The Cult of DSM

A client comes to see you. Let’s call him Fred. He tells you he has a dream job, one in which he’s mostly left alone to do what he loves. But there’s a hitch: in order to get paid (which he does, and well), he has to stand in front of a video camera once every hour, raise his left hand, stand on his right foot, and say, “I declare obeisance to the Great Gazoo.” He tells you that he knows the Great Gazoo doesn’t exist. He tells you that he, and all his coworkers, think the ritual is stupid and undignified, and he worries that someday the digital video archive of his hypocrisy will come back to haunt him. He also tells you that he’s appalled at himself, at the ease with which he engages in a pointless exercise purely for the sake of money and then drives awareness of his bad faith out of his mind. “Isn’t this how the worst acts are committed—when people still their consciences to get on with the business of daily living?” he asks himself (and you).

At first, the complaint seems rich, intriguing, even piquant. All the tortured ambivalences of a postmodern life seem captured in his hourly degradation at work. It provides fodder for conversation about his expectation that the world will conform to his needs, his disappointment at finding out that it won’t, the difficulties imposed by his quest for integrity. It gives rise to meaningful talk about the fear of poverty, the cruelties of capitalism, the needless difficulty of our economic lives. You discuss alternatives with him: finding a different job, refusing to participate in the ritual, organizing a protest with his coworkers. Sometimes he leaves your office determined never again to declare allegiance to the Great Gazoo, only to come back a week later, sheepish and forlorn, with a story about how he just couldn’t follow through.

After months of this, both of you are becoming impatient. Fred’s stasis now strikes him as failure and cowardice, which means he’s unhappier than when he began. For you, the intriguing conversations have become boring, the once piquant complaint, a banal whine. You’re ready to throw in the towel—or, as therapists call it, to reframe the discussion. Now, his need for integrity and his wish for the world to reflect his values are unmasked as narcissism, his disappointment and resistance to the professional ritual as the childish shame and rage that shatter the mirror when it fails to flatter. The new therapeutic task is to push the ritual into the background, to accept it as part of reality—like death and taxes and the inevitability of loss—in short, to grow up. And, you tell yourself, the ritual isn’t such a bad thing: it doesn’t harm anyone and only takes about 30 seconds, and, besides, its crosslaterality is probably good for Fred’s brain. You and Fred agree on a new goal: to stop worrying and learn to love the Great Gazoo.

You’re feeling pretty good about this outcome as he leaves your office and you sit down to make your session notes. To sign the note, however, you have to provide a diagnosis. You’ll probably use the same one you entered when you first saw Fred: 309.28 (adjustment disorder with mixed emotional features), or perhaps 300.02 (generalized anxiety disorder), or any of the other of the handful of diagnoses whose codes you’ve memorized. You probably think this is an innocuous enough diagnosis, not likely to impede his access to health or life insurance or to become an issue should he decide to run for elected office or seek a security clearance.

And it is, except for one thing, or more accurately, three things. First, you know that the only reason you’re entering that diagnosis is that Fred’s insurer isn’t going to pay you to sit around with Fred and figure out the meaning of his life, at least not if that’s what you say you’re doing. It’ll pay for therapy only if he has a medical disorder, which is why you shelled out a hundred bucks for your copy of the Diagnostic and Statistical Manual (DSM) in the first place.

Second, you know, or at least you should, that there’s no such thing as adjustment disorder or generalized anxiety disorder or any of the other 200 or so diagnoses in the DSM—at least not in the same way that there’s such a thing as strep throat or diabetes. Although it’s debatable whether the DSM provides an accurate anthropology of suffering, a working catalog of our common miseries, its status as scientific medicine isn’t in doubt. As Thomas Insel, head of the National Institute of Mental Health, acknowledged last year—by way of explaining why his agency is going to stop requiring researchers to tie their work to DSM diagnoses—the DSM’s diagnostic categories are constructs that have no validity. There are no blood tests or lab studies or x-rays that can confirm the reality of something like generalized anxiety disorder or attention deficit hyperactivity disorder. At its best, the book provides a set of useful constructs that make it possible for one clinician to have a good idea of what another one means when she says that a particular patient has a particular disorder.

Third, you know that your diagnosis isn’t helping you figure out how to treat Fred. It’s not really for his benefit (other than that it helps him pay for it), and ultimately, it’s not even for your benefit, but for the benefit of a mental healthcare delivery system that increasingly demands a kind of accountability that has little to do with mental health.

