Down with the DSM: how we pathologize being human
If you’ve read my things before, it should come as no surprise that I have a genuine, deep, passionate distaste for the DSM and all its minions.
Hearkening back to the days when we drained people’s blood (virgin or not; less discriminating than Dracula), and when we treated anything that happened to women as a bona fide mystery, we began to formulate the DSM, the “Diagnostic and Statistical Manual of Mental Disorders”. Our cause was brave and bold and virtuous, for we sought the holy grail of scientific formalization. Yet in our passion, we lost sight of the goal—for we were intent to improve the lives of the citizenry. In the today’s parlance, we done made a royal mess of it.
For you see, we committed a philosophical crime that has continued to haunt us to this very day—we reduced experience to behavior. It turns out to be much easier to fit humans into a behavior-shaped box than to fuss about their lived experiences. This is broadly referred to as “behavioralism” and it is still the gold standard by which serious people in healthcare approach mental health. Again, this came from a reasonable place. If we have limited understanding and resources with which to capture objective data about a person, looking at behavior is a good approach. It works pretty well, some of the time.
By now, you have been swimming in the same sea that the DSM people swim in, so none of what it identifies as disorders should be surprising—they’re just a part of our language and understanding of what can go wrong in people’s brains. The curators have identified six main classes of mental disorder:
- Neurodevelopmental Disorders: This includes conditions like Autism Spectrum Disorder, Attention-Deficit/Hyperactivity Disorder (ADHD), and Specific Learning Disorder1.
- Schizophrenia Spectrum and Other Psychotic Disorders: Disorders such as Schizophrenia, Schizoaffective Disorder, and Delusional Disorder are part of this category.
- Bipolar and Related Disorders: This encompasses Bipolar I Disorder, Bipolar II Disorder, and Cyclothymic Disorder.
- Depressive Disorders: Major Depressive Disorder, Persistent Depressive Disorder (Dysthymia), and Premenstrual Dysphoric Disorder are included here.
- Anxiety Disorders: This category covers disorders like Generalized Anxiety Disorder, Panic Disorder, and Social Anxiety Disorder (Social Phobia).
- Obsessive-Compulsive and Related Disorders: Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder, and Hoarding Disorder are examples of disorders in this section
Mind you, these are just the major categories. There are over 300(?!) different classifications. Act now, and your doctor might just give you a dozen or so of these, with some prescriptions to go with them!
This is what happens when you try to classify based on behavior. You start with just a few, realize those don’t work for everyone, tack on a few more, and then you’re suddenly classifying everything people do that other people agree they shouldn’t do as a pathology. If you be hammer, all is nail.
Despite my facetiousness, I’m not denying that there are many different ways that our brains work against our best interests. In fact, I’m totally on board with these general classifications (the six areas), since they help provide a map of different ways of being. But I don’t think the right approach to wellbeing can anchor itself to arbitrary thresholds, no matter how sophisticated our measures become. This is because the only thing that really matters is that we’re happy and free to make good choices (that don’t adversely affect other people/non-people that matter). The DSM and its friends have accidentally positioned themselves between us and these goals.
In what ways does the DSM do this? Variously.
Perhaps the worst thing the DSM does is that it promotes the idea that we are somehow carriers of a sort of condition, a plague that infects us and those we care about. If I have depression, it is understood that I am playing the role of Eeyore, the objectively worst creature in the Hundred Acre Wood. I am a wrecking ball of tailless sadness incarnate. All who are before me cannot help but be dragged into my miserable maelstrom. I am also made to understand that this is a core part of my identity. I am depressed and depression is the thing that I carry with me in a big, sad sack. This based on a series of questions that the DSM people and their friends have developed in order to make me aware of this fact.
But wait, hope beckons! If I want to not be depressed, I need but have my depression treated—that is, eliminated, leaving me free to be whatever I am when I am not depressed (this part is unclear). Sure, maybe I have reasons to be depressed. Maybe the reason I feel sad all the time is that there are sad things happening to me and mine and that it’s a reasonable defense mechanism that can prevent me from being over-exposed to negative stimulus. Not to worry! The DSM will get you pills for that. Now, these pills turn out to not actually work for almost anyone (and even then, you must continue to take them indefinitely and even then, it is much more likely it’s not the pills but your intentions that are carrying you through this), but they could work for you.
