Categories for Human Anguish? DSM 5: The New Inventory of Mental Illness

People who look for a consultation with a member of Princeton Family Institute engage in a relational process that is at the same time simple and profound. Parents who worry about a child, the partner in a couple who is confused and disappointed about the couple’s life together or an individual in distress or pain begin a conversation with a fellow human being who is listening. The partners in this unique exchange don’t know yet where the encounter is headed or whether it will provide sustenance. As the listener is responding to the other they attempt together to sort out a puzzling experience, to find a way to reduce personal distress, to live with a challenging dilemma, to calm down unbearable inner turbulence and anguish, or to get unstuck and move forward toward achievable goals.

At the end of their conversation the partners get involved in a transaction that seems to be incongruous to their personal encounter. The people who sought out the conversation (called “clients”) pay a fee to the one who was listening and attempting to be helpful (called “therapist”). In addition, the therapist summarizes the clients’ distress or confusion in a “diagnosis”.

This transaction has broad and significant consequences. It is contradictory to the evolving interpersonal relationship between the parties considering the intimate character of the conversation that now gets a commercial overlay and morphs into a professional interaction between people designated as clients and experts.

A client’s “diagnosis” opens up the possibility that she or he may be reimbursed by a health insurance company for the expenses of seeing a therapist. The involvement of medical insurance classifies the therapeutic conversation as a medical consultation or examination and assumes that the client has symptoms of a medical illness. In addition, if the therapist is a psychiatrist, i.e. a medical doctor, it is likely that the client will also be prescribed medication. If the psychotherapist is a psychologist or social worker or other mental health professional the client may be referred to a medical doctor for medication.

What started out as a private conversation that focused on a family’s or couple’s escalating conflicts or on an individual’s anguish or sense of being stuck in his or her life; or what began as a consultation prompted by overwhelming sadness, anger, or anxiety or mental or spiritual confusion ends up with “clients” being “diagnosed” with a medical, albeit mental, illness needing a “mental health” professional for treatment, invariably a hierarchical affiliation.

The encounter between “clients” (or “patients”) and “mental health providers” involves powerful societal institutions that determine many aspects of the meeting: professional organizations of psychiatrists, psychologists and social workers etc.; insurance companies (including Medicare and Medicaid), pharmaceutical corporations, academic and private research institutes, psychiatric hospitals and federal regulatory institutions such as the FDA and NIH. At stake are very significant financial and political interests that determine these institutions’ interactions with each other and with the people they are supposed to support, i.e. the consumers. And this is where an inventory of psychiatric illnesses in medical language is needed; without such an agreed upon catalog of illnesses professional communication would be very difficult, if not impossible.

I am writing this post for the PFI blog because the American Psychiatric Association published recently what is called DSM 5, the 5th edition of the official “Diagnostic and Statistical Manual” ($ 199, Hardcover). This “manual” describes and categorizes “mental illnesses,” less serious “mental disorders,” and other forms of human distress. On the basis of these categories “mental health” providers of any professional background arrive at a “diagnosis”; insurance companies then decide whether they reimburse their members for treatment by a “mental health” professional; and physicians, mainly psychiatrists, but often also pediatricians and primary care doctors write prescriptions for specific medications that fit a DSM 5 diagnostic label.

As a relationship centered therapist and “mental health” professional at Princeton Family Institute I would like to give you some clarifications about this veritable compendium of “disorders” and human “pathologies”, called DSM 5.

What you should know about the DSM 5:

• This manual was compiled by a small group of psychiatrists, who were appointed by the American Psychiatric Association (APA) or self-selected; many of them have financial ties with the pharmaceutical industry. There was no transparent, critical, and public decision process among psychiatric (and other) experts toward a scientific consensus as to what would be considered a “mental illness” or “mental disorder” or what human behavior or experience would constitute part of a “symptom” cluster that could be designated as a DSM 5 category and summarized in a “diagnosis”.

• Underlying the construction of the DSM 5 is the general assumption by the authors that “mental illnesses” are much like medical illnesses, such as diabetes, immune system disorders, heart disease, cancer, asthma, infections or brain disorders. These assumptions are scientifically unproven and lack external validity, i.e. they are not independently researched and verified according to the standards of scientific medical research. Brain and gene studies exist, but the resulting claims do not hold up under critical scientific examination. The promise of medical mental health research, “to be able to identify disorders using biological and genetic markers … remains disappointingly distant”, admits the chair of the DSM 5 task force, D. Kupfer, MD (Press Release No. 13-33, May 3, 2013 by the American Psychiatric Association).

• Instead, decisions about the system of psychiatric diagnostic categories often appear arbitrary; they are not based on biological tests, but on observations of people’s behavior that are then organized in collegial agreements among an elite group of DSM 5 authors. Diagnostic categories are influenced by the authors’ preferences and political, economic, or social considerations. (By the way, this is nothing new: The psychiatric establishment decided in 1973 to remove homosexuality from the list of “mental illnesses,” because that categorization had become socially unacceptable. You could say, in an instant literally thousands of people were cured of a “mental illness”!)