If you’ve ever felt guilty about this, you might take comfort in the fact that after a couple of years spent talking to virtually every prominent psychiatric nosologist in the country about this question, I can report that finding someone who will say that the DSM is of clinical value, let alone that it’s an accurate compendium of mental disorders, is like walking around Athens with a lamp lit in the daylight looking for an honest man. I once asked a former president of the American Psychiatric Association (APA) how he used the DSM in his practice. “I recently had a patient I had to diagnose in order to bill,” he told me, “so I turned to the DSM and came up with obsessive compulsive disorder,” he said.

“Did this change the way you treated her?” I asked.

“No,” he replied.

“So what was its value, would you say?”

“I got paid.”

For everyone, from lunchbucket therapists like me to the nation’s psychiatrist-in-chief, making a DSM diagnosis is the ritual you have to perform to get the system to work. It may not be quite as silly as Fred’s ritual at work, at least not on the surface, but we therapists have responded to it just as Fred did (which makes sense, since I crafted Fred to serve my interests here, just as the APA crafted a book of diagnoses to serve its interests). Like Fred, we’ve engaged in all sorts of evasions and subterfuges to avoid the glaring and simple truth: the DSM is our Great Gazoo. Invoke it, and the cash rolls in.

Most of us have groused about the absurdity of this situation—that the cornerstone of a practice presumably devoted to ferreting out and facing the truth is, in fact, a fiction. Some of us have struggled with the irony, resolved to do something about it, and maybe even engaged in some organized protest of it. But it’s easy to tire of this, to decide that the neurosis is in us, that resistance is no more than a childish insistence on having things our way; and besides, there are mortgages to pay and children to educate and retirement plans to fund, so we stand on our right foot, raise our left hand, and declare our obeisance. It’s possible, however, that the time has come to stop doing that, to take our dismay seriously and to turn it into something other than a bitter complaint.

The philosopher who carried a lamp around Athens was known as Diogenes the Cynic. As much fun as cynicism can be, what with its opportunities for black humor and ironic detachment, we can do better. The cynical stance is a victim’s stance, a weary shrug of the shoulders at conditions beyond our control. But unlike mortality and perfidy, the DSM isn’t part of nature, human or otherwise. Neither did it land on us from outer space. It’s tightly woven into the history—and the allure—of our profession. As with many troubling behaviors, understanding that history might help us understand how we arrived in this dark place, and point us in a direction out of it.

Swallowed by Medicine

The origins of our DSM discontent syndrome can be found in a tawdry primal scene. In 1925, a woman named Caroline Newton applied for membership to the New York Psychoanalytic Society. She was by all accounts qualified; she’d been in treatment with Freud in Vienna, was translating Otto Rank’s psychoanalytic writing, and was a member of the International Psychoanalytic Association. Nonetheless, the society refused to admit her and objected to her opening a practice as a psychoanalyst on the grounds that she wasn’t a physician. At first, she was given guest privileges instead, but later, the society voted to “restrict attendance of our meetings to members of the [medical] profession,” and ultimately it announced its “unanimous decision that it is opposed to laymen practicing therapeutic psychoanalytic therapy.” A year later, it voted to make the restriction official. Newton was sent into professional exile, as were all the other lay analysts then and in the future. Henceforth, psychoanalysis in the United States could be practiced only by medical doctors.

Freud was bitterly opposed to this move. Although a doctor himself, he thought medical education was exactly the wrong preparation for being an analyst. “It burdens [a physician] with too much of which he can never make use,” he wrote, like “anatomy, biology, and the study of evolution.” It subjects him or her to the “temptation to flirt with endocrinology and the autonomous nervous system.” Left to physicians alone, Freud feared, psychoanalysis would become just another “specialized branch of medicine, like radiology.”

“As long as I live,” Freud vowed, “I shall balk at having psychoanalysis swallowed by medicine.”

But that’s exactly what the physicians of the New York Psychoanalytic Society wanted to do. They and their colleagues had been competing with neurologists for the business of the worried well for a decade or so, and psychoanalysis seemed to offer them a technique that the neurologists, with their rest cures, electrical stimulators, and special diets, didn’t have. On the other hand, those treatments had the cachet of scientific medicine. Focusing on bodily mechanisms, they capitalized on the increased confidence of the American public in medicine that followed upon the seminal discoveries of the previous 50 years—viruses and bacteria as the cause of infection, lack of insulin as the culprit in diabetes, and so forth. Psychoanalysis was hard-pressed to match this standard, and psychiatrists, who’d long been worried about their status in medicine, saw in lay analysts a threat to their credibility. As A. A. Brill, founder of the New York Psychoanalytic Society and chief architect of the exile of the lay analysts, put it, the profession had “attracted many charlatans and quacks who find in it a medium for the exploitation of the ignorant classes.” Claiming the franchise only for themselves and eliminating people like Newton, they sought to reassure the public (and themselves) that the talking cure was a legitimate medical practice.

