The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Gary Greenberg
EM: Most of our readers will only have a glancing understanding of what the DSM is or why it’s so important as part of the current, dominant mental health paradigm of “diagnosing and treating mental disorders.” What is the DSM?
GG: The DSM, the Diagnostic and Statistical Manual of Mental Disorders, is the American Psychiatric Association's compendium of psychiatric diagnoses. It lays out, dictionary-like, all the mental illnesses recognized by the APA, and the criteria by which they are known. Designed to provide a universal language for psychiatry, it is used by clinicians and researchers around the world. As a result of its predominance, the DSM's categories and concepts frame the discussion, within the mental health professions and in the general public, of mental suffering. When a person in casual conversation describes herself as "totally OCD" or when a teacher suggests to parents that they have their child evaluated for ADHD, they are, generally without knowing it, drawing on the DSM's categories.
EM: What do you see as the flaws regarding the DSM?
GG: The DSM is very good at what it explicitly sets out to be good at, which is systematically describing the ways people suffer. A clinician tells another clinician that a patient has paranoid schizophrenia; assuming the diagnosis is made carefully, and assuming the second clinician is familiar with the diagnosis, then it is likely that useful information has been transmitted. Similarly, if a researcher publishes a paper about bipolar disorder, then it is safe to assume that he or she is writing about the same collection of symptoms that are the subject of other papers on bipolar disorder.
The DSM, in other words, has scientific reliability (although not as much as is generally thought, and less in the DSM-5 than in recent editions). But it does not have scientific validity. The categories in it are constructs; there is no evidence that, for example, major depressive disorder exists in the same way that, say, diabetes or cancer exist. The disorders are purely heuristic. This aspect of the DSM, which is acknowledged by the APA, becomes a flaw when the diagnoses are reified and people--clinicians and the public alike--begin to think of them as real. At that point, what is, at best, an anthropology of mental suffering becomes a pseudoscience.
This outcome is not accidental, or the result of ignorance. Since the third edition came out in 1980, its implicit purpose has been to provide scientific respectability to psychiatry, which has long suffered from "physics envy." The DSM-III adopted a scientific rhetoric, but without providing an actual scientific basis for its rendering of the world of mental illness. This move succeeded in restoring the credibility of psychiatry, but the authority it derives as a result is not really backed up by the kind of science that backs up, say, cancer research. Psychiatry's reach, as embodied in the DSM, exceeds its grasp.
EM: You write about “manufacturing depression.” What do you mean by that phrase and what are you implying by that phrase?
GG: The idea that depression is an illness--the major depressive disorder of the DSM--is a good example of what is wrong with the DSM. To call the heterogeneous experience of depression a disease is to make a set of claims about the nature and causes of unhappiness that has profound implications. The diagnosis is the gateway not only to taking antidepressants or other treatments for a "disease"; it is also the gateway to a certain kind of understanding of oneself and one's suffering. If you are told by a person with authority that you have a biochemical imbalance that is causing your depression, you are also being told, among other things, that your suffering is not the result of anything in the external world, that it is incumbent on you to heal yourself, and that your mind is no more or less than what your brain does.
This very consequential idea is not the result of a scientific discovery. Rather, it is a historical development, the convergence of a number of political, social, and economic forces. To say it is manufactured is not to say that it is a conspiracy, but instead to give people a way of understanding this very powerful idea, to put it in context so that when and if you get depressed, you can decide to what extent you want to buy it.
EM: If you could snap your fingers and change the current mental health system and/or overthrow the current mental disorder paradigm, what would you change and/or overthrow?
GG: I think therapists should stop pretending that we are treating illnesses, starting with decoupling ourselves from the DSM. The vast majority of therapists use the DSM in the most cynical way--as a means to getting paid. Ask yourself: if there wasn't an insurance company involved would you make a diagnosis? And once you've made the diagnosis, of what value is it in the actual treatment?
Using the DSM means that many if not most therapeutic encounters start with a lie--that the client has a mental illness. Not that I think we're obligated to be truthful with insurance companies, but this is more than a little ironic: an encounter that is supposed to be about honesty has dishonesty at its foundation. More to the point, however, starting off with a diagnosis, even one that is disavowed, cannot help but affect the therapeutic relationship, even if in very subtle ways.
So I think we should at the very least level with our clients from the beginning. Tell them you are diagnosing them with a mental illness. Explain why, and which one, and remind them that this diagnosis will follow them throughout their lives. Give them the option of not getting diagnosed. Of course, this means that they will have to pay out-of-pocket, which in turn means that you will probably get paid substantially less money. So you will both have to decide what therapy is worth to you.
Pulling on this thread may begin to unravel the tapestry of psychotherapy as we practice it now. That might not be a bad thing. It might take us out from under the medical paradigm, where we don't exactly belong. But in return, it might place us on a more solid foundation to do what many of us got into the business to do--to help people find the meaning and value in their lives, which is a different endeavor from helping them cure their mental illnesses.
EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?
GG: What I and many of my loved ones have done: seek help from someone whom you trust. And expect that help to come in the form of an honest encounter with yourself and the decisions you have made and must now make. No doubt, mental suffering comes from some kind of brain process; without the brain there is surely no mind to suffer. But it is often also (and to me more importantly) an indication that some part of your life is in need of examination. Symptoms are the way we have of calling ourselves to account. So think of distress as a way of tapping yourself on the shoulder, and use it to figure out what you are trying to say.
Gary Greenberg practices psychotherapy in Connecticut. He is a contributing editor for Harper's Magazine, and the author of four books, including Manufacturing Depression: The Secret History of a Modern Disease and The Book of Woe: The DSM and the Unmaking of Psychiatry. More at www.garygreenbergonline.com
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at email@example.com, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
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