the same legal weight as the hard laws of physics. As Horgan warns, we are confusing the biological hardware with the social software, assuming that every problem of living is a problem of the brain.

If the primary funding body for psychiatric research in the United States does not trust the DSM to define biological reality, why is the State of California proposing to use it to define civil liberty? We are codifying a map that the cartographers have already admitted is flawed. Dr. Nassir Ghaemi puts a specific number on this failure. He notes that when the DSM-III was published in 1980, it introduced 292 diagnoses. Only 14 of them had valid scientific evidence. The other 278 were invented by committee consensus to unify the profession. Ghaemi argues that this means the document was 95.2% false at its inception. By codifying these political compromises into law, we are treating a trade union's negotiated treaty as if it were a biological fact. This isn't just about science; it is about survival. Ghaemi, a recent president of the Massachusetts Psychiatric Society, admitted that the DSM is the "economic engine" of the American Psychiatric Association, with royalties funding a significant portion of its budget. By mandating the DSM as the legal standard, the State is not just adopting a flawed map; it is subsidizing a private trade guild's revenue stream.

SB 331 tries to solve the difficulty of diagnosis by lowering the bar. Instead of waiting for science to provide objective limits, the law proposes we simply accept all subjective descriptions as valid grounds for detention. This creates a political danger, as the definition of who gets to be free is the most sacred duty of a democracy and should be defined by the Constitution and the People. The DSM is published by the American Psychiatric Association and revised by committees subject to academic trends, pharmaceutical lobbying, and cultural shifts. If California ties its civil liberty laws to the current edition of the DSM, it is outsourcing its sovereignty, effectively saying that if a private committee in Virginia decides next year that Prolonged Grief is a disorder, then a citizen in California can lose their freedom for grieving too long. We are confusing a billing manual for a Bill of Rights.

This isn't just a theoretical debate because the consequences are measured in lives. A July 2024 study by the Federal Reserve Bank of New York analyzed the causal effects of involuntary hospitalization. The findings were devastating. For "marginal" patients, the exact population SB 331 aims to capture, involuntary commitment nearly doubled the probability of dying by suicide or overdose in the months following release. The study found that the disruption to the patient’s social stability, such as housing and employment, outweighed any clinical benefit. By widening the net to catch these marginal cases, we are not saving them. We are statistically increasing their mortality. We are destroying their social stratification to treat a biological condition we haven't even validated.

On the floor, amidst the noise and the paper charts, the difference between struggle and sickness is palpable. The staff knows it, and the patients know it. We do not need a wider net; we need a more precise instrument. Until we have the computational tools to objectively prove that a mind has lost its capacity for agency, and until we can stratify the biological break from the social struggle, we must not allow a book of symptoms to become a weapon of the state. We must protect the distinction between the map and the territory, because once the lock clicks shut, the territory is the only thing that matters.