For many years, the union of psychoanalysis and medicine was a successful one. Doctors received the status and money accorded to healthcare professionals. They billed insurance companies to treat conditions like depressive reaction and adult situational reaction, and insurers paid without demanding prior authorizations or treatment reports. And starting in the 1960s, psychologists and other mental health professionals found their way onto the gravy train—not by wresting psychotherapy out of the hands of the medical doctors, but by fashioning themselves as medical professionals.

But this golden age of psychotherapy began to wane in the late 1960s, when the mental health industry, and psychiatry in particular, suffered a series of embarrassments, all of them having to do with diagnosis. First, a number of studies showed that doctors disagreed more often than not about what diagnosis a particular patient warranted. Specifically, it seemed British doctors were much likelier to diagnose a psychotic patient with manic depression (as it was known at the time) than schizophrenia, while the reverse was true in the United States. Then in 1972, David Rosenhan scandalized the profession when he sent graduate students into various emergency rooms complaining of no more than hearing the word “thud” in their heads. All were diagnosed with schizophrenia and hospitalized, and some were released only when their colleagues went to the hospital to spring them.

The following year, after repeated high-profile protests, the members of the APA voted to delete homosexuality from the DSM, signaling the first time in history that a disease was eliminated at the ballot box. It was the right thing to do, but it came at a huge cost, for it indicated that psychiatrists had failed to agree on what constituted a mental illness, which mental illnesses existed, and how to recognize them.

As far back as 1880, psychiatrists had worried among themselves about the effects of diagnostic confusion on their credibility. The APA’s diagnostic manuals—which first appeared in 1917; the first DSM was published in 1952—were, in part, an attempt to address their anxiety. But this time around, the consternation wasn’t only in-house. Insurance companies and government bureaucrats had taken notice of the chaos and were threatening to cut off funding of treatment and research. In 1975, a Blue Cross executive told the Psychiatric News, the APA’s in-house paper, that his company was reducing its benefits for mental health treatment because “compared to other types of services, there is less clarity and uniformity of terminology concerning mental diagnoses.” And in 1978, a presidential commission charged with setting priorities for healthcare funding concluded that “documenting the total number of people who have mental health problems . . . is difficult not only because opinions vary on how mental health and mental illness should be defined, but also because the available data are often inadequate or misleading.”

The message was clear. As Robert Spitzer, the man to whom the APA turned to solve the problem, told me, “Psychiatry was regarded as bogus. I knew it would be better off if it was accepted as a medical discipline.” If therapists wanted continued access to healthcare resources, they’d have to prove that they deserved them. Spitzer spearheaded the effort to create the DSM-III, the first of the DSMs to define mental disorders by criteria checklists. The book was four times as long as the DSM-II and featured twice as many diagnoses. It provided labels for virtually every kind of suffering that clinicians might encounter, and because it defined disorders purely in terms of symptoms, with no external validation, there was nothing to stop a clinician from providing a diagnosis that didn’t really fit the patient. A doctor who diagnoses strep throat on the basis of a sore throat and fever, but without a throat culture, is practicing bad medicine; but a doctor who diagnoses major depression on the basis of sadness and four of the other eight symptoms is, in the post-DSM-III age, simply practicing psychiatry.

The DSM-III was a huge success. Enormous numbers of copies were sold. (The APA claims not to have sales figures for it, but DSM-IV reaped in excess of $100 million.) As important, it reaffirmed the credibility of psychiatric diagnosis. It’s not an exaggeration to say that Spitzer saved psychiatry, and with it, the rest of the mental health professions. He understands exactly how the book achieved this: “If you open it up,” he said, “it looks like they must know something.”

Commanding scientific authority without actually being scientific, the book functions as a mythology, a powerful way of understanding the world of mental illness. But that power is not so much explanatory, or even descriptive, as it is social and economic. Like it or not, the DSM gives us our authority, and not only insofar as it secures us a place at the healthcare finance trough. With its imprimatur, we’re more like brain surgeons and cardiologists than ministers or rabbis. We’re not just people with opinions drawn from our ideologies about what ails our clients; we’re experts with scientific knowledge that gives us the power to pronounce the truth about the Jared Loughners and Adam Lanzas, about traumatized veterans and raving street people, about our fractured families and our shattered love lives.

The modern DSM has fulfilled Brill’s dream. It’s provided us with a comfortable living and a respectable place in society. But it’s also saddled us with the bad faith we enact every time we hold our noses and put a diagnosis on a bill, or fill out a treatment report, or kneel at the altar of evidence-based therapy. We’re the children of a shotgun marriage between psychoanalysis and medicine, and since our parents aren’t about to get divorced, then perhaps it’s time we leave the troubled home they’ve created and build one for ourselves.