There has been a lot made of some studies that show that these pills (SSRIs) don’t work as pills usually do. They can still work okay in the sense that they make people feel good (as a placebo) and that they make it feel like there is something to be done, further motivating actions that can alleviate the negative feelings. Whatever the case, the point is not the pills but that focus on observable behavior runs roughshod over the individual’s lived experience. Depression is almost always due to there being good cause for being sad. Therefore, any approach that fails to address these causes is going to be minimally effective.
Further, we have novel methods which reveal that depression can be treated by a fundamental shift in phenomenal experience. This is to say that you can change the way that you experience the world and your depression will disappear, given a big enough shift. There are various ways to cause this shift. The most lo-fi are things like traveling/trying new things, learning new languages, making new friends, (willfully) taking on new responsibilities—all simple but effective. It isn’t all that easy to go from being depressed to wanting to and actually doing these things, but they do work. Higher-intensity versions include well-defined psychedelic usage, TMS treatment, and the sorts of things that I’ve been building (AMA).
But this post isn’t about depression or its treatment—it’s about the way we (the DSM) think about the pervasively negative outcomes that our thoughts and experiences lead to. By focusing on the outcomes, we almost always ignore the human behind them. Depression is chemo for being sad, with all the parallels (e.g., destroying the good cells and weakening the host) intended. In reality, some people are sad because they have a sad life and that makes them sad. Some people are sad because they have a sad disposition—they are simply not gifted with a high capacity for joy. A third kind of sad comes from having learned to be sad as a protective strategy against further loss. These people need very different kinds of support, yet they would be classified similarly, as their end behavior will be the same.
Moving past depression, we have many many other “conditions” we could consider. I’ll do just one but this sort of approach applies to almost all of them.
I had a friend ask me the other day if I thought she had ADHD. I did a quick ADHD survey for her in my head and yes, I reckoned she would qualify for ADHD bingo night (the games never finish but the members enjoy the chaos). Did I tell her she’d qualify? Yes, but I made sure to qualify this because it’s important to be clear: qualifying for a diagnosis does not mean you need to identify with it. Nor should you, in my reckoning. They’ve done some studies on this. People who call themselves “anxious” are worse off than those who describe themselves as “feeling anxious”.
So too should it be for any condition that isn’t straight up an issue of being wired that way (neurophysiological limitations). You are not a depressed person; you are a person who is feeling sad. You are not anorexic; you are a person who is struggling to eat sufficiently. You are not OCD; you are someone who tends to compulsively fixate. And so on. This re-framing is critical and (somewhat) well-understood by practitioners (and support groups like AA), but the message is getting lost.
A recent study showed that young Americans are becoming increasingly likely to be familiar and identify with DSM pathologies. In some ways, this could be thought of as a good thing. It’s good that kids understand that they are not alone in their struggles. There are others in the same or worse state as they are. There’s comfort in this. There’s even community and support from those people, advice to be heard from people who are escaping or who have escaped. However, much like gravity, a sufficiently large collection of people with similar properties (mass) collecting together can lead to everyone getting stuck together. Instead of getting advice on how to escape, they all learn to be helpless together, getting a flicker of joy from their shared suffering. (I’m looking at you, Reddit dot com.)
More than this, though, it’s a problem that we learn to identify as our pathologies, because identity pushes us to act in accordance with these pathologies. An OCD person is someone who does OCD things. The show must go on! In contrast, someone who merely acts in OCD ways can hope to learn to act in different ways, since they do not feel as strong of an attachment to their compulsions.
I said before that the root of this issue is behavioralism—it is. Instead of rationally observing our negative behaviors and considering why we are doing them, we are made to cling onto them as though they were our defining features. It is this observation that had Viktor Frankl (Man’s Search for Meaning) raging at Freud back in the 1930s and 40s, what helped drive him to develop an alternative. Where Freud had doubled down on the self (the id/ego) and on the anchoring nature of the past, Frankl shifted the focus on coming up with proactive reframings of ongoing bad events—meaning-making (through “Logotherapy”—literally, logic-based therapy). This approach lost the war and Freud prevailed and has continued to prevail.
The current mainline approach to fixing pervasively negative behavioral patterns has two parts:
- Taking pills to lessen experience. ADHD, depression, OCD, ADHD — all are addressed by lowering the absolute amount of experience
- Sitting in a chair talking about your past and all the complex situations you are currently dealing with
It’s good that we’re at least talking about current events now, but it’s not enough.