• From the start, the development of the DSM 5 faced significant scientific critique and vehement protests not only from authors of previous DSM editions (s. Frances, Allen (2013). Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. New York: HarperCollins), but, more importantly, from numerous national and international mental health organizations (s. for example, the statement by the American Family Therapy Academy: At this point there is a growing consensus among these organizations to construct an alternative to the DSM 5 with a strong focus on contextual, cultural, and relational aspects of human suffering.

• The DSM 5 is constructed on the basis of a narrow and reductionist view of the individual person. Our network of relationships (marital partners, family, friends, work context, neighborhood etc.), our identity as determined by gender, culture, social class, religion, and individual and collective history, our personal experiences and stories, or our sufferings, passions, and hopes remain largely outside of the deliberations of the DSM 5 authors.

• And – no surprise – the DSM 5 categories hardly reflect the often very difficult social and environmental contexts profoundly determining peoples’ lives, such as poverty, social oppression, insufficient housing, violence, racism and sexism, isolation and hunger, lack of job opportunities, visible and subtle forms of injustice, and individual and collective traumatization, particularly in early childhood. Of course, when you are poor and marginalized, you probably won’t even see a psychiatrist because you have no health insurance.

• The current version of the DSM is the outcome and culmination of the increasing medicalization of psychotherapy over the last decades. It also reflects the unrelenting tendencies in our society towards individualism and social alienation. Through clever marketing, medical providers and the public learned to accept that there were bio-physiological causes for “abnormal” behaviors and for “mental illnesses” (just as there are for physical illnesses), such as “chemical imbalances,” “serotonin deficiencies,” or malfunctioning genes, even though nobody has discovered these causes through replicable research and test protocols. Researchable hypotheses became models of brain functioning simply because available drugs seem to make people feel better.
From a holistic and humanistic point of view any activity, experience, behavior or emotion is, of course, intricately connected with and accompanied by bio-physiological processes in the human brain. But these are circular, non-lineal complex processes, i.e. not simple cause – effect phenomena that could be ameliorated by one-dimensional medical interventions.

• As the psychiatric categories and diagnoses were expanded, more people were prescribed “anti-depressant,” “anti-psychotic,” or “anti-anxiety” drugs that seemed to produce miraculous improvements. We know now that most of these pills over a long time hardly perform better than placebos and can have serious “side effects”. Yet, psychotropic drugs continue to bring enormous profits to the pharmaceutical industry and the involved medical researchers. This expansion of psychiatric drugs is one of the reasons a new edition of the DSM was needed.
P.S.: There is very little research into the effects of psychiatric medications on the human organism when they are taken over many years.

• While the pharmaceutical industry flourished, research in the efficacy of individual psychotherapy, of community psychiatry, of relational and contextual forms of psychotherapy with couples and families remains underfunded and much less glamorous; nevertheless, there is enough research evidence supporting the long term effectiveness of psychotherapy.

Here are some recommendations for you to consider in the post-DSM 5 era:

• If your medical practitioner or psychiatrist recommends psychiatric medication for you or your partner or one of your children as treatment for a “mental disorder,” consult a non-medical provider together with your partner or as a family and get a second opinion. Find a therapist who has a relational orientation, who takes a holistic view, and pays attention to the full array of contextual factors that need to be taken into account before anyone can arrive at a reliable assessment of the situation. Then make your decision.

• If you or a loved one is currently on medication prescribed by a psychiatrist, do not abruptly stop without consulting the psychiatrist. Taken for a relatively short time, psychiatric medication can alleviate the worst aspects of severe emotional anguish and mental confusion. At the same time, anyone who takes psychiatric medicines should also see a psychotherapist, preferably together with a partner or as a family (if the medication is for a child or adolescent).

• Any human experience, any puzzling or “abnormal” behavior or disturbed thinking for which drugs are prescribed these days deserves to be examined as to its individual and relational meaning and possible connections with traumatic life events or current severe stresses. The meaning of what you experience in yourself or in relationship with others may not be obvious. Too often, attempts of an individual or a couple or family to cope with difficult dilemmas, with inner or relational conflicts, with new stress or an old traumatic history, with social injustices or with losses and fears that appear overwhelming can lead to psychiatric “diagnoses” that obscure the more profound and holistic meaning of the “symptoms” presented. Psychiatric diagnoses often undermine the tremendous inner strengths people have that are not immediately evident.

• Trust your own experience! Be mindful of your body and listen to your inner self. In addition, enter into conversations with a dialogue partner who can ask empathic, non-judgmental questions. A life partner, a family member, a good friend can fulfill that role once you activate the relationship with that already familiar person. Or you (and your partner or your family) can choose a therapist with whom you form a new relationship specific for the purpose of an unencumbered exploration of what may be hidden from view and the source of pain. Hopefully, in these conversations you, your spouse, your family will find yourself on solid ground to examine what is happening to you or to the others around you. With or without the (temporary) support of medication individuals, couples, and families can begin to recover and heal in these “therapeutic” conversations.

Norbert A. Wetzel

psychotherapy, psychiatry, dsm 5, medication, mental illness