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 some day 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.