Often, with talk therapy, we’re unintentionally realizing our own nightmares, making our fears real, and trying to fight these fear demons we are ourselves summoning.
We’re also doing this in a clinical environment, removed from the issues themselves. All we have is a mental model (often a dark fantasy) of the people and things that are causing us grief—an imagination. This is not to say that our imagination is incapable of being more or less accurate but that it’s just a simulation of the real thing. We cannot interact with it, nor can it interact with us. It’s as though we are trying to learn to play tennis without a net or a ball. Once we’re done imagining, we are asked to go out and try out our imagined solutions. Unsurprisingly, this rarely works.
Do I blame the DSM for this? Yes, though my blame cup for the DSM runneth over into psychology and medicine writ large. Both disciplines are over-oriented towards the negative.
For medicine, this is natural. No one wants to go to a doctor unless they’re seriously suffering, so doctors only see people who are seriously suffering. And as people who don’t like to see people suffer, they take on the role of quickly reducing suffering in the most efficient way possible. Practically, this means patching people up. It does not mean educating them or helping them change the way they see the world or manage their personal lives. All of this is understandable. You don’t expect your mechanic to help you be a better driver, nor should you expect your doctor to help you learn to be happy. Should you? I think so. Happy people make healthier decisions. If you want healthier people, you want happier people.
Psychology also has its own biases. Specifically, psychology would rather study things going wrong than things going right, and the people who fund them agree. There is an air of legitimacy that comes from studying and treating negative phenomena, so much so that there has been a need for the few people who study good things to actively and openly brand themselves as researchers of “positive psychology”. In this little niche, we have happiness, love, care, kindness, meaning—the most important things in the universe. Positive psychology occupies a tiny, unappreciated corner. Part of this is because it deals with complexity. What even is “love”? We know it when we see it but that doesn’t give us grounds to operationalize it. Yet if we could, we absolutely should. The absence of research on positive psychology is evidence of laziness, not evidence of unimportance.
Harping and digging aside, there is a better way. I’ll go more into this in another piece, but “integrative psychotherapy” directly confronts the complexity of human experience. In short, you focus on fundamental bodily/neurodynamical shifts (arousal) and highly valenced experiences—allowing for a kind of bottom-up form of psychological transformation. Unlike the DSM-styled approach, which is focused on the elimination of negative symptoms, integrative psychotherapy is centered on shifting the way we engage with the world. To quote “Man’s Search for Meaning”:
“By declaring that man is responsible and must actualize the potential meaning of his life, I wish to stress that the true meaning of life is to be discovered in the world rather than within man or his own psyche, as though it were a closed system. I have termed this constitutive characteristic “the self-transcendence of human existence.” It denotes the fact that being human always points, and is directed, to something or someone, other than oneself — be it a meaning to fulfill or another human being to encounter. The more one forgets himself — by giving himself to a cause to serve or another person to love — the more human he is and the more he actualizes himself. What is called self-actualization is not an attainable aim at all, for the simple reason that the more one would strive for it, the more he would miss it. In other words, self-actualization is possible only as a side-effect of self-transcendence.”
How does the DSM pathologize being human?
Finally, let’s address the subtitle.
The DSM and its followers put us in the precarious condition of constantly wondering whether we are or are not *deep breath* depressed/anxious/OCD/addicted/bipolar/manic/ADHD/delusional/narcisistic/sociopathic/psychopathic/schizophrenic/autistic. These are all identified on social grounds. If you were a hermit living in the woods, none of these would be intelligible (except schizophrenia, but then the woods might be more… real than before).
As social conditions, they exert social control. It is little wonder that the DSM has a dark history of classifying mere preferences (being gay) and experiential differences (being trans) as pathological—that is, deserving of systematic elimination. Autism has become the poster child for this, as it is clear that many of the smartest and creative and interesting people have been and are on the spectrum. Where does the condition begin and end? The barrier is entirely social. The DSM has and continued to create and strengthen barriers between people of different experiences by causing us to constantly question where we and everyone else stands. Lord, is it I?
It is you. You have and will have a number of these “conditions” throughout your life, as will everyone you know. It turns out that this is just being human. Once you understand that, you can take an active role in shaping yourself, classifications be damned (as Judas presumably was/is). All that matters is your happiness and the happiness that you can share with those you love. Unfortunately, there’s no manual for that. (Yet—we’re working on it.)