As with most family bust-ups, this one will cost us. Status, money, authority: it’ll all be diminished if you leave the comfortable home the DSM has provided. However, to judge from the pitches I receive in the mail, snail and otherwise, the market is already anticipating our split; entrepreneurs are at the ready to show you how to build a practice free of the insurance companies—for a fee, of course.

But alluring as the prospect of getting continuing education credits for going to a seminar on business practices may be, I’d be glad to tell you—free of charge—what I know about how to stop playing Diagnosing for Dollars. It’s not all that complicated, and while I can’t tell you I’m out of the game completely, I’ve taken some steps that make the situation feel less bad to me.

The Devil’s Pact

The occasion to dispense with the diagnostic ritual generally presents itself right away, as soon as your client asks, “Do you take my insurance?” My answer is almost always “no.” Sometimes that’s the simple truth: the policy in question pays only network providers, and I’m not in any networks. But even in the case of point-of-service plans or plans with out-of-network benefits, it’s still no. The client pays me. If he or she wants to try to get reimbursed, I can help with the paperwork. But the financial part of the relationship—like every other part of it—is between us. And, I add, that help with the paperwork will come at a cost. I’ll have to diagnose him or her with a mental illness. They don’t call it medical insurance for nothing.

This often brings people up short, especially when a couple asks the insurance question, and I ask which of them is going to be the mentally ill one. Most people who consult therapists don’t think of themselves as sick—although this has changed over the last 20 years or so, as more and more of our clientele have heard about those “chemical imbalances” that doctors are so fond of invoking. Sensible people are rightfully wary of placing a mental illness in their medical dossier. And while some of this reaction is undoubtedly the result of stigma, some of it reflects a desire for integrity, for not claiming to be something they’re not. This is surely a yearning we want to encourage.

Still, there are plenty of people who don’t mind being diagnosed, or who can’t afford the luxury of integrity, and thanks to the foresight of men like Bob Spitzer—whose expansion of the DSM was meant in part to reassure therapists afraid that their access to insurance funds would get lost as psychoanalytic language was purged from the DSM—there are diagnoses that hardly seem objectionable at all: generalized anxiety disorder, adjustment disorder, and Asperger’s, for instance, and others, like bipolar 2 and major depressive disorder, that have lost much of their stigma in recent years. This is where it comes in handy to have spent the money on a DSM, so you can take it down off the shelf and read the diagnostic criteria to make sure the client knows exactly what mental illness they’ll have (or at least will have had) for the rest of their lives and what its symptoms are. You can even give him or her a choice.

There is something delightful about turning a diagnosis into a collusion against the insurance companies—one that can help those of us with sliding scales to operate our own private socialist systems and enable people with little money or no insurance to get therapy. That’s surely not justification, however, for allowing diagnosis to remain in the shadows, or for evading the fact that it’s essentially a corrupt practice—especially not if the corruption primarily benefits us, which, of course, it does. My starting rate is $140 per hour. What exactly is it that justifies that rate? My masters and PhD degrees didn’t cost me anything like what a medical degree costs. My malpractice insurance is well under $500 a year. My equipment consists of a couple of chairs, a couch, a clock, and a box of Kleenex. What justifies my rate is the fact that the market will bear it, and the market isn’t really free: insurance, as healthcare economists love to point out, insulates it from the rough-and-tumble of supply and demand.

It’s hard to know what we would be worth in a truly free market, which is to say if we no longer availed ourselves of our association with the medical industry. People pay plumbers and auto mechanics upwards of $90 dollars an hour; usually that’s because the need is urgent and short-lived. But they pay clergy far less, and bartenders work for tips. I suppose we could take a page from the evidence-based medicine book and ask people to pay us depending on our performance in any given hour, but it’s likelier that we would end up doing more of what most of us are occasionally doing now: figuring out a fee that works for client and therapist alike.

You’ve probably already worked out a method for determining a rate. You may use an income-based scale. Or maybe you state your fee and then ask a client how much he or she can afford to pay. A surprising number of people give an answer that seems fair. However, as I discovered when a man with a modest-paying job who’d negotiated a 40-percent reduction let it slip that a rich uncle had given him millions of dollars, you can get hosed. When this method fails—often because the client doesn’t know where to begin—I sometimes ask what kind of car he or she drives and what the payment is. Kia drivers pay less than BMW drivers. Or you can ask how much money they spend every week at happy hour.

