If these difficulties have turned the DSM into a map without a territory, they’ve also, inadvertently, turned the mental health disciplines into a harbinger of what may be coming. In the absence of biological underpinnings, the architects of the DSM have increasingly turned to social justifications for their diagnoses. In fact, David Shaffer, a member of the work group considering changes to the disorders of the childhood section of the DSM-5, confessed that many of the children who’d qualify for a diagnosis new to DSM-5, disruptive mood dysregulation disorder, would also meet the criteria for a diagnosis that already existed: oppositional defiant disorder (ODD). “ODD had become tarnished,” he told me. “We couldn’t [use] it because it was a stigmatized name. It sounded like you were heading to be a crook.” (ODD is associated with sociopathy, although, according to Shaffer, there’s no scientific reason for this.) Additionally, it doesn’t command the dollars for research and treatment that the new disorder would. The committee, in other words, hadn’t discovered a new disease in nature, but rather had identified a new way to garner resources.
This may just seem like more cynicism, but it also points to a new definition of disease as a kind of suffering to which we decide to devote healthcare resources. To diagnose a condition as a medical disorder is to say that we will provide not just money, but other precious collectively held commodities, like sympathy, accommodation, and recognition. Biochemistry has served as a gatekeeper to that wealth, but there’s no reason that this needs to be the case, and as more conditions defy the model, we may have to find a new gatekeeper. For us mental health workers, this might be a happy outcome. We would no longer have to perform the diagnostic ritual or subscribe to explanations about imbalances in brain chemistry that we know are more myth than truth.
Not that the architects of the DSM-5, or any other DSM for that matter, are trying to initiate a new medical paradigm. They’re content to have it both ways, to claim that their diagnoses are rooted in science when it’s convenient to do so, and to claim social justifications when it suits their purposes—for instance, when a critic calls them out for not living up to their scientific pretensions. I don’t claim to know what the new gatekeeper would be, although I think it would have to have an explicit social dimension, one that included justice and fairness and other moral considerations normally held to be outside the bailiwick of medicine. It would have to give up the notion that only conditions with an identifiable biological cause are worthy of inclusion in the pantheon of disease. And it would have to include a definition of wellness and even of flourishing, and some agreement about which conditions that fall short of those qualities are deserving of our collective resources.
I have no idea how to achieve that, but I do know this: it’s already happening. One of the reasons that healthcare is consuming so much of our economic output is that other medical specialties have become better at what the APA has long been expert at: turning everyday troubles into illness, thereby gaining the keys to the insurance treasure chests. This isn’t exactly a scam perpetrated by the medical professions upon unsuspecting laypeople. Everyone has a stake in medicalizing suffering, in citing the latest fMRI experiment that proves this malady or that discontent is a genuine illness and reaping the corresponding rewards. But if the determination of which ailment deserves recognition were shaped by a more explicit account of how exactly it ails us, and what understanding of life makes it worthy of resources—an account that doesn’t hide behind specious claims to scientific certainty—we would all be free of the need to pay obeisance to the Great Gazoo. Abandoning diagnosis, and with it the bacteriological model, would no doubt induce confusion and maybe even chaos among us therapists, even as it reduced our income and status. But that’s often the price of honesty. And I would point out that if there is one profession suited to tolerating the difficulties of the truth, it’s ours.
Gary Greenberg, PhD, practices psychotherapy in Connecticut. His features and essays have appeared in many publications, including The New Yorker, The Nation, The New York Times, and Harper’s, where he’s a contributing editor. He’s also the author of four books, most recently The Book of Woe: The DSM and the Unmaking of Psychiatry. Contact: firstname.lastname@example.org.
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