Through some combination of these methods, I manage to average around $95 per hour. Many doctoral-level professionals make more money than that. But, on the other hand, most people make far less for doing work that’s much harder than sitting still and listening to unhappy people. In return for the money I leave on the table, I receive some semblance of my integrity, I get spared the paperwork, and I get to explore an important subject that too often goes unexamined. Those conversations about my fee, in short, can be worth their weight in gold—and not only for me.

I once saw a woman who worked as an escort, the kind who charges men for the girlfriend experience. I challenged her choice of professions, and she responded by suggesting that our jobs weren’t all that different. Her hourly rate, she told me with some relish, was higher than mine (and speaking of sliding scales, when I discovered what her fee was, I raised mine to match it). The conversation forced the subject of money to the surface. It also gave us the chance to talk about the critical difference between us: that, among other things, she was paying me not to have sex with her. Most importantly, however, by bringing to light the disturbing fact that we were both in the business of renting out love, it forced us to pay attention to what exactly our relationship was about, why she had the need she did, and what she could do to make it possible to fulfill it without paying for the privilege.

Few people present us with this kind of built-in opportunity to explore the value and meaning of therapy. Indeed, to practice the diagnostic ritual, complaining and waxing ironic even as we cash the insurance company checks, is to lose the chance to scrutinize this crucial, if upsetting, aspect of what we do. When accountability is mediated through our (and our clients’) relationship with an insurance company, we’re both beholden to the corporation. We tend to notice this only when the corporation wants to know if it’s getting value for its money and asks for treatment reports, or tosses you off its panel, or insists on a psychiatric evaluation before it will approve any more sessions—at which point we may well respond with the victim’s indignation, rather than recognize this as the price we pay for letting the third party into the room. But we don’t ignore it when our clients repeatedly cancel appointments, show up late, or call us on the phone. Neither do we let our own lapses go unnoticed, or lose sight of exactly what the purpose of the therapy is—a question that money focuses wonderfully.

To diagnose people is to hide uncomfortable truths about what we do, why we do it, and how we get paid for it. We wouldn’t leave unchallenged evasions like the ones our diagnostic ritual affords us if our clients were committing them. So why would we continue to accept them in ourselves?

Should We Abandon Diagnosis?

There are a couple of reasons to think that diagnosis is worth preserving. The first is that the authority conferred on us by the DSM does help our clients—and not only by giving them access to money. There’s plenty of evidence that psychotherapy succeeds, when it succeeds, through nonspecific factors—or, to put it more bluntly, through the placebo effect. That’s not to say it’s a sham. I tell people all the time that I provide a placebo treatment, by which I mean that it works by means of the relationship between healer and sufferer. That relationship is often strengthened by exactly the kind of clout we gain by our association with the medical industry. To render a diagnosis is to provide a token of our power to heal, and thus, at least potentially, to increase our effectiveness. Whether the ends justify the means depends on how you feel about noble lies. I tend to value the truth over effectiveness, but I may well be woolly-headed about this.

The second way to salvage diagnosis, and with it our access to healthcare dollars, is to recognize that what we therapists do can be seen as a medical practice—but only if you expand the definition of medical beyond its usual boundaries. In the last 150 years or so, we’ve come to define medicine as a discipline that seeks the sources of our suffering in biological pathologies. This is an historical accident, due largely to the discovery of germs and the drugs that could treat them—developments that turned doctors into gunslingers who sought out the biochemical culprits of disease and killed them with magic bullets, and patients into the cowering populace waiting for the marshal to ride into town. The medical model, as we have come to call it, is really a bacteriological model, and it works best with illnesses like infectious disease, the ones that have straightforward causes and cures. As time goes on, it becomes more and more apparent that the low-hanging fruit has been picked, and that the diseases that continue to elude the magic bullets—autoimmune conditions, cancers, Alzheimer’s disease—may be indications that we’ve run up against the limits of that model.

Nowhere in medicine is the mismatch between paradigm and phenomenon more pronounced than in psychiatry. The DSM’s claim to fit the medical model is purely aspirational, based on a notion that the causes and cures of mental disorders will be found in the brain, and that when this happens, the DSM will turn out to be an accurate map of them. To the extent that we have evidence for this claim, it appears to be incorrect. For instance, family studies show that schizophrenia and bipolar disorder may have a common genetic underpinning, and biological studies have shown conclusively that depression is a heterogeneous condition, not the result of a neurotransmitter imbalance. But even without this evidence, the claim is troubled—first, because it hinges on the unproven, and possibly unprovable, assumption that the brain is both the necessary and sufficient condition of our conscious experience, and second, because the brain is immensely complex, perhaps the most complex object in the universe, and may well be beyond its own comprehension.

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.